Infection control in high-risk community settings during Covid-19 - Nursing Times

How a coordinated infection prevention and control approach developed during the Covid-19 pandemic supported high-risk settings in the community, including care homes

Abstract

Like many other cities in the UK, Wolverhampton was hit hard by Covid-19 during the pandemic, which began in 2020. It was agreed that a coordinated infection prevention and control approach was needed to support high-risk settings in the community, including care homes. A team was set up to provide tailored training, audit and outbreak management in care homes and other high-risk settings, with the support of public health, the clinical commissioning group and the acute trust. The approach has now been expanded to cover other areas of infection control including MRSA and C difficile.

Citation: Corbett K, Beddow M (2022) Infection control in high-risk community settings during Covid-19. Nursing Times [online]; 118: 9.

Authors: Kim Corbett is senior matron infection prevention; Mark Beddow is senior infection prevention nurse in the community infection prevention team; both at the Royal Wolverhampton NHS Trust.

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Introduction

As with other areas in England, the impact of Covid-19 in Wolverhampton was significant in the first few weeks of the pandemic, which began in earnest in March 2020. There were many admissions to the Royal Wolverhampton NHS Trust, as well as infections in care homes, which sadly led to the deaths of residents.

It was deemed essential that the city had consistent and integrated support for infection control and prevention across the acute, community and primary care settings. This support would be particularly vital for high-risk settings, including care homes, as well as other places in the community that would be vulnerable to outbreaks such as education and faith settings, workplaces and homeless shelters.

The goal was to implement a seamless, consistent city-wide approach towards the management of infections that included:

• Audit and surveillance;
• Practice development;
• Education;
• Outbreak management.

The trust's infection prevention and control (IPC) team already had experience working with care homes during outbreaks of norovirus and influenza in previous years, so it was decided that this team would be best placed to provide this localised response, working in collaboration with colleagues in public health.

"This showed true integrated working across different systems. Focusing on patient pathways, [this project] continues to develop, meeting the infection prevention challenges faced across the health economy in a truly collaborative way"
(Judges' comment)

Response

At the start of the pandemic, the IPC team was supporting care homes, but only for managing outbreaks. Over the coming months, this developed into providing surveillance and monitoring, audit, bespoke education and training. This integrated infection control and prevention service to all high-risk settings in the community had been fully developed by August 2020, and a contract was put in place by November of the same year, with an agreement that it would be supported by public health colleagues and the clinical commissioning group (CCG) where required.

One whole-time equivalent (WTE) band 7 nurse, one WTE band 6 nurse and three band 3 healthcare assistants were recruited to the team. Regular meetings were held to ensure all parties were aware of relevant issues and to discuss any local intelligence that had been gathered.

Good IPC procedures in care homes were promoted by raising awareness of them and providing tailored advice. Work to minimise outbreaks in high-risk settings, such as care homes, through education and training was done throughout by the IPC team.

Reports of there being two or more confirmed cases, or people who were symptomatic, in a setting triggered an outbreak management response within 24 hours. The team had the capacity to deal with 10 outbreaks at a time although, at the height of the pandemic, IPC staff were managing many more than this number. In response to an outbreak, the team put in place further testing, as well as education and guidance for care home staff, on effective IPC procedures.

All care homes were part of the pillar 2 swab testing, with results reported through NHS Test and Trace; however, the team was unable to access these results. To ensure accurate screening and identification of cases, once an outbreak was identified in a care home, the IPC team visited and completed pillar 1 testing, through Public Health England laboratories.

Education packages and audit tools were developed, and all care homes received the training, with support from the CCG. Audits were done in all care homes with outbreaks. The IPC team also sent out daily emails informing staff in the acute trust, public health and the CCG of care homes that had closed due to outbreaks; anticipated opening dates were given to enable discharge planning.

Outcome

The IPC team managed 15 outbreaks in November 2020, nine in December, 28 in January 2021 and four in February 2021. Through pillar 1 screening, the team identified cases that had not previously been picked up:

• In November, 452 screening tests were done and 27 new cases were identified;
• In December, 310 screening tests were done, with 22 new cases identified;
• In January, 150 screening tests were undertaken and 18 new cases identified;
• In February, 105 screening tests were carried out – no new cases were identified.

Over the four-month period, 44 meetings were held with public health colleagues and 23 with the incident management team. During this time, IPC staff carried out 97 Covid-19 audits, 47 visits to offer support to the high-risk setting and 16 training sessions requested by the incident management team.

The biggest problems identified by the team during visits were:

• Lack of knowledge of the use of personal protective equipment (PPE);
• How to screen residents.

Tailored support was provided to ensure care homes were able to consistently apply the correct IPC techniques. The goal is to make it easy for settings to comply. Feedback from the care homes and other settings involved showed that they welcomed the support from the IPC team at this challenging time. Many homes commended the high level of work the team completed and felt supported.

This joined-up approach has meant consistent, integrated support and oversight across the city, which has also supported the acute trust with the admission or discharge of care home residents from hospital. The team has also been able to apply its expertise to outbreaks in other high-risk settings, including an abattoir and a drug and alcohol rehabilitation centre.

The success of the service led to it being commissioned for two years to continue its work on promoting good IPC in high-risk settings, and preventing and managing the impact of infectious disease spread in care homes. This contract, which runs until November 2022, will go beyond Covid-19 to consider MRSA, carbapenemase-producing Enterobacterales and C difficile surveillance. The team will also carry out hand-hygiene audits and short infection prevention audits.

Challenges

Due to the regular turnover of staff and the use of agency staff, some care homes that had ongoing problems required several visits. The team continued to visit care homes until they felt assured that the staff were competent with infection control procedures, and the residents and staff were no longer at risk.

At times, the number of outbreaks created large pressures for our team beyond the workload that had been planned for. This was also an incredibly difficult and emotional time for those working in care homes, with fluctuating guidance and pressures from relatives who were keen to see their family members who were residents. Often team members would be providing emotional support as well as practical guidance on what steps they needed to put in place to protect those for whom they were caring.

Conclusion

At the start of the Covid-19 pandemic, it was recognised that a coordinated, consistent and joined-up approach was needed to support IPC in high-risk settings across Wolverhampton. The expanded community IPC team, with support from colleagues in public health, the CCG and acute trust, provided training, audit and outbreak management for care homes and other high-risk settings in the community. This collaborative approach also helped to manage hospital discharge planning for care home residents. Care homes welcomed the tailored support they received at this challenging time.

Having proved to be an effective approach, the contract was extended to late 2022 and the team is widening its remit to include other infection prevention targets such as MRSA and C difficile.

Key points

• Wolverhampton agreed a joined-up approach to infection control and prevention in high-risk community settings during the Covid-19 pandemic
• With support from public health staff and the acute trust, the community team provided training, audit and outbreak management
• Included in the training was additional pillar 1 swab testing to identify cases and prevent onward transmission of Covid-19
• Care homes were the main settings supported by the approach, which was tailored to their individual needs
• The success of the approach means it has now been expanded to other areas of infectious disease prevention

Advice for setting up similar projects

• Hold regular meetings with members of the multidisciplinary team
• Keep the safety of the residents and staff in the health economy at the forefront
• Ensure that all parties have input to the plan and are involved in communication
• Care home managers need to be involved if infection prevention and control measures are to be implemented
• Agree what high-risk settings are to be included and what level of outbreak the team can manage