This blog is based upon a short lecture given by Simon Mardel OBE (1,2). He is an emergency physician who has extensive experience in humanitarian work. He has worked in many infectious disease outbreaks around the world and has shared his thoughts on where we are at the moment with regard to infection control measures(3) and why we must act now to prevent a disaster for our department, patients and staff. Especially for our staff.
This blog is based on my conversations with Simon via email and his video below. You should also read the editorial and paper in the month’s BMJ that identifies that 1 in 6 admissions to hospital in the UK were amongst health care workers and their families (5,6).
Please view the short video below and share widely.
In the UK we are well into the second wave/surge/tsunami of COVID-19 cases. In the North West of England we are very close to the same numbers of patients in hospital as we were at the height of the pandemic in April, and with far fewer population control measures in place to reduce transmission. It seems inevitable that the second wave will be worse than the first.
Crowding is a catalyst
In addition, there is increasing ‘normal’ activity both amongst emergency department attendances and also for elective surgery which continues as we try to clear the backlog of urgent cases delayed during 2020. Pressure exists across the system and although St Emlyn’s focuses on emergency care we are acutely aware of the harms taking place through the lack of access to other speciality work. The bottom line is that our hospitals are very busy, our emergency departments are once again crowded, and patient waits for admission are increasing.
Crowding makes it harder to deliver effective infection control and significantly risks nosocomial infection. This is especially difficult in the ED when the infection status of patients is unknown. It is much harder to separate COVID-19 positive patients from those without the disease as we usually do not have the results of testing for several hours. In a crowded department undifferentiated patients mix together and risk infecting each other and staff members.
It is virtually impossible to deliver effective infection control measures in a crowded emergency department.
We should also recognise that 2020 has been incredibly tiring for staff. Working in PPE, in departments that have been hastily reconfigured to cope with COVID and non-COVID (maybe) streams is exhausting and it’s easy to become complacent.
At the beginning of the pandemic the transmissability and impact of COVID-19 were unknown and so adherence to IPC processes was clearly high, but they are tough. Many colleagues from across the country tell me that they see less compliance as time goes on and that is a real worry.
Over the last 7 days I have contacted colleagues in other large departments in the UK and they have all reported grave concerns of slippage in infection prevention and control (IPC) standards, and they all comment on how difficult it is to turn this around. We think a campaign is needed to get standards to the right level.
Colleague elsewhere summed it up in writing :
My experience of the first wave was staff panic and anxiety of the unknown which propelled ED staff to follow guidance and take advice.
This time round the panic has been replaced with complacency and I am really surprised at how IPC standards have fallen.
IPC compliance is awful at the moment. We are horribly crowded with patients
Simon talks about the 3 factors that combine to increase our exposure to the virus and thus to the nosocomial spread to staff and patients. In the ED our case load is increasing, we must deal with patients for longer periods of time such that a greater proportion of our patients are COVID positive and we are with them for longer. Crowding will inevitably lead to an increase in the viral load exposure to our staff.
Timing and delays
I was really interested to see how the delays associated with health care worker deaths lead to complacency. There is a considerable lag, probably 6-12 weeks between health care worker exposure and deaths. This lag means that we don’t always see the link between poor infection control and harm to our colleagues and patients. What we do now affects who lives and who dies in December/January. That seems a long time away.
Complacency and discipline
Complacency may impact IPC measures. Thus far most departments or hospitals have not been “burned” by the tragedies of colleague mortality, and colleagues report “fear” or “concern” in the first wave as drivers that enhanced IPC measures. Complacency carries an inherent problem as in every outbreak there is always a “pipleline delay” (serial interval or incubation period + clinical deterioration + lengthy ICU attempts at rescue therapies in the most severe cases) between appreciating the individual tragedies that follow nosocomial spread and subsequent implementation of IPC to the required 100%.
Complacency may be manifest amongst HCWs who have already had COVID-19 and who feel that they may not be able to catch and transmit the virus. However, their poor examples of behaviour together with the potential to transmit through fomites will undermine infection control measures.
We must also remember that all professions/tribes/groups must act as one, and yet the hierachies in hospitals do not encourage this. Differences in information cascades, governance, compliance and discipline between the various different groups combined with a reluctance to challenge those in different groups will again undermine compliance. We have to develop a system where everyone is able to challenge and support anyone.
Contamination is common in the ED.
The following video shows just how much contamination is possible during a procedure such as intubation in the ED. This emphasises the need for good infection control procedures and also means that everyone has to comply (irrespective of whether they have personally had the virus in the past).
Simon Mardel’s summary
- This is preventable if we have a campaign now
- PHE guidance on infection control is still grossly undervalued and misapplied but this is fixable.
- As a locum ED consultant I am witnessing high quality department(s), with highly motivated colleagues struggle to get IPC to the required standards.
- I have done a rapid poll of trusted colleagues in other emergency departments – both in, and some outside of the North West – who are uniformly describing a drop in standards, overcrowding and difficulty getting all staff to comply 24h a day with IPC guidance.
- I have clinical and WHO experience of working with these viruses including COVID-19, SARS, Ebola, Lassa, Marburg, and severe H5N1 going back as far as 1997. There is no doubt these ingredients in the second wave WILL summate to produce an unprecedented increase in health care acquired covid.
- If we wait until nosocomial amplification becomes apparent – we will have a weakened and demoralised workforce. Furthermore, access to health care for the full range of essential services such as earlier intervention in stroke and mycocardial infarction, cancer diagnosis, sepsis – will be hampered further by public fear, a weakened workforce or the late application of more stringent compensatory measures.
- Mortality form health care acquired infection will only be apparent at a very much later stage – especially in the patient and staff group who are candidates for intensive care – due to survivor bias in reporting.
Simon Mardel’s call to action
- We need to restore IPC compliance to the 100% needed. In the same way that theatre nurses and surgeons have always managed to “scrub” to the required level to prevent wound infections, COVID IPC measures need to become so routine that anyone would notice and comment on a colleague departing from the norm.
- This has to be achieved with respect for each other, as the Chair of the GMC says “be kind and look after each other”.
- BUT, we need to remind medical staff that GMC guidance also states that doctors should use PPE in line with the most up to date guidance issued by the four UK health departments. For consistent non-compliance due to a distrust of PHE guidance, this should be escalated to understand the problem, deliver appropriate reassurance, re-training and then re-evaluation.
- Nursing leads and authorities must help all their nursing staff to view COVID specific IPC practices as important and any other patient or safety issue. No matter how busy they are, or how acute someone’s needs are, safety measures remain critical, just as nursing colleagues are traditionally the outstanding advocates for patient safety when it comes to following the checking requirements for blood products, drugs or aseptic techniques.
- Target measures that keep reinforcing appropriate “belief” in the ever present threat from this virus. Protection of our vulnerable mucous membranes of eyes, nose and mouth. Constant hand hygiene that can protect us from self-contaminating or spreading the virus to objects and surfaces. Helping each other, nursing and claeaning colleagues to deliver enhanced cleaning and disinfection of equipment and work surfaces has a knock on effect in constantly reinforcing beliefs about where the virus may be present, and is reassuring to witness.
- Think big, share the problem at every level: To change practice on the scale and timeline needed will need a campaign at every level. It should also exploit outside professional bodies and inside hospital trusts the heads of organisations with their communication and cascade abilities.
- Timeline – act now – and use messaging that reinforces this urgency. My experience abroad with these viruses is do NOW what we will regret not doing in a few weeks time, and “in retrospect” those future actions will always have been obvious. These viruses are unforgiving and breaches in IPC + high viral burden in our patients together WILL cause nosocomial spread or even amplification.
- Our COVID group suggested I put a brief presentation last week into a short video: Please critique and share the video at the top of this email and use it to encourage change.
The St Emlyn’s summary
This is a really important contribution from Simon Mardel, a real expert in the management of infectious disease and in particular in the safe conduct of health care workers. It is chilling to heed his words that we will eventually get better at infection control, but that history tells us that we will pay an unacceptably high price if we leave adherence to the rules until we see our colleagues fall.
As individuals we cannot do this alone. Whilst we must all strive to personally maintain high standards of infection control it is vital that the systems, environments and workloads of the departments we work in also permit us to do this.
We can and must do all that we can to protect ourselves and those around us. Simon Mardel is happy for this blog, his comments and the video to be shared widely. We hope it helps.
- These people treated Sars, Ebola and swine flu: what is their advice on beating coronavirus? https://www.telegraph.co.uk/news/2020/03/08/treated-sars-ebola-swine-flu-need-know-coronavirus/
- The #COVID-19 bubble: St Emlyn’s https://www.stemlynsblog.org/the-covid19-bubble-st-emlyns/
- COVID-19: infection prevention and control (IPC) https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control
- Covid-19: risks to healthcare workers and their families https://www.bmj.com/content/371/bmj.m3944
- Risk of hospital admission with coronavirus disease 2019 in healthcare workers and their households: nationwide linkage cohort study https://www.bmj.com/content/371/bmj.m3582