Safe spaces

During the Covid-19 pandemic, hospital infection prevention and control (IPC) procedures were thrust into the spotlight like never before. With a deadly new virus sweeping the globe, the onus was on all of us to mask up, wash our hands, and limit our contact with others. Meanwhile, clinics were forced to up their game. For many of us, the sight of a healthcare worker kitted out in full personal protective equipment (PPE) became one of the abiding images of 2020.

Hospitals didn’t do a perfect job. According to the Guardian, one in seven patients treated for Covid-19 in the UK between 1 August 2020 and 21 March 2021 (40,670 people) caught it in hospital while being treated for a different condition. However, it’s clear that doctors and nurses made a herculean effort, curbing transmission rates considerably. In 2022, the World Health Organisation (WHO) declared that 70% of hospital-acquired infections can be prevented through good IPC practices.

Dr Tedros Adhanom Ghebreyesus, WHO director general, remarked that while the pandemic had exposed many gaps in infection control, it also gave healthcare systems the push they needed to improve. “It has provided an unprecedented opportunity to take stock of the situation and rapidly scale up outbreak readiness and response through IPC practices, as well as strengthening IPC programmes across the health system,” he said.

Nearly four years since Wuhan went into lockdown, healthcare is to all intents and purposes back to ‘normal’. While Covid-19 is still a threat, it is no longer classed as an international emergency and the rules around it are mostly a thing of the past. The question remains: to what extent have lessons truly been learned? Has IPC returned to its pre-pandemic baseline, or has Covid-19 changed the status quo for good?

How did IPC change during the pandemic?

If we think back to the early days of the pandemic, it’s easy to recall the sense of urgency. Hospitals rose admirably to the challenge, adapting their IPC procedures very fast.

While the exact guidelines varied from country to country, some procedures looked much the same across the board. Hospitals would triage patients on admission, isolating Covid-19 patients until the infection risk had passed. The doctors and nurses treating them wore fluid-resistant gowns, gloves, face shields, eye protection, hair covers, shoe covers and high-quality masks.

Visitors, once allowed, needed to wear face masks and use hand sanitiser. Triage areas were partitioned, physical barriers were placed around reception areas and nurse stations, and anyone walking around the hospital would have found oneway systems in place.

Meanwhile, cleaning protocols, hand hygiene practices, and ventilation procedures were stepped up. Some hospitals started using ultraviolet light to check that surfaces were properly cleaned, while others invested in air purifiers. At the very least, they kept the windows open and were regimented in their use of disinfectants.

Where did the challenges lie?

While these kinds of practices sound uncontroversial, this was also a time when SARSCoV- 2 was incompletely understood. Professor Lyn Gilbert is an Australian infectious diseases physician and microbiologist who served as chair of Australia’s Infection Control Expert Group (ICEG) from February 2020 to March 2021. She remembers the early days of the pandemic as being a time of fervent debate among IPC teams.

“There were wide variations in IPC guidance and protocols, despite what we had hoped would be a single ‘source of truth’ – as much as anyone could claim to know the truth as the situation evolved,” she recalls.

One hot-button issue was the question of masking. Very early on in the pandemic, the WHO warned that there were global shortages of personal protective equipment. This applied specifically to N95 respirators – high-grade medical masks designed to filter viruses. Healthcare workers were permitted, albeit controversially, to use surgical masks instead.

“ICEG recommended use of N95 respirators for aerosol-generating procedures, and surgical masks for most other situations,” says Gilbert. “This was consistent with both the epidemiology at the time and what bodies like the World Health Organisation were recommending. However, the people recommending routine use of N95s were very vocal and many healthcare workers were confused, fearful for themselves and their families, and angry because they felt they were being denied adequate protection.”

She adds that, while there was a strong emphasis on the respirator issue, few people were using eye protection (which ICEG had recommended). There were also arguments about the role of surfaces and hands in transmission, and what types of gowns should be used.

For most healthcare workers, none of the IPC practices they were being asked to follow were completely new. However, Gilbert points out that (for Australian healthcare workers at least) there had been little routine IPC training in the preceding years and the level of knowledge surrounding PPE was poor. What’s more, she suspects that other routine IPC measures, like hand hygiene, may have been partly neglected as hospitals became busier and staff absenteeism increased.

“Even before Covid, there was an unmet need for greater awareness of IPC and regular refresher training for hospital staff in the use of PPE,” she says. “I doubt this need has been addressed and I suspect it will not be long before there is a return to baseline.”

Which changes have persisted?

The IPC guidance evolved throughout the pandemic, in keeping with a fast-mutating virus. By 2022, many countries were relaxing their Covidspecific guidelines, with a view to freeing up capacity and tackling the treatment backlog that had accrued.

For instance, NHS England published its revised guidance in April 2022. It stated that healthcare workers would no longer need to adhere to physical distancing measures or special cleaning protocols. Instead, they should carry out risk assessments to determine whether extra precautions were needed.

In Australia, the requirement to wear a mask persisted until August 2023, marking the end of the winter flu season. Since then, many healthcare facilities have been mask-free zones. In general, Gilbert believes that most Australian hospitals have reverted to business as usual, except when caring for known Covid patients.

“Even then, many staff probably feel they are no longer at risk because they have been vaccinated, and they are likely to revert to often not wearing masks even when they are supposed to,” she says.

On the other hand, it seems likely that rapid diagnostics (an integral part of infection control) has changed for the better, for good. Many hospitals have also implemented new procedures for tracking outbreaks and are embracing rejigged ward layouts and new approaches to ventilation.

What still needs to change?

All this said, Covid cases are no longer being tracked as they once were, which means it’s difficult to gauge how successfully hospitals are minimising its spread. What is clear is that, in the absence of strict rules, a hospital’s ability to curb nosocomial infections will depend on other factors. Organisational culture is surely at the top of the list.

In a 2022 research paper, Gilbert argued that doctors and nurses tend to operate differently when it comes to IPC procedures, with some nurses tending towards the rigidly rule-driven and many doctors hating to be told what to do. These ‘interprofessional differences and inconsistencies’, she thinks, can turn IPC into something of a minefield. In practice, the different professions need to meet in the middle and develop a contextspecific set of rules, consistent with IPC guidelines but still practicable.

“Covid may have helped to facilitate this in some places, but trying to change entrenched attitudes and behaviours in the middle of a crisis is not ideal,” she says.

On top of that, she thinks hospitals ought to implement regular refresher training and to track at least some types of healthcare-associated infection. Hospitals also need strong leaders at all levels who have the time and resources to focus on these issues.

“All healthcare workers need to believe in the importance of IPC. Senior clinicians need to be role models by adhering to IPC practices themselves, and to make it clear that they expect their teams to do so as well,” she says. “This may seem naïve, but I know there are some hospitals where it happens. It takes a lot of effort to change the culture, raise the priority of IPC, and allocate adequate resources in the ones where it doesn’t.”

None of this will be easy, given entrenched staffing shortages and a general lack of interest in IPC. However, if nothing else, the Covid pandemic underscored the importance of trying. According to some estimates, the world faces a 27.5% risk of a new Covid-like pandemic within the next 10 years. That means it’s vital to integrate the lessons Covid has taught us while we have a bit of breathing space.