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NHS Wales shares learning from healthcare-acquired COVID-19 patient safety reviews

Reviews into suspected patient safety incidents of healthcare-acquired (nosocomial) COVID-19 during the onset of the pandemic have concluded their initial investigation, following a national programme of work to coordinate investigations of the unusually high number of incidents recorded.

The reviews aimed to provide as many answers as possible to patients, families and carers, as well as identifying opportunities for learning and improvement to enhance the quality and safety of care in NHS Wales.  

Jennifer Winslade, Executive Director of Nursing at Aneurin Bevan University Health Board, said: “On behalf of NHS Wales, I would like to take this opportunity to offer my sincere condolences to all those who lost loved ones after acquiring COVID-19 in healthcare settings – the impact cannot be underestimated.

“Additionally, I’d like to extend my gratitude to everyone who has engaged in the review process, recognising how difficult this has been. Developing our understanding about nosocomial COVID-19 and people’s experiences will have a lasting impact on improving the quality of healthcare services we provide in Wales.

“The learning that has been identified - and in some areas already implemented - remains a priority for all NHS organisations, as part of our continued commitments to providing high quality, safe and effective care.”

Healthcare acquired infections are sometimes considered a patient safety incident, depending on how and when the infection was acquired. Between March 2020 and April 2022, there were 18,360 suspected cases of healthcare-acquired COVID-19 identified in Wales. Due to the scale of the pandemic, despite being in a healthcare setting, patients in hospitals and other in-patient settings faced an increased risk of hospital-acquired COVID-19.

In April 2022, the National Nosocomial COVID-19 Programme was established as a collective membership of health boards and trusts in Wales, supported by the NHS Wales Executive. The programme was designed to support NHS Wales organisations to adopt the National Nosocomial investigation framework as consistently as possible to the investigation process, ensuring investigations were done once and done well. The programme also enabled across Health Board learning, promotion of good practice and the identification of system wide opportunities to enhance the quality of care Nationally.

A spokesperson for the NHS Wales Executive, added: “The National Nosocomial COVID-19 Programme has worked in collaboration with NHS organisations to identify and maximise opportunities for learning and improvement that are focused on enhancing quality and safety of care in Wales. Whilst the programme has concluded in its current format, we would like to assure patients and their families that we remain committed to continuing to embed learning opportunities and good practice across Wales.”

Following the review process, NHS Wales organisations have identified a number of national learning themes which have been summarised in the National Nosocomial COVID-19 Programme End of Programme Learning Report, and include;

  • The value of bereavement support and care-after-death services for people experiencing grief.
  • The benefits of support for people navigating the concerns process.
  • The impact of visiting restrictions, and consideration of balancing risk with the value of visiting.
  • Opportunities for improvement in communication with families and carers when visiting is restricted.
  • 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.
  • Improving experience of the application of DNACPR (Do Not Attempt Cardio-Pulmonary Resuscitation) through better understanding and communication.
  • Developing clinical record keeping standards and the value in digital solutions.
  • The continuing need to invest in staffing and resource to build in resilience.
  • The need for improvement in how infection prevention and control (IP&C) guidance, is reviewed and communicated to NHS Wales staff.
  • The strong interdependences between policies and processes with outbreak management.
  • Impact of discharge delays on health and care.
  • Ageing healthcare settings pose challenges in relation to infection prevention and control, in addition to patient experience.

Health boards, trusts and the NHS Wales Executive have ongoing plans in place to continue to embed learning from investigations to improve the quality of future healthcare provision and people’s experiences.

Suspected healthcare-acquired COVID-19 patient safety incidents of that took place after April 2022 will continue to be investigated by NHS Wales organisations as part of their duties.