NCA Nosocomial COVID-19 Infection

Prevention Collaborative

Change Package

What we have learnt so far

Version 1 20/10/2020

2

Introduction

COVID-19 is a novel “new” coronavirus:

• CO – stands for coronavirus

• VI – stands for virus

• D – stands for disease

• 19 – stands for the year the virus was first detected

Therefore, the scope of this collaborative is to prevent the acquisition of COVID 19 across

all of our care organisation sites.

We define a nosocomial COVID infection

across the NCA as:

Probable cases: Admitted in last 8-14 days

Definite cases: Admitted in last 15+ days

What is a Nosocomial Infection?

Definition:

A nosocomial infection is defined as a disease that originated in hospital.

There are many types of human coronaviruses that commonly cause mild upper

respiratory illnesses

Typical Symptoms of Coronavirus

Tiredness

High Fever

Loss of taste or smell

Difficulty Breathing

Dry persistent coughing

How is it spread?

Respiratory droplets

Coughing

Sneezing

Close contact

Surfaces

Scale of the problem

In March 2020, a global pandemic, never to be seen before in this modern time, was

declared.

Cases of COVID-19 escalated rapidly around the UK, with the Northern Care Alliance

being one of the worst hit sites in the UK based on the number of confirmed cases and

deaths.

Staff have worked tirelessly amongst escalating cases and uncertain times and achieved

so much throughout the COVID 19 pandemic. However, we know a number of patients

have acquired COVID 19 on our sites and a number of these patients have died.

The average age of patients whom contracted a HACI and sadly died is 84 – our most

vulnerable patients.

We achieved across July and August up to 75 days without a nosocomial COVID 19

infection at a number of our sites. Now, as we head into a second wave and prevalence

of COVID 19 in our NCA communities is increasing, we are also seeing an increase in

nosocomial COVID 19 infections across all of our sites.

What are we doing?

In July 2020 we launched the COVID 19 Nosocomial Infection Collaborative. It is

designed to unite the Northern Care Alliance organisations in a shared purpose to

achieve no nosocomial COVID 19 infections across all sites and community settings.

The collaborative aimed to help staff to understand the rationale behind the required

IPC measures and do their utmost to avoid transmissions in all aspects of their daily

routines including both patient facing and not patient facing

The aims of the Nosocomial Infection collaborative are:

That there are no nosocomial infections across all of our sites

To go 100 days without a nosocomial infection

Timeline of events

1st Expert Faculty Meeting

July

Launch Event

July

Learning Session 2

September

Learning Session 3

November

Supporting Structure

NCA Expert Faculty Care Org Steering

Groups Collaborative Teams

We truly are living in unprecedented times. Covid-19 is a new disease, and we are grappling daily with learning to manage it. We are contributing to research and putting that into practice at incredible speed. The very nature of a pandemic adds a new dimension to our work. Our whole lives are upside down. We are afraid – for our loved ones, our patients, our friends, our own security in life. Nothing is certain right now. But,

We are the key workers that stepped up to the challenge in the 1st wave. We were applauded, gifted and praised for our efforts. We worked so hard for our patients, our loved ones, ourselves. We are stronger than we seem, braver than we believe. When our processes fail the price is high – not just to those who are infected with Covid-19 but also the impact on services from sickness, from staff isolation. On the staff covering extra shifts. On those who have to shield. Now as we head into a second wave, we know more about how to prevent the spread of COVID 19 and we know we need to be vigilant in our approach. We still don’t know for sure all the answers but we are not without knowledge and skills. We understand reliability – that we need to make the fundamentals of care as simple as we can, so routine that it happens unthinkingly. That frees us up to feel, to learn new things, to grapple with the challenges we face. WE know that when a patient comes to hospital, a clinic, lets us into their environment, they are trusting us even more than they have before. They trust that we are doing everything we can to protect them. Our colleagues trust that we are doing everything we can to protect each other. We are the NCA family, we know we can rise to this challenge like we have risen to so many before. This is the place where we care and are safe, secure and here for you.

Why is this Change Package so important?

We ALL have our part to play in Infection Prevention

Control (IPC) and breaking the chains of

transmission.

By implementing the proposed change ideas in this change package, we

can reduce the risk of transmission of COVID-19 across our sites.

