- How many care home residents from a) Shropshire and b) Telford & Wrekin were admitted to hospital with suspected or confirmed Covid-19, and died in hospital with Covid-19 on their death certificates?”
We can confirm that we do have data on the number of patients who died in hospital who had tested positive for COVID-19 but we cannot, without reviewing every death certificate, confirm whether their death was due to COVID-19 i.e. they died from COVID-19 as distinct from dying with COVID-19.
We have good systems in place for managing patients with a positive test result either before or subsequent to admission to hospital but I’m sure you will appreciate that patients who die in hospital do so for a number of reasons and so having a positive COVID-19 test result and subsequent sadly passing away does not mean the same as having died from COVID-19.
In terms of mapping the data on patients who tested positive for COVID-19 and lived in a care home again this is possible, although better and more complete sources may be available from outside of an acute hospital and Public Health/Local authority partners may be better placed to provide this information.
For the Trust we do have nationally-defined admission fields which identify patients in care homes, with nursing and without nursing care, and so can extract this for you, providing the detail does not make the information patient identifiable. However unfortunately this information would still be incomplete as a further admission field exists within our systems that captures patients admitted from “normal place of residence” (which includes patients whose normal residence is owned by a local authority ie a care home). As care homes are the normal place of residence for patients this field is frequently used and so we would have to manually search within this to identify patients who normally reside in a care home, rather than a private dwelling.
The Information Team tried to do carry out this search for you by searching on the postcodes of all our known care homes. Unfortunately while this provided a filter of the patients, the postcode is not unique to a care home and so would need a further manual sort of the records to identify whether the patient’s address matches a care home or they happen to live in close proximity to a care home. Again extracting the information would not be able to state whether the patient died of COVID-19 or with COVID-19 but would be able to say they were COVID-19 positive at some time during their hospital stay.
The other source of information that we have explored is through our Incident Control Centre (ICC). All organisations were required to set-up an ICC as part of the national COVID-19 response. They receive data which is submitted to NHSE/I which is then included in a regular confidential daily Midlands Winter Pack report (28 slides/pages) which is shared across the Midlands Trusts, CCGs and Local Resilience Forums (multi-agency partnerships from local public services, including the emergency services, local authorities, the NHS, the Environment Agency and others known as Category 1 responders under the Civil Contingencies Act. They also work with other partners in the military and voluntary sector and are supported by Category 2 responders eg Highways Agency who have a responsibility to work with Category 1 Responders and share relevant information within the LRF).
The daily reports cover various items of information and modelling relating to A&E, Urgent & Emergency Care and COVID-19, which is used to review activity/workforce response etc. It includes COVID-19 bed occupancy (non/suspected 7 day averages), new inpatient Covid cases by age group, COVID-19 patients occupying general and acute beds in absolute and relative terms and direction of travel by Trust, forecasts of new cases based on estimates of doubling time/half-life using data from last 7 and 14 days, number of new admissions and inpatients diagnosed in past 24hr – 7 day average with trend analysis, critical care bed capacity and availability and escalation levels, daily inpatients death tested positive, nosocomial COVID-19 cases diagnosed 8+ days after admission. These are sent to Incident Control Centres at all NHS Trusts, CGs and LRFs who in turn disseminate and share to all relevant organisations/partners/individuals.
The information is also shared upwards through each of the regional NHSEI sources and this is reviewed at national level to help shape the guidance that is then issued back down through the NHS, CCGs and LRFs. It is also available on national publicly-available sites. However from the wide list of information that is reported, none is specific to the question you have asked.
However our Incident Control Centre (ICC) (set up in response to COVID-19) have been collecting data on ALL patients who were confirmed as COVID-19 positive before their death since March 2020. This was supplied to them manually through our bereavement service. They have records of all patients from March 2020 where the patient was confirmed as having COVID-19 at the time of death, although again it cannot be said that COVID-19 was the cause of death.
I’m sorry we can’t provide you with a straightforward answer to what appears a relatively simple question, but hope by providing you with this information you will understand the limitations of our information and the large amount of data that is shared.
Please let us know whether any of the limited information would could provide would be useful to you and we will happily provide subject to the normal considerations of patient confidentiality.
2. The CO-CIN reports for SAGE (eghttps://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/935139/dynamic-co-cin-report-sage-nervtag-all-cases-s0854-281011.pdf) suggest that nosocomial transmission of COVID-19 started to rise in October. Has the Trust collated data on cases of COVID-19 occurring up to 14 days after admission – if so what do the figures indicate, over time, about infection control?
This information on infections following admission is held by our Infection Prevention & Control Team (see chart below) and is shared across the Trust by IPC. There is also a system-wide Task & Finish Group which receives this information
Quarterly data is submitted to Trust Board which includes Covid classification and is also reported monthly to our Quality & Assurance Committee which reports through to Board through the monthly AAA report in public session.
