Jan Dyer

In late March 2020, Cedric Steiner was keeping watch on the case numbers of a new threat to nursing home residents: coronavirus disease 2019 (COVID-19).

Steiner was interning at a nursing home in Lancaster County, Pennsylvania, completing state and federal requirements for a license as a nursing home administrator. The facility’s COVID-19 task force, which he served on, was looking for solutions to what seemed an inevitable crisis. The Pennsylvania Department of Health “epi curve” chart showed that cases in that state were spiking scarily fast, from just a handful at the beginning of March to 40 and climbing within a 

Reading everything he could get on how to protect nursing home residents and healthcare workers from COVID-19—particularly scientific solutions—Steiner came across a 2017 study led by 

Shelly Miller, PhD, and Nick Clements, PhD

. In it, they described how they had turned a regular hospital unit into a negative-pressure isolation space virtually overnight by modifying the existing 

Could something like that work for a larger area—say, an entire wing of a nursing home? With a potential pandemic looming?

Steiner reached out to Miller on March 28 to ask if she’d be willing to help his nursing home replicate what she and Clements had done.

Negative pressure isolation space is an effective method to meet needed surge capacity during a healthcare crisis like the COVID-19 pandemic, Miller has written, and being able to create it rapidly is a boon, especially in nursing homes and other congregate living areas. She and Clements had shown that “rapid” means “rapid”—in 24 hours they converted a 30-bed hospital ward to an airborne infection isolation area in anticipation of a flu pandemic.

Steiner broached the idea to the task force, which included the CEO, vice president of healthcare, director of nursing, and infection control nurse. It wasn’t an immediate sell, he acknowledges. But after he rounded up donations in materials and money (including from himself) to reinforce the feasibility, they were willing to try it. Valerie Hatt, RN, the infection control nurse, says, “I wasn’t sure that we would have the capability, but our environmental services director is very knowledgeable and thought it could be done.” She notes that the respiratory therapist also thought it was a good idea.

Nursing homes designed on a hospital model (ie, with rooms branching off central corridors with corresponding HVAC systems) are architecturally able to sustain negative pressures that meet or exceed CDC guidelines, Miller says. The hall being modified in this case is on the bottom floor of a wing of a larger building. It had 13 beds within 7 rooms, 6 double-occupancy rooms, and 1 single-occupancy room, each with a single bathroom. The single-occupancy room included an anteroom with a separate sink and medical cabinet. The rooms each had a sealed solid glass window facing the hall and an exterior window. Heating and cooling were self-contained in each room with designated units, fans, and air ducts.

The director of facilities, John Becker, determined that he could make the necessary adaptations to the HVAC system similar to those done in the Miller study. The engineering and environmental services teams began the HVAC and plastic barrier modifications on April 2 and finished on April 6. They added 2 new blowers, turned off the incoming outdoor ventilation fan using a breaker, and mounted an exhaust to the outside of the intake grate on the side of the building traditionally reserved for incoming outdoor ventilation, thus reversing the flow of air and converting the hall to 100% exhaust. They removed the preconditioning unit of the energy recovery ventilator and closed the fire damper. Originally, HEPA filters were placed in the energy recovery ventilator (ERV) but, due to restricted air flow, these units proved prohibitive. The solution, Miller says, was to use Minimum Efficiency Reporting 8 filters and cordon off a 15.2-meter 

radius around the exhaust vent on the east side.

They installed 2 sets of 3-sheet plastic barriers to construct a temporary anteroom (the fire door was still usable). The barriers were rolled at the bottom just above carpet level and taped at the sides to identify separations for healthcare workers to access. The anteroom contained a 240 clean-air-delivery rate HEPA purifier fitted with ductwork to exhaust air into the hallway and toward the extremity of the wing.

In 4 days they had created a “cascade” of negative pressure zones between the isolation space, the anteroom, and the rest of the facility.

Once it was all in place and operational, they left it alone, Steiner says. “It worked very well from the outset. We didn’t adjust anything after that point on the timeline.” Acting as the go-between—the “boots on the ground”—Steiner went to meetings and “conveyed suggestions,” collected data, and made sure everything was working.

