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National Nosocomial COVID-19 Programme

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Learning from hospital-acquired COVID-19 infections in Wales

The COVID-19 pandemic has had a significant impact on population health and healthcare systems worldwide. NHS Wales rapidly adapted and altered its operational focus to minimise harm as far as possible. NHS staff worked tirelessly to maintain healthcare services for those most in need. However, COVID-19 was a new and unpredictable infection which made it extremely difficult to manage.

Due to the scale and severity of the pandemic, patients who required care in hospitals and other in-patient settings faced an inevitable increased risk of acquiring COVID-19. Managing the spread of COVID-19 in healthcare settings was challenging, particularly when prevalence was so high in the community, and in hospitals, there were higher levels of seriously unwell patients, longer lengths of stay and more people in hospital beds.

The nature of the pandemic has meant that usually high numbers of patient safety incidents of nosocomial (hospital-acquired) COVID-19 have been recorded, affecting approximately 18,000 service users/families across Wales.


What is the National Nosocomial COVID-19 Programme?

In April 2022, the National Nosocomial COVID-19 Programme was established to support NHS Wales organisations in their duty to conduct investigations into patient safety incidents of nosocomial COVID-19. Healthcare acquired infections are sometimes considered a patient safety incident, depending on how and when the infection was acquired.

The National Nosocomial COVID-19 Programme has created a framework to ensure NHS Wales organisations adopt as consistent an approach as possible to the investigation process, ensuring investigations are done once and done well. So far, the programme has supported NHS Wales organisations to investigate over 5,000 cases, providing some answers to loved ones, as well as capturing learning and experience.


Learning and improvement across NHS Wales

Acknowledging the impact of COVID-19 on service users, families, carers and NHS Wales staff, the programme has adopted a learning approach that seeks not to place blame, but maximise the opportunity for learning and improvement.

NHS Wales has published its National Nosocomial COVID-19 Programme Interim Learning Report, providing an overview of the programme and identifying some of the early learning themes emerging through the programme. Some of the early learning themes have been categorised as follows:

  • People’s experiences
    • Bereavement support and care-after-death services
    • Supporting the service user during the investigation process
    • Visiting restrictions
  • Patient safety incidents and concerns
    • Patient safety incidents outside of NHS Wales hospitals
    • Identification, reporting and investigation of Health Care Acquired Infections (HCAIs) as a patient safety incident
    • Application of Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) decisions
  • National infection prevention and control guidance
    • Roll out of guidance
    • Outbreak management

More information on each of the learning themes can be found in the National Nosocomial COVID-19 Programme Interim Learning Report.

Read an Easy Read Summary of the National Nosocomial COVID-19 Programme Interim Learning Report.