Scientists around the world have warned of the airborne nature of Covid-19 since the start of the pandemic, but how does this impact on patient safety and what can be done to reduce risk?
In this long read blog, GP trainee Lindsay Fraser-Moodie, describes how she witnessed the impact of poor ventilation and inadequate PPE on staff and patient safety while working on a hospital ward during the second UK Covid-19 wave. Lindsay describes how her CEO welcomed her concerns, and the changes that were put in place to reduce the risk of hospital acquired transmission.
This article includes a comment from her CEO David Carter, who highlights the challenges of the situation and praises Lindsay for her approach to patient safety.
I’ve been a hospital doctor for 10 years, but in February 2020 I switched to GP training. As part of that I’ve spent the last 18 months in hospital rotating around different specialities. In December 2020 I rotated onto a Department of Medicine for the Elderly (DME) ward, populated with very vulnerable patients.
The ward has five single side rooms, and six bays. There are mainly DME patients in the bays, but the side rooms are used by patients who need isolating for a variety of reasons. Originally built in 2005 as an ‘isolation ward’, it still retains that name. Throughout December and January during the UK’s second wave, the ward had a combination of Covid positive and negative bays and side rooms (as it had in the first wave).
Concerns about the ward air
As soon as I started work on the ward it was clear to me that patients and staff were getting infected from the ward air.
We had devastating numbers of hospital acquired infections in both patients and staff. I knew that my colleagues were doing everything asked of them with regards to droplet precautions and hand hygiene as I could see what was going on in front of me. I started to read the science around airborne transmission of Covid, and it fitted exactly with what I was witnessing.
UK PPE guidance wasn’t protecting staff
As per UK infection control prevention (IPC) guidelines, we didn’t have access to higher grade respirator masks (FFP3s) unless we were doing what is called an ‘AGP’ (aerosol generating procedure). This was rare, so most of the time we were all in surgical masks whilst providing close Covid patient care. I know I certainly felt very vulnerable in a surgical mask and petrified of taking Covid home to a loved one, so I’m sure most my colleagues felt the same.
Surgical masks are only designed to block large bits of virus droplets. However, Covid spreads primarily in smaller airborne particles called aerosols, which are expelled from an infected person’s nose and mouth (together with droplets) every time a person with Covid breathes, speaks or coughs. Unlike droplets, which drop to the floor within a few metres like the name suggests, aerosols are light and hang around in the air like invisible smoke in indoor spaces. Hence being outside is safer, as aerosols disperse quickly.
It was previously thought that AGPs were the only way aerosols were produced, but this science is very outdated now, and we know that humans simply breathing is aerosol generating! The laws of physics dictates that you can’t get droplets without aerosols too.
Aerosols cause Covid infection through inhalation. Loose fitting surgical masks will block a lot of aerosols, but some will also leak out, and in, around the poorly fitting edges. The closer you are to someone infected, the higher your chances of breathing in their exhaled aerosols. If that person is in a mask then your chances of getting infected by them is dramatically reduced, however very few patients when unwell in hospital with Covid can tolerate wearing masks. Staff caring for Covid patients have to get up close to unmasked Covid patients, putting them at high risk of inhaling short-range aerosols, which is why they should be in well fitted respirator (FFP3) masks which are designed to completely block aerosols.
A recent observational study from Addenbrooke’s Hospital showed that staff on Covid medical wards in surgical masks had up to a 47 x higher chance of being infected with Covid than their colleagues who were also wearing surgical masks on non-covid wards (who had the same rate as community infections). Following the change in protective equipment to FFP3s for all staff on the Covid wards, the incidence of infection on the two types of ward was similar. Their risk of being infected at work was effectively eliminated.
The risk to patients
Being in an indoor environment puts anyone sharing the same air as someone infected with Covid at risk of inhaling their long-range aerosols. I noticed very early on that even patients in our side rooms were tragically contracting Covid on the ward, despite staff following all the guidelines on preventing fomite (surface) and droplet transmission. This especially got me thinking about the flow and quality of the air on the ward.