Our lead IPC nurse has advised that it is really difficult to draw any conclusions from this chart – it is difficult to control an airborne virus which has a long incubation period, which is the pattern we are experiencing with COVID-19. We can’t always maintain a 2m distance within the patient environment on the wards. However there are clear “barrier” curtains around all beds which we introduced as a response to COVID-19, but it is difficult to evidence their efficacy. Ventilation on the wards also probably has a huge impact in controlling this virus. We have robust protocols for responding to outbreaks on a ward (outbreak is defined as two or more patients or staff contracting COVID-19 who work or are being cared for in the same clinical area
Our lead Consultant microbiologists have advised that airborne transmission, the long incubation period and asymptomatic infection make this a very difficult infection to control. Ideally we’d like patients to be in side rooms for several days post admission so they could be tested at least twice before putting them into the general wards. Obviously that’s impossible with our estate and the numbers of patients we were dealing with.
We have reduced transmission compared to the early days. What we do know is that not mixing contact bays hugely reduces the risk of contacts becoming positive. Testing regularly allows us to act quickly to isolate positive patients and reduce transmission, and the barriers seem to help. Increasing ventilation would definitely help. Staff adherence to PPE and social distancing is very important. A lot of this is not so obvious from the graph but is from looking at individual outbreaks.
However the biggest driver of cross infection in the hospital is how much it’s circulating in the community and how good overall immunity is. This affects how many patients are admitted incubating the virus but testing negative on admission. It’s a similar situation to norovirus.
More side rooms would probably have most effect. Failing that, more ventilation. But neither of these are easy fixes. We have put in readirooms and bioquell pods (isolation structures) which have helped. We could look at boosting eligible patients when they are admitted which might have some effect at a week though that may already be too late.
Omicron is going to be interesting. With its shorter incubation period, it will probably infect more patients before a post-admission test detects it. The attack rate in described outbreaks is high. But there may be less late transmission
3. How can a local authority be expected to learn lessons from the first wave of COVID-19 unless local intelligence provided by all active agencies is pooled?
4. Does the Trust consider that pooling of local intelligence including patterns of hospital admissions, discharges and inpatients deaths, relating for example to care home residents, at the height of the pandemic could have helped reduce further loss of life in the second wave to COVID-19.
In addition to the extensive network and data sharing outlined in the response to question 1 through NHS Trust, CCGs and Local Resilience Forums the local health and social care system very quickly set up processes for all organisations to work together to work very closely together. This included
- Robert Jones & Agnes Hunt
- Shropshire Community Trust
- Midland Partnership Foundation Trust
- Both CCGs
- Both Local Authorities
The SATH Microbiology lab was also involved in a lot of care home testing in the initial waves. This took the form of
- Silver meetings (now known as Covid Management Group)
- IPC ICS groups and
- Test and trace / testing groups.
So throughout the pandemic there have been multiagency meetings so there has been a recognition and awareness of where the system has stood across all elements.
The frequency of these meetings has varied through the different waves of Covid but all elements have been discussed, advised, informed and shared learning etc has happened.
The Trust also had its own Incident Control Centre that was manned and responded to and shared data as it came in from all sources, internal and external. As previously described in response to Q1 all organisations were required to set-up an ICC as part of the national COVID-19 response across NHS Trusts, CCGs and Local Resilience Forums (LRFs). The LRFs cover multi-agency partnerships across local public services, including the emergency services, local authorities, the NHS, the Environment Agency and others known as Category 1 responders under the Civil Contingencies Act. They also work with other partners in the military and voluntary sector and are supported by Category 2 responders eg Highways Agency who have a responsibility to work with Category 1 Responders and share relevant information within the LRF). So there is a clear line of information-sharing across partners to maximise the lessons learned. Information is is also reviewed and aggregated at national level to inform guidance.
Locally there is also system-wide IPC Task & Finish Group which receives information from across the system and which our lead microbiologist attends to advise and share information. The lead Microbiologist has advise that she believes that everything was done to ensure that all data was shared to ensure patient safety as much as possible whilst responding to an ever-evolving clinical picture.
Quarterly data is also submitted to Trust Board which includes Covid classification and is also reported monthly to our Quality & Assurance Committee which reports through to Board through the monthly AAA report in public session.
When an outbreak is identified outbreak meetings are held to identify issues and actions and shared with partner where necessary. There is also a wider dissemination of the findings by the IPC team (see attached presentation)
5. With regard to the CQC inspection what is the evidence (qualitative and quantitative) to suggest that all aspects of EOLC are now meeting the standards all patients deserve.
