This week’s blog is by Dr Evonne T Curran (@EvonneTCurran).
Managing an outbreak starts with data, (e.g., surveillance data: a rise in the number of x, clinical data: someone calls saying “we have 4 people with diarrhoea and vomiting”, or laboratory staff identify alert organisms). You then decide whether you can exclude an outbreak. If you can’t exclude – you immediately act. The first act is to put in place everything needed for Patient, Healthcare Worker (HCW) and Visitor (PHV) safety. For example, you might close a bay or a ward (norovirus), stop showers (Legionnaires disease), or isolate cases (infected wounds). You don’t wait for a committee – this is ‘first aid’ for PHV safety. Then you investigate. The investigations may identify the need for more control measures. Control measure implementation assurance checks are made, and the epidemic curve is monitored. This is the daily graph of new cases. If all necessary control measures are being followed, after a lag for the incubation period, the epidemic curve will fall as no new people are being exposed. If cases continue to arise, there must be an omission of one or more control measures indicating further investigations and control measures are needed. This process continues until the outbreak ceases.
The epi curve for the % hospital acquired covid in England can be seen in Figure 1 (source Dr. T. Lawton)
I am an outsider to the decision-making on this outbreak at both hospital and national level and thus vulnerable to errors of heuristics. However, this curve shows a protracted outbreak with an exponential rise at the end indicating the situation is currently out of control.
I have often heard ‘when it goes up in the community; it goes up in the hospital’. This is a statement of what is happening. It’s not a statement about whether there are ongoing efforts to investigate and effect a change. So, for PHV safety the statement should be ‘when it goes up in the community, we are prepared for and act differently, to prevent transmission and provide PHV safety. If you stop looking for a rationale for ‘its going up’ when control has not been achieved, transmission will increase with each wave. And, if some of the effective precautions in place are stopped, there will be more transmission until the number of cases inhibits the ability to gain any control, e.g., the Lawton epi curve.
If you fail to gain control in an outbreak, investigations should identify whether there is:
- A failure of the process – the precautions are wrong or insufficient, and or
- A failure to follow the process due to:
- insufficient resources to enable the process to be followed (Opportunity)
- insufficient training / knowledge as to how to follow the process (Competency)
- a lack of commitment to following the process (Motivation)
(See the COM-B model).
Recently, Minutes of the IPC Cell’s decision regarding RPE for HCWs were released. These show that some of the decision makers believed there was a failure to follow the process, e.g., one recommended a ‘need to emphasise other key IPC measures including enhanced cleaning’. However, just because you find something is not perfect – it does not mean you found the reason for a failure to control the outbreak. Finding something and deciding it’s the problem, is known as Satisfaction of Search bias. The decision-makers’ error was failing to realise it was a failure of process – an airborne pandemic needing airborne precautions. The decision-making here left HCWs inadequately protected. That was December 2020, and we are no further forward, or are we…
This preprint presents hope, puzzlement, and possible procrastination. It’s a study of air in patients’ rooms which found SARS-CoV-2 in the absence of AGPs. The hope is from the authors stating that “their data supports the use of FFP2/3 medical masks for HCWs caring for COVID-19 patients… …in line with HSE guidelines15.” The puzzlement is that the reference ‘15’ is to the withdrawn UKHSA pandemic guidance – which omitted such a recommendation. The procrastination is that the data collection finished 12 months ago, and it’s only now a preprint. Let’s hope the decision-makers have already been alerted to this additional firm evidence for HCWs needing RPE.
So, the Lawton epi curve of the % of new hospital acquired COVID appears out of control. Explanations could include failures of the process, i.e., stopping effective precautions (some) testing/masking, and omitting airborne precautions for an airborne pandemic. Further, evidence has emerged to support HCWs needing RPE. Of note, IPCTs are not experts in indoor ventilation. If we are ever to get back in control, decision makers need the correct the process and use airborne precautions for this airborne pandemic – by including ventilation experts.
Like Oliver with his begging bowl, we must all keep asking the decision–makers if HCWs can get RPE now?