A lot of things took on significance they hadn’t had before, such as wind. One day, Steiner recalls, they had fierce winds, with the alarming prospect of blowing virus particles into the rest of the facility. But that never happened, he says. According to continual data being recorded on a laptop, even with high winds it all kept working just fine.

The respiratory therapist gave nursing staff (RNs, LPNs, CNAs), nurse practitioner, and physical therapy staff who needed to enter the negative pressure space a 2-day training in donning and doffing protective equipment (PPE). The nurse practitioner conducted the SARS-CoV-2 testing. By April 6, Steiner says, everyone was operating on a higher PPE standard than in most similar settings.

Then, on April 8, they had to put it all to the test: The nursing home accepted its first COVID-19-positive patient. Steiner says the facility was unusual in this, as the only nursing home taking in COVID-19 patients in those early days of the pandemic. They were seen as “reckless,” he says: “Why are you doing this? You’re endangering everybody.”

But the specialized unit, Steiner says, offered patients who went through the “revolving door,” from nursing home to hospital and back, a place to quarantine safely in familiar surroundings. The healthcare workers also saw the isolation unit as a safe space—they were requesting to work there, in fact, Steiner says.

“As we took on COVID-19 patients from the hospital setting who were on the mend, it seemed like we had a good thing going,” says Hatt. “We didn’t have any ourselves.”

Miller, Clements, and Steiner, along with Debanjan Mukherjee and Joseph Wilson, from the University of Boulder (CO) environmental engineering program, began collecting data on May 14 for a study on the 

. Two to 4 known patients with SARS-CoV-2 were being treated in the isolation space during the study. From April 8 on, the facility had no known positive result within its own population. None of the healthcare workers assigned to work in the isolation space presented with symptoms or tested positive thereafter. Mandatory testing on July 24 revealed some asymptomatic staff and residents, but Steiner says to his knowledge, as of early September, “COVID never came out of that place.”

The isolation unit and the rest of the facility had different experiences. “We had an outbreak on the second floor,” Hatt says. “We took some of the residents downstairs to the COVID Hallway, but then started to treat in place, not wanting to move them through the building. We lost 11 of our own residents.” Among those lost was Hatt’s own mother, who had asthma when she contracted the virus.

Again, the short answer, from those involved, is “yes.” The isolation unit isn’t meant to be permanent, Steiner says. It was meant to serve an emergent need, to protect healthcare workers and give patients a safe place to be treated.The bonuses, as the researchers pointed out, were that the community benefited from the expansion of available health services and reduced community spread in facilities that lacked sufficient mitigation strategies, and residents were spared the stress of transfers to and from emergency facilities.

As for lessons learned, Hatt says, “Both nursing and non-nursing staff learned the proper way of wearing isolation gowns. Also, we didn’t have a reason to use N95 in the recent past and are now comfortable with fit testing and wearing N95s.” Moreover, “I think staff all learned new or refreshed seldom used procedures and will be more aware of spreading infection and how to prevent it in the first place.”

Miller says, “From my point of view, the only thing we could have improved was more pressure measurements (we only had 1 device to do the pressure measures) and the ability to measure the outdoor air ventilation rates in each room on the hallway. Oh, and try to make the bathrooms more negative with respect to the rooms, but that is much harder to do.” The researchers also suggest adding upper-room germicidal ultraviolet lights within the area to inactivate any airborne virus, and using air purifiers to exhaust air from each room to the outdoors.

The man who initiated the project, Steiner, says many of his business classes focused on caring for employees. “I felt you had to give your clinical workers the best situation so they could succeed.” But “the emotional side of this can’t be lost, even in a dynamic, unique situation. We had to address the ability to say good-bye to loved ones.”Making it possible for family to suit up in PPE to spend valuable time with their relatives meant a great deal to them, Steiner says. He remembers one son: “A big guy, with tears in his eyes. He was so thankful that they had a place to go for their mother, because at the hospital they couldn’t see her. He wanted to give me a bear hug, but we did the ‘elbow thing’ instead.”

Thanks to this on-the-job experience, Steiner and a partner are now working on projects to help facilities manage isolation solutions and infection control. He wants to design buildings with the same “on-off deal”—that is, flexible designs that allow areas to be converted into negative-pressure as needed. “We have to make a healthy building. We have to make an environment that’s protection for residents and healthcare workers.”