Quality Improvement Methodology

The collaborative followed the Breakthrough Series Collaborative Model using learning

sessions to bring teams together to share tests of change and introduce quality

improvement methodology.

The collaborative used the Model for Improvement to provide a clear aim, structure and

driver diagram to guide improvement work.

By using this methodology we recognise that in healthcare, we could not make the

necessary improvements that our patients deserve without the skills, knowledge and

expertise of dedicated staff. Through this collaborative, we want to empower our staff to

test their change ideas and spread successful improvements across the organisation.

Our driver diagram

Over 100 teams across all NCA sites are engaged in the collaborative, a phenomenal

response. Given the limitations of IPC the collaborative is being run via a virtual

platform, improving accessibility to it.

Teams were asked to complete PDSAs within one of the following 5 themes:

What we have done so far?

Environment Hygiene

and Cleanliness

Personal Protective Equipment

(PPE)

Health and Safety

Visiting

Where are we now?

The Nosocomial infection collaborative has reached a crucial point in the improvement

cycle where the tests of change developed by staff are beginning to be shared; the

collaborative focus is shifting to the spread and sustained roll out of the key changes

which we believe are likely to result in improvement.

An audit tool has been rolled out – please contact the QI team for the most up to date

version.

The proposed changes within this change package have been compiled

from tests that have been developed across the collaborative teams, as

well as learning from acquisitions. We believe that if they are applied in

your area the risk of a Nosocomial COVID 19 infection will be reduced.

Change Package

A Change Package is a group of changes which, when

adopted, will address a particular problem.

This Change Package has been designed using preliminary evidence to

provide teams with the necessary toolkit to reduce Nosocomial Infections,

specifically COVID-19.

There are 5 key themes highlighted as areas of focus. These themes are

listed below and dictate the Change Package items which are described in

the following pages:

Environment Hygiene

and Cleanliness

Personal Protective Equipment

(PPE)

Health and Safety

Visiting

It’s important to remember that you are not alone in your QI journey.

Teams across the NCA have actively participated and tested the changes

listed within this package and is a great resource to use for advice,

support, shared learning and understanding the rationale behind each of

the change items.

“Know that we can have more freedom tomorrow.

The actions we take today, will preserve our

tomorrow” World Health Organisation (WHO)

This change package can be used to:

• Identify which of these changes already exist within your areas; if they do,

do they require further work? If they do not, you may consider

implementation.

• Highlight and prioritise some changes that your team may begin testing

around each theme. Remember that testing takes time in order to build

reliable systems and that not all tests of change lead to improvement. It is

just as valuable to learn from what did not work as it is to learn from what

did work. You can adapt your change ideas to suit your area.

• Map out and prioritise what other changes need to take place within your

areas and devise a plan to get started. A great tool for this is the Model for

Improvement, it acts as a compass to identify your starting baseline point

and guide you in the right direction for your improvement ideas.

Based on the 5 key themes, teams were asked to conduct PDSA cycles to

address the issues that fall within these categories. We have picked out the

proposed change ideas based on current evidence and listed them in the table

below (table 1.0).

The Model for Improvement provides the foundation to any tests of change

Theme Change

Environment • Visual aids

• Social distancing

Hygiene and cleanliness • Making clean visible

• High touch Cleaning rota

PPE • Checklists

• C19 Champions / Role Allocation

Health and Safety • Room Capacity risk assessments

Visiting • Visitor ID Badges

Table 1.0

NCA Nosocomial Infections Collaborative

Change Package

Theme 1: Environment

Visual Aids WHY: This is arguably one of the most essential changes we can make. Ensuring our

surroundings give off constant reminders of what is acceptable and what is not can

reinforce the IPC guidance and impact the behaviours of ourselves, our colleagues as

well as patients and visitors.

WHO: Every team, clinical and non—clinical, should have the appropriate signage,

informative posters and guidance displayed upon entrance and exit to and from their

areas, within break rooms and bathrooms

WHAT: The aim is to ensure every member of staff, patient or visitor is aware of the level

of IPC standard that is expected of them within said area.

WHERE: All areas must reflect the IPC standards. Clinical and non-clinical settings,

including break rooms, kitchens, bathrooms and offices.