Were the long-range aerosols drifting into the non-Covid bays and side rooms?
Also, were unknowingly infected staff taking Covid in and breathing Covid aerosols out of the sides of their poorly fitting masks?
I felt like it was probably a combination of the above, mainly the first as genomic sequencing studies show that patients are mostly infected by other patients.
We were only being PCR tested once weekly, plenty of time to sadly infect a colleague or a patient before you knew you were infected. There is little chance to distance from colleagues or patients on the ward. When staff are spending 12 hour shifts in wards with covid patients and working together in close proximity with colleagues in a high-risk environment, they need the best masks available.
We felt very helpless to protect our patients on the ward. Despite the best efforts of everyone on the fantastic team I was proud of be working with, we were having heart-breaking regular hospital outbreaks together with an alarming number of staff infections. The worst phone calls I’ve had to make in my career were the calls to the relatives, letting them know that their loved one had tested positive for Covid, often likely nosocomial (originating from the hospital). I felt like I was letting my patients and their family’s down, and it went against ‘first, do no harm’.
I also wanted to speak up to defend my colleagues. It was clear to me that Covid wasn’t spreading on the ward as staff don’t wash their hands, or were wearing masks under chins, as some asserted without evidence. We were working through the most traumatic and challenging time of our careers, and I was not going to accept my hardworking, selfless colleagues being laden with unfair guilt. Individual behaviour may have played a small role at times, but it was not the cause of the huge issue of nosocomial Covid infections that we saw nationally in the UK this pandemic.
Auditing the air and ventilation
Wanting to help the situation, I spent hours reading on the topic of airborne transmission and reached out to experts in the field to learn more. I bought my own C02 and particle counter to audit the air quality on the ward, which showed it was indeed poor. I went around the ward looking for any ventilation extracts/inflows. I also spoke to our hospital estates about the ventilation and filtration on the ward (ventilation provides fresh air – it can be natural or mechanical, and filtration means air filters to clean the air. Air can also be cleaned using UV technology.
It transpired that there was no mechanical ventilation or filtration on the ward, we were relying solely on natural ventilation (i.e. opening windows), which was very difficult to do in winter months and with safety latches on the windows limiting opening. Nobody knew the direction of air flow on the ward, particularly into or out of the side rooms.
Raising concerns with my CEO
I emailed our hospital’s CEO about my concerns regarding inadequate PPE and lack of attention to airborne spread within the hospital. He was fantastic and got back to me very promptly to kindly acknowledge my concerns. We had a meeting several weeks later, together with my ward manager, matron, and ward consultants. The head of infection control was invited, and I had emailed my concerns to the infection control team separately. I made it clear that I was by no means an expert on this topic (the experts are the engineers, aerosols scientists, and architects with a specialist interest in this area – we need to listen to them on this and work together to tackle it), but I simply wanted to raise the issue that the air we breathe in healthcare settings is incredibly important to reduce airborne disease transmission.
Changes were implemented to improve safety
In the second half of January 2021, my trust changed their own local PPE guidance to allow FFP3s for all staff caring for covid patients, if their manager felt the local risk assessment warranted this. National guidance still said surgical masks alone were adequate, but many trusts had begun to cotton on to the vast numbers of staff sickness on covid wards which were following national DHSC/PHE guidance. I am very pleased to say that since this time any staff member who has needed an FFP3 mask has had access to one.
After the meeting to discuss ventilation and air cleaning, our CEO organised a trust ventilation audit to ensure the hospital meets the ventilation standards set out by NHS England. Obviously, it takes time to update inbuilt ventilation systems, so in the meantime any areas with poor ventilation have portable air cleaning (HEPA filters). This includes this ward that I worked on, which once again has Covid admissions. There are also window stickers on the ward that the ward manager and I stuck up, to remind staff of the importance of fresh air, and all staff always have access to FFP3 masks regardless of AGPs.