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Cedric Steiner: “We had to address the ability to say good-bye to loved ones. A big guy, with tears in his eyes. He was so thankful that they had a place to go for their mother, because at the hospital they couldn’t see her. He wanted to give me a bear hug, but we did the ‘elbow thing’ instead.” 

How to Build Negative Pressure Rooms in Nursing Homes During COVID 

When the first tentacles of the coronavirus disease 2019 (COVID-19) pandemic reached Navajo Nation—the Native American territory occupying more than 17 million acres in Arizona, Utah, and New Mexico—leaders President Jonathan Nez and Vice President Myron Lizer responded quickly. They instituted strict curfews, issued stay-home orders, and shut casinos down—even though those are central to the local economy.

They also ramped up testing and contact tracing. They had the highest test rate per capita in the country: As of August 15, more than 40%, or about 80,000 individuals of a 200,000 service population.1 By comparison, on August 13, the United States as a whole had a testing rate of 2.14 tests per thousand.2

President Nez and Vice President Lizer were proactive in every way they could think of. In fact, Nez declared COVID-19 a public health emergency on March 11, 2 days before President Donald Trump did. Nez and Lizer were urging people to wear masks in public even before the US Centers for Disease Control and Prevention (CDC) did, and they issued a public health emergency order to do so in mid-April.

Nonetheless, the Navajo Nation was hit devastatingly hard by the virus. In May, the Nation had the highest infection rate per capita in the country, surpassing the epicenter of New York: 2344 cases per 100,000 residents.3

On August 13, though, the population reported 48 consecutive days of fewer than 100 daily cases of COVID-19 reported and 13 consecutive days with under 50 daily cases.4 Last week the Navajo Health Command and Operations Center declared the Nation to be in Orange status, or “moderate-high restrictions”, in which most businesses are allowed to reopen with 25% maximum occupancy, and restaurants and banks are allowed to operate drive-through business (casinos and other places where groups gather are still closed).5

The Navajo leadership achieved this despite the fact that many Navajo live far from hospitals and clinics, about one third don’t have access to running water, and many live with extended families in small homes. Add to this a seriously debilitated infrastructure in the form of miles of dirt or gravel roads (70% of roads are in “poor or failing condition,” according to the 2016 Navajo Nation long-range transportation plan).6 There is also no electricity in many areas.7 In 2012, only about 60% of Navajo natives had landline phones; many now have cellphones but live miles from a tower8 (access has been improving since 2014, and has been accelerated due to the COVID-19 crisis).9

How do you handle infection prevention and control under extreme conditions—exacerbated by a nightmarish virus that has claimed hundreds of thousands of lives worldwide? Jonathan Iralu, MD, FACP, Indian Health Service (IHS) Chief Clinical Consultant for Infectious Diseases, Gallup Indian Medical Center (GIMC), and his staff are exemplars of tackling it promptly and effectively.

GIMC, located on the border of the Navajo Reservation, has one of the largest workloads in the IHS—250,000 outpatient encounters and 5800 inpatient admissions annually—and the largest staff of all Navajo Area IHS facilities. Its catchment area is roughly a 50-mile radius, but if patients need to contact an infectious disease specialist, they may need to travel up to 150 miles one way, often on those bad roads. Telehealth is difficult because of the technological obstacles.

Given those parameters, GIMC personnel had to be deliberate and practical—and they had to make dramatic shifts in the way they delivered care. Early on, they shut down the clinics to focus on the influx of people coming in with COVID-19. They also set up drive-up testing, including rapid testing, “really early,” Iralu says, in part to take the potential pressure off the “aging facility” (the hospital is about 60 years old). Patients go through a screening and triage is handled outside the hospital.

Staff also prepared to focus on patients who would require hospitalization—at 99 beds, GIMC is small (“but large for the IHS”). They had only 2 medical-surgical wards and a small intensive care unit. To get ready, they repurposed rooms that were formerly used for tuberculosis (TB) patients, plus some pre-op and office space. In early March they were short on supplies, like most of the country. So, they created a personal protective equipment committee to order, track, and project what the hospital’s needs would be.