This narrative aims to give an overview of some of the developments within the provision of Palliative and end of life care (PEoLC) at SaTH. It is aligned with the recommendations made to the trust in the most recent CQC report and was supplied by the Lead Consultant for the service.
Identification of end of life care patients
The early identification of patients who are in the last year of life and deteriorating towards the last days of life is key and allows for important conversations to be held regarding identifying where that patient would like to be cared for and other individualised aspects of their care.
At SaTH we are developing a number of ways to enhance this identification process. This includes the use of IT systems, clinical meetings and specialist team input to support staff to identify patients who are in a palliative phase of illness. Once identified, care can be individualised and delivered more effectively. As we improve our identification of these patients we can give assurance that their needs are being met. Education and audits are also being reviewed and developed to support and monitor this (see below).
Referral and triage process to the specialist team
In September 2021 the Hospital specialist palliative care team and the end of life care team combined as one, The Palliative and end of life care (PEOLC) team. This resolves the problem of confusion around which team to refer to and also makes the referral process for clinical teams to access support far more efficient and straight forward.
The referral and triage process to the PEOLC team has been reviewed and updated and is now able to demonstrate that all referrals are seen within a specified time scale and that these time scales are based on clinical need. Information regarding triage and referral is now kept on a data base which can regularly be reviewed to demonstrate and ensure that patients with urgent needs are seen as a priority.
Specialist team workforce development
Two additional specialist palliative care nurses have been recruited to the team during 2021. An advertisement is currently placed for a senior nurse to lead the PEOLC team. Several attempts, in 2021, to attract a further two consultants in palliative medicine have been unsuccessful, however alternatives are now being explored which include a joint consultant position with the Severn Hospice. All attempts to recruit to these post are being explored.
We have ensured that all staff in the specialist team are competent in their role by ensuring trust mandatory training is completed, ensuring that specialist training requirements are completed and reviewed regularly and also that team members access the correct level of mentoring and support so that they may continue to provide care in this challenging area of practice. (This mentoring is also referred to as clinical supervision).
Specialist palliative care 7 day service and out of hour’s advice
The recruitment to the specialist team has allowed the trust to extend the previous 5 day per week, face to face provision of specialist palliative care, to 7 days per week. This started in September 2021. This allows for earlier access to specialist care and enhanced quality of care. For example earlier identification of and achievement of a preferred place of care and earlier symptom control.
In Shropshire Telford and Wrekin a consultant led advice service is also available 24/7, meaning that all clinicians, including those in the acute trust, can access specialist palliative care advice after hours and at any time.
Symptom control and individualised care
In addition to the new 7 day service other ways to improve symptom control and individualised care are being explored.
The trust has reviewed and updated its care plan for the last days of life which helps clinicians to review every aspect of holistic care required in an individual way at this import time. Also to support families and those important to the patient. The new care plan has undergone a successful trial in 2021 and will be rolled out to all wards in early 2022. New sections found in this plan include a holistic assessment page and regular ‘comfort observations’.
Education and staff support
PEOLC is for all clinicians to deliver, not just the specialist team. We are exploring many ways to enhance the education and support to clinicians and ward teams all across the hospital including:
- Reinforcing our network of ward PEOLC champions so that each ward has a number of individuals who literally champion this area of care. We will deliver enhanced training sessions to these individuals and support them to act as a link between the specialist team and their ward areay.
- A review of all PEoLC mandatory training for clinical staff in early 2022
- A comprehensive review is going on regarding the full PEOLC training offer at SaTH. This includes champion training and mandatory training but also training for newly qualified nurses, oversees nursing colleagues and medical teams in a range of topics from syringe pump training, spiritual care training, care after death training and holistic/ symptom control assessment.
Governance and overview of PEOLC
During 2021 the governance structure for PEOLC has been fully reviewed and updated so that the trust has full oversight of developments. All aspects of PEOLC governance are discussed at the bimonthly steering group which is supported by a wide range of staff from across the hospital. This meeting reports to the central trust governance meeting on a quarterly basis. In view of the fact that we recognise continued improvements are vital, in 2022 the steering group meetings will increase in frequency to monthly. An annual report is also produced by the specialist team.
Steering group meeting are designed to collate and act on any learning identified through complaints and compliments, clinical incident reports and bereavement survey feedback. It is also an opportunity to review progress against our strategy and action/ improvement plan for PEOLC including clinical projects, education and audit plans. Key performance indicators will be logged monthly on newly developing dashboards in 2022 so that we can monitor and act on areas of concern at speed and with confidence.
Key individuals are:
Non-exec director for PEOLC- Mr David Brown
Executive director/ lead for PEOLC- Director of Nursing, Hayley Flavell
Clinical lead for PEOLC/ Consultant in Palliative Medicine- Dr Emma Corbett