HSIB: COVID-19 transmission in hospitals: management of the risk – a prospective safety investigation (October 2020)

Summary

This Healthcare Safety Investigation Branch (HSIB) report charts a four-month patient safety investigation that was launched following concern that patients were contracting COVID-19 after being admitted to hospital. The report references data presented to SAGE in mid-May that suggested around 20% of patients were reporting symptoms seven days after admission.

The aim of the investigation was to understand the factors that could contribute to the risk of transmission, how the NHS operates to reduce that risk and where there may be opportunities to reduce that risk even further.

The investigation represented the voices of those working across the health service, from strategic national planners to hospital porters. It also captured experiences of patients and families, providing further insight into the challenges of managing the transmission of COVID-19.

Content

The report concludes with short, medium and long-term measures that support both immediate and future responses as the NHS continues to tackle the virus. The measures include eight national safety recommendations, safety observations and a tool that NHS trusts can use straight away to review their approach.

Safety recommendations

1: It is recommended that the Department of Health and Social Care, working with NHS England and NHS Improvement, Public Health England, and other partners as appropriate, develops a transparent process to co-ordinate the development, dissemination and implementation of national guidance across the healthcare system to minimise the risk of nosocomial transmission of COVID-19.

2: It is recommended that NHS England and NHS Improvement

• supports additional capacity for testing for NHS patients and staff (Pillar 1 testing)
• facilitates the accessibility of rapid testing for NHS trusts, as soon as an increase in rapid testing supplies becomes available.

3: It is recommended that NHS England and NHS Improvement:

• develops a national intensive infection prevention and control (IPC) safety support programme for COVID-19 which focuses on leadership, IPC technical support, education, practice, guidance and assurance
• develops a national IPC strategy which focuses on developing IPC capacity, capability and sustainability across the NHS in England.

4: It is recommended that NHS England and NHS Improvement reviews the principles of the hierarchy of controls in its health building notes (HBN) and health technical memoranda (HTM) for the design of the built environment in existing and new hospital estate to reduce the risk of nosocomial transmission.

5: It is recommended that NHS England and NHS Improvement responds to emerging scientific evidence and shared learning when reviewing guidance for NHS trusts on the role of hospital ventilation systems in nosocomial transmission.

6: It is recommended that NHS England and NHS Improvement investigates and evaluates the risks associated with the potential impact of staff fatigue and emotional distress on nosocomial transmission of COVID-19.

7: It is recommended that the Department of Health and Social Care reviews and identifies the mechanisms which enabled regional and local organisations to adapt and respond with agility during the pandemic. This should inform the development of a strategic approach to national leadership models at times of crisis and under normal conditions.

8: It is recommended that NHSX considers how technology can assist in mitigating nosocomial transmission in the ward environment with regard to:

• the use of digital communication technologies in assisting with the deployment of staff and the dissemination and circulation of key information
• the increased use and availability of personal computing devices and electronic health record systems.