My CEO thanked me for bringing this important issue to his attention and commented how difficult it was for them with the lack of national guidance for hospital trusts (and social care settings) on how to mitigate against airborne spread of Covid. You can see his comments at the bottom of this blog.
UK guidance remains unsafe
There has been plenty of guidance for trusts on how to clean surfaces, but no guidance on the most important mitigation measure of all – how to clean the shared air. DHSC/PHE PPE guidelines saying surgical masks were adequate for Covid patient care in the absence of AGPs also put trusts in difficult positions.
National PPE guidance is still woefully inadequate. Their latest update in June 2021 leaves trusts to decide where FFP3 masks are required for staff, after saying for well over 12 months that they were only required in the presence of AGPs. In my opinion, they needed to come out and clearly say this was an error, and that all health and social care workers caring for Covid patients need access to FFP3 masks. Ideally re-usable ones, better for the environment, and often more comfortable for the wearer.
If you have concerns locally…
If you have safety concerns, speak to your colleagues. People were incredibly supportive of me speaking out. It was a team effort to make our ward a safer place for patients and staff.
I am also very grateful to our trust’s CEO, for being an inspirational leader and taking the time to listen to, and act upon, my ‘Concerns from a junior doctor’ emails. I will always be indebted to him.
Even if you do not have support, I would encourage anyone to speak out for what you believe is right, especially if the health of your patients is at risk. Being silent is being complicit. Ask, would you want a relative of yours being admitted to that ward and treated in that way? If the answer is no, you know what to do.
Comment from David Carter, Chief Executive, Bedfordshire Hospitals NHS Foundation Trust:
“When Dr Fraser-Moodie first contacted me, it was 12th January 2021. This period was probably the most difficult and challenging time for us during the whole COVID period, as like other hospitals, we were trying to manage the rising numbers of admissions and the risk of nosocomial infection which was becoming part of the national picture. Indeed that week has proven to be the week with the highest number of positive inpatients at the Trust during the whole pandemic. We relied heavily on the national guidance to drive our local policies recognising that whatever reservations we may have, compliance with that guidance was the safest position for us to take and indeed in relation to PPE in the early waves, the difficulty in the supply chain meant that hospitals had little choice.
Dr Fraser-Moodie’s email to me challenged that guidance specifically in relation to the transmission risks and did so in a well - researched and informed way but also in a very personal way, bringing home the impact the pandemic was having on both staff and patients. It also chimed with the concerns we, and other members of staff, were starting to have regarding the way that the new Kent strain of the virus appeared to be spreading. Throughout the pandemic we have been fortunate to have been able to call on the wise counsel of our DIPC and microbiologist, Dr Mulla who himself was concerned about the difficulty in providing adequate ventilation, particularly on wards in winter when opening windows was very difficult. Myself and Dr Mulla took some time to talk to the ward about their concerns and also to explain some of the constraints we operate under, including our need to adhere to national guidance wherever we can. Nonetheless as a result of Dr Fraser-Moodie’s highlighting of these issues, we made some changes to our approach including a modification to our PPE policy which allowed for more local risk assessment, an increase in our purchase of portable air filtration units and the acceleration of our site-wide ventilation audit which is now guiding the infrastructure works on the site.
I strongly believe that when individuals raise concerns, we have a duty to listen and only by creating a culture when individuals feel safe to do so can we learn and change and ultimately provide the care we aspire to. However those who raise concerns also have a duty to do so in the right way. In the midst of a pandemic it was incredibly important to not cause alarm amongst patients, not to damage the morale and reputation of the services being delivered and to recognise some of the practical difficulties inherent in managing the situation in an ageing NHS estate. Dr Fraser-Moodie found that balance and I would like to thank her for having the bravery to raise a concern but also doing so in a respectful, evidence driven way which made it much easier for me to engage in a non-defensive way. I am sure that Dr Fraser-Moodie will continue to be a positive force for change as she continues her career.”