Meanwhile, they had to factor in their regular patient responsibilities for a population rife with chronic health issues including diabetes, alcoholism, and cardiovascular disease. GIMC transferred staff into the inpatient and emergency departments and left a skeleton crew back in the clinics to handle emergencies and routine primary care.

Unlike many rural hospitals, GIMC delivers not only direct patient care, but it is also responsible for public health. Where another hospital might make referrals to the county Department of Health to do contact tracing investigations, for instance, Gallup staff members have to do that themselves.

Patient education—a critical part of managing the public health crisis throughout the country—is not always easy in an area on the wrong side of the “digital divide,” where fewer than half of the residents have access to high-speed Internet service.10 So GIMC healthcare providers have to make the most of every opportunity. In addition to public service information and social media posts, they do their educating at the drive-up testing sites, for instance, and have a follow-up system in which public health nurses do more education.

Iralu has worked at GIMC since 1994, with special interest in HIV, TB, and sexually transmitted disease (STD) care in rural communities. His research has focused on undifferentiated febrile illness in the American Southwest and on rural HIV care delivery. In the 1970s, the tribe, along with the IHS, created a TB treatment program using Navajo-speaking community health workers who made home visits to manage care and medications. About 14 years ago, Iralu says, he and his staff started doing the same with HIV care. Now they’re taking lessons learned from the established TB, HIV, and STD programs and translating those for this latest health challenge.

Necessarily, much of the care for the spread-out and isolated patient population is home care. The hospital has a 3-person HIV team and about 6 public health nurses who visit patients in their homes. They all speak Navajo (COVID-19 is 

Diko Ntsaaígíí-Náhást’éíts’áadah

The home-care teams emphasize the importance of handwashing, of course. Although water may be in short supply in some places, Iralu says it hasn’t been an insurmountable problem. For one thing, “it’s been easy to get alcohol wipes.” He also points to volunteer groups that take water out into the isolated rural areas. Contrary to reports of lack of water being a major issue, he says, “it’s a bit of an exaggeration” to say so.

Another thing that they’ve done “beautifully,” he says, is to create “alternate facilities” to care for patients with COVID-19—albeit in a kind of counterintuitive way. When a member of a multigenerational family is diagnosed with COVID-19, the first idea might be to isolate that person in a different room from the rest of the family. “That’s really impractical,” Iralu says. So they do the opposite. They quarantine the healthy members in a hotel.

GIMC physicians Jennie Wei, MD, MPH, and Mia Lozada, MD, run the program, working in a federal/nonprofit/volunteer consortium to take care of people who have been exposed to the virus and have no other place to stay. More than 800 patients have been isolated in hotels since March.11 Lozada credits the program with helping to drive down the case numbers in Gallup.

Those kinds of culturally sensitive care solutions are important for all their patients, but particularly for Native American elders, who are vulnerable to the SARS-CoV-2 virus. Older people are highly valued in Native American culture, and protecting them is a high priority. “Elders carry tradition,” Iralu says. “We have to keep them safe.”

President Nez has also made this plain in his overall pandemic plans. “I challenge the Navajo people: Let’s protect [our elders] by staying home,” he said during a virtual town hall on June 9.12 “It’s our responsibility as family members.” Vice President Lizer echoed that, saying supporting elders benefits everyone. “Love for our elders means we all win.”

In the early days of what became a pandemic, Iralu and his colleagues were reassuring people that there were few cases. Then, as things worsened, they began advising extreme caution. They’re still advising caution. In an interview in July, Iralu expressed “cautious optimism” about managing the COVID-19 case numbers. He’s now concerned about what might happen as winter brings influenza, and how a combination of the 2 viruses might affect his hospital. There’s also the issue of neighboring states with conflicting rules and surges in cases. But overall, he says, he remains cautiously optimistic.

The pandemic has been good for something, too. “It has been really beautiful to see the staff rally together with single-minded purpose,” Iralu says. “We’re working better as a team now than ever in my 26 years here.”

JAN DYER is a writer and editor specializing in clinical topics. She lives in Suffern, New York.