Does your environment, both working and off duty, reflect the correct information and

guidance? Do the surroundings of the estate enable you to minimise risk of transmission

and comply with IPC guidelines?

Examples of posters

Social Distancing WHY: This is a key change that has been advised not only within the NCA, but the NHS

as a whole, nationally and even globally as a safety precaution to reduce risk of

transmission from one individual to another.

WHO: Every single staff member regardless of role, should be socially distanced from

their colleagues and patients and visitors where possible*. Visitors and patients need to

remain socially distanced at all times i.e. when in outpatient waiting rooms, corridors etc.

*it is understood that clinical staff cannot socially distance themselves from their

colleagues or patients in a setting where care and treatment is being delivered.

This is mitigated by wearing adequate levels of PPE.

WHAT: The aim is to ensure we are following national guidance and distance 2 metres

apart where possible to prevent unnecessary risk of transmission as we are aware of the

science behind this virus being airborne; this distancing can help us to reduce the rates

of nosocomial infection.

WHERE: Every environment that is not restricted by delivery of care should have socially

distanced forcing functions in place. Be this the removal of chairs, or reducing the

number of people working in an office by removing computers. This is also to be

practiced in areas of down time such as kitchens, break rooms and includes the

outdoors.

Case Study

Independent Living Services

Salford Royal Foundation

The Independent Learning Services team at SRFT explored how

they could make their environments safer and IPC compliant. They

put measures in place to reduce the use of offices by a number of

different teams from different organisations. They identified ‘hot’ and

‘cold areas’ all around the building and displayed the appropriate

signs and posters informing of IPC guidelines. The ILS team also

created one way systems in their building to try and control the

influx of traffic coming into and out of the building which reduces the

number of people building up or gathering in any one area

Theme 1: Environment

Theme 2: Hygiene and Cleanliness

Making clean visible – ‘I’M CLEAN’ stickers WHY: This change idea allows all staff members, patients and visitors to know what date

and time the items they come to use have been cleaned. This is important as we are

aware from the science again, that there is a risk of transmission from surfaces.

WHO: Every staff member is responsible for the cleanliness of their areas, equipment

and work surfaces.

WHAT: The aim is to reduce transmission from contaminated, unclean surfaces and

make clean visible.

WHERE: All areas clinical and non-clinical.

HOW: Stickers are available from procurement as a normal stock purchase item.

High touch cleaning Rotas WHY: This change idea is an additional cleaning rota on top of the regular day to day

cleaning which takes place already. This adds a further layer of assurance that high

standards of hygiene and cleanliness are reached in compliance with IPC guidance and

reduce risk of transmission from unclean surfaces and equipment.

WHO: Each team clinical and non clinical is able to devise a rota to share and allocate

between their colleagues.

WHAT: The aim is to reduce transmission from contaminated and unclean surfaces.

WHERE: All areas clinical and non-clinical.

HOW: Rotas can be devised within each team based on their individual schedules.

Teams may choose set times in the day to carry out this cleaning i.e. setting alarms,

ringing bells (see case study).

Case Study

Outpatients Department

Rochdale and Bury Care Organisation

The Outpatient Department at BARCO aimed to ‘make clean

visible’ for ensuring patients and users were aware and at ease

knowing when cleaning had last taken place in the department.

The team would update a notice board with the date and time of

when high touch cleaning was carried out. Waiting area chairs

were cleaned regularly in between clinics using the cleaning

equipment they have been provided with. This is an additional

layer of cleaning as the Domestics team had assured the OPD of

their evening cleaning, however the day time and in between

clinic cleaning was an extra step the team had to embed.

Theme 2: Hygiene and Cleanliness

Case Study

Ward B3 Salford Care Organisation

• Ward B3 is a Comprehensive stroke unit with high turnover of

admission and discharge with multiple investigations. For this reason, there are a lot of staff who access this ward. This led to increased risk of COVID transmission via contact with high touch areas.

• During COVID-19 the senior management team on HASU decided to incorporate cleaning high touch areas into our daily ward cleaning .

• They picked particular times to cover both day/night for the clean to take place – 10:15, 14:15, 18:15 and 22:15. All staff were made aware and was discussed at their safety huddles.

