Early learning from hospital-acquired COVID-19 patient safety investigations published

29th March 2023

NHS Wales has published a new report detailing the good progress being made to investigate and learn from hospital-acquired COVID-19 in Wales.

Established in April 2022, the National Nosocomial COVID-19 Programme is supporting NHS Wales organisations to carry out a review of nosocomial (hospital acquired) COVID-19 patient safety incidents that occurred between March 2020 and April 2022. The programme has prioritised the investigation of the most complex cases, with an aim to provide as many answers as possible for service users, families, carers and staff impacted by nosocomial COVID-19. The programme also aims to maximise learning opportunities across NHS Wales, to drive quality and safety improvements.

Due to the scale of the pandemic, despite being in a healthcare setting, patients in hospital and other in-patient settings faced an increased risk of hospital acquired COVID-19.

In its first year, the programme has supported NHS Wales organisations to assess and investigate over 5,000 cases of nosocomial COVID-19, where they meet the definition of a patient safety incident and is on track to have successfully investigated all cases of hospital-acquired COVID-19 by March 2024.

Findings in the report include;

The value of bereavement support and care-after-death services have for people experiencing grief and signposting to support at the earliest opportunity.
The benefits of a single point of contact and support for people navigating the concerns process.
The impact of visiting restrictions and visiting considerations should continue to be carefully balanced with risk.
Inequities in the concerns process for people who receive healthcare via independent providers.
Inconsistent approaches to the management and reporting of health care acquired infections across Wales.
The need for improved application and improvement of DNACPR (Do Not Attempt Cardio-Pulmonary Resuscitation.
The need for improvement in how Infection prevention and control (IP&C) guidance, is reviewed and communicated to staff.
Better communication with families and carers around ward movements.

A spokesperson for the National Nosocomial COVID-19 Programme, said: “NHS Wales rapidly adapted and altered its operational focus to minimise the harmful impact of COVID-19 in response to the pandemic and staff worked tirelessly through the most challenging period in its history. Despite best efforts, COVID-19 severely disrupted healthcare activity. Developing our understanding about nosocomial COVID-19 and people’s experiences is allowing us to identify areas for improvement and share learning to futureproof infection prevention and control measures. A significant amount of work still lies ahead over the second year of the programme and it is important that this programme offers transparent insights that will continue to lead to meaningful change.”

The Deputy Chief Medical Officer for Wales, Chris Jones said: “The National Nosocomial COVID-19 Programme and Welsh Government extend sincere condolences to those who lost loved ones after acquiring COVID-19 in healthcare settings. COVID-19 was a new and unpredictable infection which made it extremely difficult to manage and the impact of the COVID-19 pandemic on service users, families, carers, NHS staff and the wider public cannot be underestimated. I want to thank NHS colleagues and everyone who has engaged with the programme so far. These findings provide an extremely valuable national insights that will improve the quality and safety of healthcare services in Wales.”

The National Nosocomial COVID-19 Programme will be working with NHS Wales organisations to further identify, share and embed learning in the second year of the programme. Patient safety incidents of nosocomial (hospital acquired) COVID-19 that took place after April 2022 will continue to be investigated by NHS Wales organisations as part of their duties.