The challenge of keeping hospitals safe in the era of covid

During the first wave of the pandemic, patient facing healthcare workers and their families were statistically more likely to be admitted to hospital with covid-19 than non-patient facing staff or the general public. [1] Between March and May 2020, the NHS lost the equivalent of more than 1.3 million staff days owing to covid-19 and related reasons. [2] In a letter to all NHS trusts, general practices, and primary care networks, dated June 2020, the chief operating officer, chief nursing officer, and national medical director for NHS England set out important steps to minimise these infections. [3] Yet in October 2020, 17% of covid-19 infections still fit the NHS England definition of probable hospital acquired infection. [4]

We know that wearing masks, using personal protective equipment (PPE), social distancing, adequate ventilation, and reduced person-to-person contacts will bring down the number of infections. [5,6,7] Micro-organisms from within the patient wards, transfer to clothes, curtains, computers, stethoscopes, clinical records, mobile telephones, and other devices have been implicated in healthcare associated infections. [8,9,10] Although covid-19 transmission is dominated by airborne routes, the 653,000 cases of healthcare associated infections in adult patients per year in NHS general and teaching hospitals, even before the current pandemic, are alarming. [11,12]

Numbers of hospital beds in the UK have fallen, and much NHS land has been earmarked for development, but patient numbers have increased. [13,14] This means that more work is packed into smaller spaces that were not built to enable multiple zoning areas in hospitals. Relatives are becoming more important for delivering care at the bedside, not just because staffing levels are depleted, but also because families wish to care for their loved ones themselves. Visiting hours have become more flexible. The consequences include potential crowding of patients, relatives, and staff; loss of unobstructed walkways to wash basins or other disinfection areas in the clinical part of the ward; and loss of safe spaces for staff to eat, rest, shower, change clothes, or use the toilets. Clinical and non-clinical staff mix in offices. Computers can be shared, may not have screens around them, and be positioned less than 2 metres apart. [15,16]  Domestic staff work tirelessly, but hours may be cut because of outsourcing. Staff spending hours in a workspace cannot go without food and drink, which means they will need to remove their facemasks. Older areas may not have adequate ventilation systems. Not everyone is aware of the guidance of the Federation of European Heating, Ventilation and Air Conditioning Associations for how we improve clean air circulation. [17]

The increased use of “scrubs” at work is welcomed, but the absence of changing spaces in some areas can lead to additional overcrowding; as staff queue to change in small spaces or ward toilets. [18,19] In some countries, laundering is outsourced and staff need to take work clothes home to wash. But not all staff are aware of, or follow, safe laundering advice, and even so, micro-organisms are more likely to survive domestic rather than commercial or industrial laundering. [20,21] Evidence of methicillin sesistant Staphylococcus aureus transmission via healthcare uniforms already exists. [9]

Remote working may be the only viable solution to many of these problems and, despite multiple challenges, was taken up efficiently in the first pandemic. This reduces healthcare associated infections and improves air quality, with a positive impact on transmission and symptoms of many diseases. [22,23] Changing travel patterns lessens the risk of new viruses transferring from animals to humans. [22,24]

A striking feature of this epidemic has been the growth in information sharing across borders, without reference to political affiliations and often provided free at source, using modern information technology. [24,25,26] Seven thousand professionals from at least three continents attended WenHong Zhang’s webinar on the Shanghai experience of covid-19. [27] Working together rather than in competition has been inspirational and has helped tackle various problems. For example, PPE is more available, as is education on donning and doffing, but more needs to be done to raise awareness of the risk of infection through multiple interactions within a patient zone. [21,28]

The medical clinical lead for infection control can help to identify issues, provide local solutions, and link with Public Health England and similar bodies. Testing asymptomatic staff will help control infection rates. [29] Liaison with social care and educational services should be part of the new spirit of information sharing, nationally and internationally, to support cohesive strategies. Concepts of infectious diseases and infection control and the links with public health sciences must be embedded within the medical curriculum or taught even earlier, in school programmes. 

So yes, we do need to talk about healthcare associated covid infection as the risks of not doing so are enormous. Beyond covid-19, the risks of other infections continue to be substantial. We need to tackle this now; for our own health, our patients’ health, our colleagues’ health, and our communities’ health.

Alexandra CH Damazer, Yorkshire and the Humber Future Leaders Fellow, Hull University Teaching Hospitals (corresponding author).
Deborah Wearmouth, Consultant Microbiologist and Clinical Lead for Infection Control, Hull University Teaching Hospitals.
Hilary Klonin, Paediatric Intensivist, Hull University Teaching Hospitals 
Competing interests: none declared. 