• On the day of roll out, they decided to get everybody's attention, they would ring a bell to alert everyone that it was ‘time to clean’.

“We had a good response to the cleaning especially from nurses/care support workers and the therapy team. It was harder to get the medical team involved but after a few days they eventually came on board and got involved”. • The team have decided to continue with this and aim to make this

the new normal so that it continues post COVID-19 • They will audit using a sign in sheet which the ward coordinator

will complete each shift • They next plan to engage B4 in preparation for the merge of the 2

wards and include SRU to aim for a standardised approach across stroke services

Theme 2: Hygiene and Cleanliness

Theme 3: Personal Protective Equipment (PPE)

Checklists and C19 Champions/Role Allocation WHY: Personal Protective Equipment (PPE) is absolutely essential to protect all those on

site from infectious agents and reduce the rate of transmission by minimising the risk of

spread.

Checklists are a useful tool for ensuring that the right PPE is used on each area and for

each task.

To allocate a role on a rotational basis within the team, allows each individual to be

educated on the IPC guidelines as they monitor their colleagues against PPE

compliance.

It should be emphasised that there is a component of psychological safety linked to

challenging the use of PPE; this should be addressed as part of this change and

supported by the leadership team. Some teams have resorted to scripted challenges and

slogans (“It’s cool to call out”).

WHO: Each staff member within the team is responsible for complying with PPE and

challenging colleagues who are not compliant.

WHAT: The aim is to reduce transmission by ensuring all staff members are compliant

with the adequate levels of PPE that is dictated by the environment they find themselves

in at any given moment.

WHERE: All areas clinical and non-clinical. Indoors and outdoors.

HOW: All PPE is provided by the Trust and a checklist can be devised internally based

on the area you are. Guidance can be found on the intranet as it is consistently changing

and updated.

Rochdale Care Organisation

Case Study

Rochdale Care Organisation

Rochdale Care Organisation have been actively involved in the PPE

Test of change by allocating roles as ‘C19 Champions’. These roles

are responsible for using checklists to monitor themselves and their

colleagues against the compliance of adhering to the correct levels

of PPE in their respective environment.

Theme 3: Personal Protective

Equipment (PPE)

Theme 3: Personal Protective

Equipment (PPE)

Case Study

Bury Care Organisation

Critical Care

The Critical Care team at Bury Care Organisation have been involved in a

test of change exploring the PPE compliance theme. It was highlighted to

them that it was not always clear as to which PPE precautions staff should

be using.

A plan was devised to compile a poster highlighting what PPE should be

worn and when. These were placed in visible areas within the unit.

A three step guidance was given on the poster along with a list of all AGP’s

(aerosol generated procedures) as follows:

1. On entering the unit please don a blue surgical face mask, This

should be worn around the nursing station and away from the patient

area. All staff entering the unit to have temperature checks

completed.

2. An FFP 3 mask, visor goggles, apron and gloves was to be worn

within 2 metres of the patient.

3. For AGPs and when repositioning a patient a FFP 3 mask, visor,

goggles and waterproof long sleeve gown / Hazmat suit and gloves

must be worn.

During the course of test of change, it was highlighted that it was becoming

too difficult to assess two metres from each patient – so the decision made

was that Full PPE as stated would be worn within the curtain track of the

bed area, which was greater than two metres.

Audits compiled during the test of change highlighted that the changes had

worked and that staff were compliant with the correct PPE.

Theme 4: Health and Safety

Room Capacity risk assessment WHY: Room capacity is a key risk assessment which enables staff members to know

how many people can safely be in specific rooms at a given time. This leads to socially

distanced surroundings and enables a safe working environment by minimising the risk of

transmission.

WHO: Each staff member is responsible for adhering to any signs highlighting the

maximum capacity of a room.

WHAT: The aim is to limit the number of people gathering within a confined space which

in turn reduces the risk of potentially catching an airborne virus.

WHERE: All areas that allow a restriction of numbers i.e. offices, break rooms, kitchens

etc.

HOW: Estates teams are risk assessing each room on site to highlight how many people

are safe to be in each room.

Case Study Salford Care Organisation Critical Care Unit On Salford Royal’s Critical Care Unit they have implemented from Estates and Facilities the room capacity risk assessment signs which are clearly visible outside each applicable room. This is a visual reminder to all that the room has been assessed and that no more than the number displayed must occupy it.

Theme 5: Visiting

Visitor ID Badges WHY: Visiting in general has its restrictions, however, where there are visitors allowed it

is vital that they are seen to be adhering to PPE and IPC guidelines and challenged

appropriately when they are not. This will prevent a spread from visitor to the sick patient,

the staff members and also from going back out into the community when they leave for

home.

Clinical staff members and students, visiting other wards and areas, must also be able to

demonstrated in the form of an ID Badge who they are and have the relevant adequate

levels of PPE for the area they are to enter.

WHO: Each staff member is responsible for adhering to the correct levels of PPE and

having an ID badge to present who they are. Visitors in the form of friends and relatives

have a responsibility to follow all guidelines and it is staff members who have the right

and the responsibility to challenge when the guidance is not being followed correctly.

WHAT: The aim is to protect and reduce transmission for all visitors entering a ward,

patients on the ward and the staff members.

WHERE: All areas

HOW: Ensuring the entrances are stocked with adequate PPE and is available to all

those visiting the ward. ID Badge allocation and checking.

Case Study

Oldham Care Organisation

Ward F9 at Oldham Care Organisation conducted a daily audit for visitors.

They set up a visitor log book for visitors to sign in and sign out of. The nurse

in charge was tasked with ensuring the entrance was fully equipped with

adequate levels of PPE. A poster was also displayed at the entrance flagging

to visitors what is expected of them i.e. wash hands and what PPE to wear.

They would regularly check the soap, hand gel and hand towel dispensers

were working to prevent visitors being unable to use this function. There

were constant reminders of the importance of PPE during safety huddles and

via email communications to reinforce the message. Ward F9 team also

introduce a closed bay sign to ensure visiting MDT members were flagged

and aware of isolating patients.

As they conducted their audit, they found 90% compliance. As they awaited a

face mask dispenser, in the interim, face masks placed at the entrance would

go missing. The intercom for the door would work to liaise with the visitors,

but the door release would not. These are a couple of challenges they found

with their changes. The isolation signage was approved by the IPC team and

the constant PPE checks by the nurse in charge proved to be a useful and

necessary task. The Visitor badges were widely accepted by all visiting the

ward and demonstrating reasons for being there.

Theme 5: Visitor ID Badges

Thank you We wanted to say a massive thank you to all of the collaborative teams, Care Organisation steering groups and Expert Faculty members who have enabled to produce this Change

Package. We are so grateful for you efforts and inspiration as we work on this collaborative. Contact Details You can contact the Quality Improvement Team for any further information or support regarding the Nosocomial COVID 19 Infection collaborative. We are available by email on: Rui Maricato, Quality Improvement Lead Rui.Maricato@pat.nhs.uk Zainab Mogra, Quality Improvement Project Manager Zainab.mogra@srft.nhs.uk Laura Hammond, Quality Improvement Project Manager Laura.hammond@srft.nhs.uk

Please always refer to the intranet for IPC guidance as it is consistently changing and being updated.

Rochdale Care Organisation

Tudor Court Unit

Floyd Unit

Outpatients Department

Theatres

Day Surgery Unit

Wolstenholme Unit

Volunteer services

Integrated Therapy Services

Urgent Care

Oasis Unit

ENT Max Fax

IV Therapy

Rochdale Community teams

Salford Care Organisation

Audiology

CNRT

Independent Living Services

Acute Neurology Unit

Care home Medical Practice

EAU

Ward L2

Ward L3

Ward L4

Ward L5

Ward L6

Ward M2

Community Dental

Orthopaedics

IV Team

Podiatry

Perioperative Care

Haematology

Dermatology

Ward M3

Palliative Care

Ward H7

Ward H4

The Limes

Pendleton Unit

Volunteer Services

Bury Care Organisation

Ward 18 Discharge Lounge

Ward 21

Theatres team

AMU

Critical Care

Ward 12 Day Surgery Unit

NMT

Bury Community teams

Volunteer services

Ward 1

Ward 2

Community Physiotherapy

Emergency Department

Oldham Care Organisation

Ward F9

Volunteer Services

AMU

Critical Care

Estates team

Participating Teams