The burden of nosocomial SARS-CoV-2 infection remains poorly defined. We report on the outcomes of 2508 adults with molecularly-confirmed SARS-CoV-2 admitted across 18 major hospitals, representing over 60% of those hospitalised across Wales between 1 March and 1 July 2020. Inpatient mortality for nosocomial infection ranged from 38% to 42%, consistently higher than participants with community-acquired infection (31%–35%) across a range of case definitions. Those with hospital-acquired infection were older and frailer than those infected within the community. Nosocomial diagnosis occurred a median of 30 days following admission (IQR 21–63), suggesting a window for prophylactic or postexposure interventions, alongside enhanced infection control measures.

ObjectivesTo define the burden of nosocomial (hospital-acquired) novel pandemic coronavirus (covid-19) infection among adults hospitalised across Wales.DesignRetrospective observational study of adult patients with polymerase chain reaction (PCR)-confirmed SARS-CoV-2 infection between 1st March – 1st July 2020 with a recorded hospital admission within the subsequent 31 days. Outcomes were collected up to 20th November using a standardised online data collection tool.SettingService evaluation performed across 18 secondary or tertiary care hospitals.Participants4112 admissions with a positive SARS-CoV-2 PCR result between 1st March to 1st July 2020 were screened. Anonymised data from 2518 participants were returned, representing over 60% of adults hospitalised across the nation of Wales.Main outcome measuresThe prevalence and outcomes (death, discharge) for nosocomial covid-19, assessed across of a range of possible case definitions.ResultsInpatient mortality rates for nosocomial covid-19 ranged from 38% to 42% and remained consistently higher than participants with community-acquired infection (31% to 35%) across a range of case definitions. Participants with nosocomial-acquired infection were an older, frailer, and multi-morbid population than those with community-acquired infection. Based on the Public Health Wales case definition, 50% of participants had been admitted for 30 days prior to diagnostic testing.ConclusionsThis represents the largest assessment of clinical outcomes for patients with nosocomial covid-19 in the UK to date. These findings suggest that inpatient mortality rates from nosocomial-infection are likely higher than previously reported, emphasizing the importance of infection control measures, and supports prioritisation of vaccination for covid-19 negative admissions and trials of post-exposure prophylaxis in inpatient cohorts.Trial registrationThis project was approved and sponsored by the Welsh Government, as part of a national audit and quality improvement scheme for patients hospitalised covid-19 across Wales.Key MessagesWhat is already known on this topicWe searched PubMed and ISI Web of Science up until 31-December-2020 for studies reporting on patient outcomes following hospital-acquired infection due to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We identified a range of case-definitions for hospital-acquired infection, based on timing of diagnostic testing 5 to 15 days following admission. The largest and only multi-centre study concluded individuals with nosocomial infection are at a lower risk of death from SARS-CoV-2 than those infected in the community, however, was performed early in the pandemic and utilised a conservative definition of nosocomial infection.What this study addsOur multi-centre observational study represents the largest assessment of clinical outcomes for patients with nosocomial covid-19 in the UK to date, and suggests the burden of nosocomial SARS-CoV-2 infection has been underestimated. Nosocomial-infection occurred in older, frailer, and multi-morbid individuals, and was consistently associated with greater inpatient mortality than amongst those who were infected in the community across a spectrum of case-definitions. Our findings support implementation of enhanced infection control measures to reduce this burden during future waves, especially given the recent emergence of novel viral variants with enhanced transmissibility. Furthermore, roughly half of the patients meeting the Public Health Wales definition of definite nosocomial SARS-CoV-2 infection had been admitted for 30 days prior to diagnosis, highlighting a potential window of opportunity for inpatient pre-exposure and/or post-exposure prophylaxis.

BackgroundThe COVID-19 pandemic created a unique situation where a national clinical guideline would address uncertainty, and provide a trusted source for up-to-date information and advice. We developed a dynamic online infrastructure together with a dedicated implementation team to deliver this at scale and pace. The guideline was implemented through a digital implementation framework (SIMPSI framework) deploying facilitators to maximise guideline adoption, particularly targeting senior clinical decision makers (consultants) involved with the care of COVID-infected patients across six Health Boards (HB) in Wales. Methods We evaluated guideline implementation using the Taxonomy of Implementation Outcomes Model. The primary outcome was consultant engagement, with a target of 193 registrations. We assessed wider impact through analysis of guideline platform activity and a user survey, with additional sensitivity analysis to derive penetration ratios, catchment population, clinical staff, acute beds, and COVID-19 admissions. ResultsThe guideline platform had 4521 total registrants, with over 170,000 page views during the first wave. We exceeded the target nearly six-fold (1159 consultant registrants). This represented 45% of all medical consultants in Wales, and made up the highest proportion of guideline registrants of all professional groups (23%, 1159/4521). We observed significant variation in guideline penetration across the six HBs, ranging from 31% to 74% of consultants registered. The HB with highest penetration had the most active guideline facilitator. The HB with the lowest penetration was the region first impacted and most affected by COVID-19 at the time of guideline publication (37% inpatients of peak, versus 10% or less for the other HBs). ConclusionWe utilised a digital implementation framework to construct a system that could be rapidly applied throughout all hospitals in Wales. Whilst we exceeded the intended target demonstrating full implementation, we identified two key factors to account for differences in the penetration rates across the different HBs. First, an experienced and active facilitator with the capacity to undertake the role was associated with significantly better penetration. Second, timeliness of implementation was crucial as evidenced by lower penetrance is the one HB that was impacted earliest by COVID-19 at the time of guideline dissemination. Nevertheless, the rapid implementation of the guideline has coincided with Wales demonstrating more favourable intensive care survival rates and maintaining one of the lowest mortality rates when compared to the UK as a whole for the first wave of the COVID-19 pandemic.

BackgroundThe COVID-19 pandemic created a unique situation where a national clinical guideline would address uncertainty, and provide a trusted source for up-to-date information and advice. We developed a dynamic online infrastructure together with a dedicated implementation team to deliver this at scale and pace. The guideline was implemented through a digital implementation framework (SIMPSI framework) deploying facilitators to maximise guideline adoption, particularly targeting senior clinical decision makers (consultants) involved with the care of COVID-infected patients across six Health Boards (HB) in Wales. Methods We evaluated guideline implementation using the Taxonomy of Implementation Outcomes Model. The primary outcome was consultant engagement, with a target of 193 registrations. We assessed wider impact through analysis of guideline platform activity and a user survey, with additional sensitivity analysis to derive penetration ratios, catchment population, clinical staff, acute beds, and COVID-19 admissions. ResultsThe guideline platform had 4521 total registrants, with over 170,000 page views during the first wave. We exceeded the target nearly six-fold (1159 consultant registrants). This represented 45% of all medical consultants in Wales, and made up the highest proportion of guideline registrants of all professional groups (23%, 1159/4521). We observed significant variation in guideline penetration across the six HBs, ranging from 31% to 74% of consultants registered. The HB with highest penetration had the most active guideline facilitator. The HB with the lowest penetration was the region first impacted and most affected by COVID-19 at the time of guideline publication (37% inpatients of peak, versus 10% or less for the other HBs). ConclusionWe utilised a digital implementation framework to construct a system that could be rapidly applied throughout all hospitals in Wales. Whilst we exceeded the intended target demonstrating full implementation, we identified two key factors to account for differences in the penetration rates across the different HBs. First, an experienced and active facilitator with the capacity to undertake the role was associated with significantly better penetration. Second, timeliness of implementation was crucial as evidenced by lower penetrance is the one HB that was impacted earliest by COVID-19 at the time of guideline dissemination. Nevertheless, the rapid implementation of the guideline has coincided with Wales demonstrating more favourable intensive care survival rates and maintaining one of the lowest mortality rates when compared to the UK as a whole for the first wave of the COVID-19 pandemic.