  1. Editorial. Mistakes made in the first wave must not be repeated in the second. BMJ. 2020; 371:m3944.
  2. NHS Employers. New Statistics show COVID-19 related NHS staff sickness absence. Published 24/09/2020. Accessed online:–content-page
  3. Pritchard A, May R, Powis S. Minimising nosocomial infections in the NHS. Letter. 9/6/2020.
  4. Heneghan C, Howdon D, Oke J, Jefferson T. The Ongoing Problem of UK Hospital Acquired Infections. The Centre for Evidence-Based Medicine. 30/10/2020.
  5. BMJ’s Coronavirus (covid19) Hub. BMJ. 2020. Accessed online:
  6. Chu DK, Alk EA, Duda S et al. Physical distancing, face masks and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis. Lancet. 2020 Jun 27;395(10242):1973-1987.
  7. Centers for Disease Control and Prevention. Considerations for Events and Gatherings. Updated 17/11/2020. Accessed online:
  8. Canano JC, Echeverri LM, Szela C. Bacterial Contamination of Clothes and Environmental Items in a Thrid-Level Hospital in Colombia. InterdiscipPerspect Infect Dis. 2012; 2012: 507640.
  9. Sanon MA, Watkins S. Nurses’ uniforms: How many bacteria do they carry after one shift? J Public Health Epidemiol. 2012 Dec; 4(10): 311-315.
  10. Kampf G, Todt D, Pfaender S et al. Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents. Journal of Hospital Infection. 2020; 104(3): 246-251.
  11. Editorial. The Lancet Respiratory Medicine. 2020; 8(12): 1159.
  12. Guest JF, Keating T, Gould D et al. Modelling the annual NHS costs and outcomes attributable to healthcare-associated infections in England. BMJ Open. 2020; 10:e033367
  13. The Kings Fund. NHS hospital bed numbers: past, present, future. Published 26/03/2020. Accessed online:
  14. The Guardian. Amount of NHS land in England earmarked for sale soars, figures show. Published 09/09/2018. Accessed online:
  15. Gomersall CD, Tai DYH, Loo S et al. Expanding ICU facilities in an epidemic: recommendations based on experience from the SARS epidemic in Hong Kong and Singapore. Intensive Care Med. 2006: 32(7); 1004-13.
  16. Sprung CL, Zimmerman JL, Christian MD. Recommendations for intensive care unity and hospital preparations for an influenza epidemic or mass disaster: summary report of the European Society of Intensive Care Medicine’s Task Force for intensive care unit triage during an influenza epidemic or mass disaster. Intensive Care Med. 2010: 36(3): 428-43.
  17. Federation of European Heating, Ventilation and Air Conditioning Associations. REHVA COVID-19 guidance document. April 2020.
  18. Callhan BC, Seifi A. The Scrub Revolution: From Hospital Uniform to Public Attire. Southern Medical Journal. 2016; 109(5): 326-327.
  19. Centers for Disease Control and Prevention. Environmental Infection Control Guidelines, Background C. Air. Updated 22/07/2019. Accessed online:
  20. Chiereghin A, Felici S, Gibertoni D et al. Microbial Contamination of Medical Staff Clothing During Patient Care Activities: Performance of Decontamination of Domestic Versus Industrial Laundering Procedures. Current Microbiology. February 2020; 77: 1159-1166.
  21. Hoe Gan W, Wah Lim J, Koh D. Preventing Intra-Hospital Infection and Transmission of Coronavirus Disease 2019 in Health-care Workers. Saf Health Work. June 2020; 11(2): 241-243
  22. Kumari P, Toshniwal D. Impact of lockdown on air quality over major cities across the globe during COVID-19 pandemic. Urban Climate. 2020; 34:100719
  23. Public Health England. Emergency Department Syndromic Surveillance System: England 2020 (21). Published 27/05/2020. Accessed online:
  24. Parrish CR, Holmes EC, Morens DM et al. Cross-Species Virus Transmission and the Emergence of New Epidemic Diseases. Microbiology and Molecular Biology Reviews. 2008; 72(3): 457-470.
  25. Coronavirus Virtual Event Series. Labroots. Last updated 03/12/2020. Accessed online:
  26. The Global Alliance to Combat COVID-19 Webinar. Tencent. 07/05/2020. Accessed online:
  27. KashmirWatch. Dr WenHong Zhang summarises how to fight Coronavirus. 28/03/2020. Accessed online:
  28. Jin YH, Huang Q, Wang YY et al. Perceived infection transmission routes, infection control practices, psychosocial changes, and management of COVID-19 infected healthcare workers in a tertiary acute care hospital in Wuhan: a cross-sectional survey. Military Medical Research. 2020; 7(24)
  29. NHS England and NHS Improvement coronavirus. Asymptomatic staff testing for COVID-19. Last Updated 7/12/2020. Accessed online: