3.7 COVID-19 Investigations

3.7.1 IPC practice and compliance (including AGPs)

3.7.2 Review of visiting

3.7.3 Testing during an outbreak

3.7.4 Whole Genome Sequencing

3.7.5 Contact tracing

3.7.6 Ventilation considerations

3.7.7 Bed spacing

3.7.8 Review of physical distancing

3.7.11 COVID-19 messaging

 

3.7.1 IPC practice and compliance (including AGPs)

Compliance with IPC practice on the ward should be reviewed to determine any practice which may have contributed towards onward transmission.  Previous hand hygiene audits and any audits of staff practice and the environment undertaken should be reviewed to establish any education gaps which are required to be addressed. 

Where AGPs are undertaken on the ward, IPCTs should check to ensure staff are wearing the appropriate PPE and the appropriate fallow times are being observed prior to other patients using the room in which the AGP was undertaken.  The IMT may choose to repeat audits as part of the investigation. 

Ensure that staff on the ward are compliant with COVID-19 IPC guidance contained within the National Infection Prevention and Control Manual (NIPCM) and advice contained within Appendix 21 COVID-19 pandemic controls.

Ensure that patients are wearing face masks appropriately as per the NIPCM and Scottish Government Extended use of face masks guidance.

3.7.2 Review of visiting

When investigating a COVID-19 cluster, ascertain from ward staff if there has been any non-compliance with visiting rules for example, visitors presenting symptomatic or declining to wear face coverings.  Consider what, if any, measures need to be introduced to mitigate any risks identified.

Further hospital visiting guidance can be found here: Coronavirus (COVID-19): hospital visiting

3.7.3 Testing during an outbreak

Contact tracing and asymptomatic testing in an outbreak should be based on local outbreak management and on the advice of the local Infection Control Doctor.

Any patient who develops symptoms should be tested immediately using laboratory based PCR. Rapid Diagnostic Test (PCR or non-PCR based) or LFD may be used in addition to laboratory based PCR test to support rapid patient placement decisions whilst PCR results are awaited. If LFD (or other non-PCR based test) is positive at any point, a follow up PCR test is required and TBPs must commence. Further detail of current testing requirements is provided in the Hospital Testing table.

All staff who are symptomatic of COVID-19 must be tested and excluded from work and follow advice outlined in Annex B of the Directorate Letter of 14th September 2022 (DL 2022 (32)).

3.7.4 Whole Genome Sequencing

Public Health Scotland offer a whole genome sequencing service to support outbreak investigations and address important clinical and epidemiological questions.

3.7.5 Contact tracing

Contact tracing and asymptomatic testing in an outbreak should be based on local outbreak management and on the advice of the local Infection Control Doctor.

In the event of a decision to undertake contact tracing, anyone who has been in the same room/area with the confirmed case in the 48 hours prior to symptom onset (or 48 hours prior to positive test if asymptomatic) until the point when the confirmed case was appropriately isolated/cohorted/discharged should be considered as a potential healthcare setting contact. 

Assessing patient contacts

Typically, any patients in the same bed bay as a confirmed case should be considered a contact.  For larger open bedded areas such as ITUs or nightingale wards. IMTs should agree which patients should be classed as contacts, as a minimum this should include patients on either side of the confirmed case and an assessment of the whole area/ward must take account of the patient group and circumstances surrounding potential exposures. Local risk assessment should be undertaken taking into consideration the Hierarchy of Controls

Any asymptomatic contacts identified as part of local outbreak management should be observed for symptom onset. Symptom vigilance is essential for all patients, irrespective of whether a contact.

Depending on considerations above and any other potential contributing transmission risks, the IMT may decide that all the patients and staff in the large open bedded area should be considered contacts.

For cases who have been in a single side room for the exposure period, only staff and patients who have entered the room of the confirmed case should be considered potential contacts.  If the confirmed case has entered the room of any other patients or shared communal spaces with others, these should also be considered as potential contacts.

IMTs must also consider any patient transfers to other areas of the hospital within the exposure period e.g., radiology, other wards and consider any potential contacts in these areas.

Staff contact tracing in an outbreak situation should be based on local outbreak management and on the advice of the local Infection Control Doctor.

Contact tracing visitors

There is no expectation that contact tracing amongst visitors will be undertaken routinely.

3.7.6 Ventilation considerations

Learning from the COVID-19 pandemic to date has highlighted the risk of COVID-19 transmission associated with closed environments that have poor ventilation.  It is important to consider best practice on ventilation.  See Appendix 20 - Hierarchy of controls for more information.

The impact of the ventilation and any contribution it may have had to the onward transmission of COVID-19 should be noted for future learning and wherever possible mitigated. 

The following should be considered when deciding if the ventilation may have been a contributing factor in the outbreak;

3.7.7 Bed spacing

Bed spacing in the affected ward should be reviewed to ensure that it is adequate to prevent onward transmission of Healthcare Associated Infections (HAIs) and to ensure that mitigation measures implemented to support physical distancing (if necessary) are adequate.

See Chapter 4 of the NIPCM for more detail

3.7.8 COVID-19 messaging

The IMT should consider if the COVID-19 messaging in the ward for both staff, patients and visitors is adequate.  COVID-19 messaging should be in place to promote;

Every opportunity to promote this messaging should be considered.