Earlier this year Dr Ryan Buchanan posted a blog  describing how a team of researchers and clinicians from Southampton had set up a trial to test whether care home staff would be happy and able to wash their nose and mouth with salt water to prevent spread of COVID-19 to the vulnerable people they look after. The trial is now complete and we would like to share some of our findings.

Salty water is known to be effective in treating viral infections and there is some evidence that it can reduce the spread of respiratory viruses including corona viruses. We developed a trial that randomly assigned staff in some care homes to the intervention-rinse their noses and gargle their mouth with salty water 2-3 times during their shifts. We contacted 30 care homes and seven agreed to participate in the trial. Four were asked to do the intervention.

Two care homes that were randomised to do the rinsing did not complete the trial. Conducting research during the pandemic for one was understandably difficult and the other care home staff felt the need to do the rinsing had passed as the second wave of COVID-19 waned. In the remaining two care homes uptake of the rinsing was good. In one, 100% of the staff did the rinsing in the early weeks of the trial.

Six interviews with staff were conducted to understand their experience of rinsing. Staff said that having a manager who was enthusiastic about the rinsing procedure and having appointed ‘champions’ to run a group training, provide staff with relevant information, answer any questions or queries they have and maintain enthusiasm were  important factors for the success of implementing the rinsing. Although some of the staff found the procedure was uncomfortable (particularly the gargling) there were no reported ‘adverse events’ during the trial from the salty water. Staff who appreciated the potential benefits of the intervention and who wanted to do anything to fight the virus were more likely to apply the rinsing and gargling procedure. Making the rinsing and gargling part of staff daily routine was also important.

Overall, we showed that salty water rinsing of the nose and mouth could be done by care home staff during their shifts. Furthermore, we showed that it is safe and identified ways to encourage staff to do the rinsing. We did not examine whether the salty water rinsing prevented transmission of COVID-19 to the vulnerable people they look after. To do this we would need a much larger trial involving dozens of care homes and would need to carefully collect data showing how many residents contracted COVID-19.

Prevention is an important part of the fight against the virus. This rinsing procedure could also be an important part of care home infection control procedures (such as washing hands, social distancing and wearing masks). Some useful tips if you are interested in implementing the salty water rinsing and gargling in your care home:

• Nominate an enthusiastic champion or champions in your care home to facilitate the adoption of the rinsing procedure
• To enable staff to perform the rinsing correctly let them watch this training video (https://vimeo.com/289739888). You need a plastic 60ml galley pot, 1.5g of sea salt in two sachets and a plastic stirrer. Make up the solution using cooled boiled water.
• Best to offer group training to staff to allow building shared commitment and interest and to answer any specific questions they have. Empower the champions to lead the training and monitor staff performance.
• To ensure competency, champions can watch their colleague staff performing the rinsing procedure.
• Integrate the rinsing procedure in staff daily routine. For example at the beginning of their shift and during the breaks.
• Ask staff frequently for feedback and address any concerns

For me I was proud to make this contribution to the fight against COVID-19 pandemic in the population that have felt its consequences the most. I was also proud to be part of a fantastic team of individuals from the University of Southampton, the Southampton Clinical Trials Unit and University Hospital Southampton. The team developed and ran this trial alongside looking after patients with COVID-19 and other important research work into COVID-19. I will remember this as a difficult time but also a time of fantastic collaboration and innovation.

The whole team are enormously grateful to the opportunity to collaborate with care home staff and managers to conduct this research. We are also grateful to the Wessex Applied Research Collaboration who funded the study.

Dr Kinda Ibrahim, Senior Research Fellow, Academic Geriatric Medicine, University of Southampton (k.ibrahim@soton.ac.uk )

Research Team

Co-Chief investigators – Dr Thomas Daniels, Consultant Respiratory Physician, Honorary Senior Clinical Lecturer, University of Southampton, and  Dr Ryan Buchanan, Academic Clinical Lecturer, Primary Care, Population Science and Medical Education, University of Southampton

Co-applicants – Professor Julie Parkes, Professor of Public Health, University of Southampton, Professor Helen Roberts, Professor of Medicine for Older People, University of Southampton, Emeritus Professor Jeremy Wyatt – University of Southampton, Dr Beth Stuart – Medical Statistician, Southampton Clinical Trials Unit, Dr Kinda Ibrahim – Senior Research Fellow, Faculty of Medicine, University Hospital Southampton NHS Foundation Trust, and Dr Andrew Cook – Public Health Consultant, Fellow of Health Technology Assessment, University of Southampton

Partners: NIHR ARC Wessex & University Hospital Southampton NHS Foundation Trust, Southampton CTU