Sky high hospital covid infections underline risk of IPC relaxation

Trust chiefs will welcome the latest relaxation in infection control rules, but the spread of covid within hospital settings remains a significant risk.

New updated guidance from national bodies represents another major scaling back in infection control measures in hospitals.

The changes will see a relaxation in isolation requirements for inpatients who either test positive for covid-19, or are identified as close contacts of covid cases.

Intriguingly, NHS England has now also relaxed its own infection control advice to hospitals over and above the UK-wide guidance released last week.

A letter to trust chiefs recommended the “[return] of pre-pandemic physical distancing in all areas” – whereas the guidance published by the UK Health Security Agency still recommends one metre distancing in healthcare settings, rising to two metres in areas where suspected or confirmed respiratory infections are being cared for.

The push for pre-pandemic rules

NHS managers have told Recovery Watch they are keen to get back to pre-pandemic infection control precautions as soon as possible. They see a changing in the balance of risk between preventing infections within hospital settings, and the constraints on capacity this brings.

One trust chief executive said: “We all need to get to pre-covid infection prevention and control as soon as possible. There will be nervousness in some quarters to do this, but we need to recognise the risks of not doing this now, and that the disease is different and we have a largely vaccinated population.”

Meanwhile, Newcastle upon Tyne Hospitals Foundation Trust, in its public board papers in March, outlined its “ambition to return to pre-covid principles as soon as possible”, and that it is working with local trusts to achieve this. Although the trust said it does not have a set timeline for this.

But it shows how some trusts and systems are becoming more willing to see where infection control guidance can be relaxed, sometimes ahead of national policy changes.

Before the guidance was announced last week, James Thomas, medical director of the West Yorkshire Integrated Care Board, told me their system was developing principles to help trusts “look at where the flexibility is with the infection control guidance”, as the current pressures on the system meant they “[didn’t] want to wait” for the national guidance to be updated.

Balance of risks

While NHS England sees the latest changes to the national guidance as “a step in the transition back to pre-pandemic IPC measures”, there are still remaining measures which have the potential to significantly impact patient flow.

Among these are the recommendations that patients with respiratory symptoms should still be isolated from other patients in the hospital, in single rooms where possible, and patients with confirmed respiratory infections should be cohorted with patients confirmed to have the same infections.

However, any further relaxations in infection control rules carry risks of increasing the number of people who catch covid in hospital after being admitted for other illnesses, especially considering the increased transmissibility of omicron and the numbers of covid patients at the moment.

These are risks which senior NHS leaders are aware of, but are weighing this against other harms for patients.

In a letter to local leaders earlier this month, several NHSE regional directorates acknowledged that relaxing IPC rules would lead to increased nosocomial transmission.

But they added: “This risk needs to be weighed against other potential harms to patients on [urgent care] pathways and consequence on congestion in part, due to those IPC measures…

“It is therefore entirely reasonable for local organisations to complete their own risk assessments and tailor their processes to their own unique organisational requirements during the next phase of the pandemic, rebalancing this risk across the whole pathway with support from the regional team where required.”

In the week to 14 April, 22 per cent of covid cases in hospital were detected eight days or more after a patient was admitted – meeting the NHSE definition of “probable” hospital acquired, or “nosocomial” infection. This is one of the highest proportions of “probable” hospital-caught covid throughout the entire pandemic.

The percentages have been far higher at some individual trusts.

The big question arising from this is what scale of patient harm are these rates of hospital-caught cases causing?

Covid can of course be either the primary or “incidental” reason why patients are in hospital – though either way confirmed cases will still have to be isolated.

We know that hospital-caught covid infections have already caused thousands of deaths. Research by HSJ before the omicron wave found that, across 32 acute trusts, a total of 3,223 covid hospital deaths between April 2020 and March 2021 were at least “probable” nosocomial cases – and of those, 2,776 had covid listed as an “immediate cause” or contributory factor on their death certificates.

The Academy of Medical Royal Colleges has recognised the need to relax infection control measures. However, Professor Dame Helen Stokes-Lampard, chair of the academy, has warned of “fall[ing] into the trap of reverting to pre-pandemic standards, which in many areas were just not good enough”.

Risks from hospital-acquired covid need to be balanced against the harm to patients happening right now from patient flow and constraints on beds in hospitals. Ambulance services have warned that delays to response times and handovers are costing lives, while bodies such as the Royal College of Emergency Medicine has warned about thousands of patient deaths driven by long accident and emergency waits.

As the drive for pre-pandemic rules continues, NHS chiefs face a tough balancing act.

The email version of this newsletter mistakenly contained a draft version. The version published here is the final edited version. Apologies for any confusion.