Navajo Department of Health. Dikos Ntsaaígíí-19 (COVID-19). Available at: 

Our World in Data. Statistics and Research. Coronavirus (COVID-19) Testing. Available at: 

https://ourworldindata.org/coronavirus-testing#the-scale-of-testing-compared-to-the-scale-of-the-outbreak

Stoney A. Navajo Nation surpasses New York for highest infection rate in the US. 

https://www.azcentral.com/story/news/local/arizona-breaking/2020/05/19/navajo-nation-passes-new-york-highest-coronavirus-infection-rate/5218748002/

The Navajo Nation. Office of the President and Vice President. Nez-Lizer Administration issues guidelines and plan to carefully reopen the Navajo Nation with phased-in approach. Press release. Aug. 13, 2020. Available at: 

https://www.navajo-nsn.gov/News%20Releases/OPVP/2020/Aug/FOR%20IMMEDIATE%20RELEASE%20-%20Nez-Lizer%20Administration%20issues%20guidelines%20and%20plan%20to%20carefully%20reopen%20the%20Navajo%20Nation%20with%20phased-in%20approach%20w%20health%20order.pdf

Navajo Department of Health. Public Health Emergency Order No. 2020-020. Public Health Emergency Order Implementing the Navajo Nation Reopening Plan and Declaring “Orange Status.” Aug. 13, 2020. Available at: 

https://www.navajo-nsn.gov/News%20Releases/NNDOH/2020/Aug/NDOH%20Public%20Health%20Emergency%20Order%202020-020%20Dikos%20Ntsaaigii-19.pdf

Wilson & Co. 2016 Navajo Nation Long Range Transportation Plan. Final Plan. April 2016.Available at: 

https://www.wilsonco.com/sites/default/files/images/LRTP%20The%20Plan.pdf

Morales L. For many Navajos, getting hooked up to the power grid can be life-changing. National Public Radio. May 29, 2019. Available at: 

https://www.npr.org/sections/health-shots/2019/05/29/726615238/for-many-navajos-getting-hooked-up-to-the-power-grid-can-be-life-changing

Smithson S. 4G network creates opportunities on Navajo Nation. National Public Radio. Available at: 

https://www.knau.org/post/4g-network-creates-opportunities-navajo-nation

Globe Newswire. Choice NTUA Wireless provides greater speed & bandwidth to the Navajo Nation. Press release. May 13, 2020. Available at: 

https://www.globenewswire.com/news-release/2020/05/13/2033022/0/en/Choice-NTUA-Wireless-Provides-Greater-Speed-Bandwidth-to-the-Navajo-Nation.html

Groetzinger K. Navajo families without internet struggle to home-school during COVID-19 pandemic. April 22, 2020. Available at: 

https://www.kunc.org/npr-news/2020-04-22/navajo-families-without-internet-struggle-to-home-school-during-covid-19-pandemic

@PIH. Dr. Jennie Wei discusses the plan to begin providing safe spaces for COVID-19 positive people in Gallup, NM to isolate safely, which led to organizing to turn hotel rooms into isolation shelters for COVID-19 in March. This plan expanded to multiple hotels in April. 

https://twitter.com/PIH/status/1283482283375243271

Reinhart K. ‘It just feels like they’re forgotten’: Navajo women mobilize to protect elders from COVID-19. Cronkite News. Arizona PBS. Aug. 13, 2020. Available at: 

https://cronkitenews.azpbs.org/2020/08/13/covid-indian-country-navajo-women-elders/

Much of the care for the spread-out and isolated patient population is home care. The hospital has a 3-person HIV team and about 6 public health nurses who visit patients in their homes. They all speak Navajo. (COVID-19 is Diko Ntsaaígíí-Náhást’éíts’áadah.)

Practicing Infection Prevention in Isolated Populations: How the Navajo Nation Took on  COVID-19

By last December, the rates of some hospital-acquired infections (HAIs) were on the way down. For instance, by 2016, central line-associated bloodstream infections (CLABSIs) had declined 10%, catheter-associated urinary tract infections (CAUTIs) 6%, hospital-onset methicillin-resistant Staphylococcus aureus 6%, hospital-onset Clostridium difficile infections, 7%.

But for the time being that’s pretty much all we’ll know. Because shortly after the 2019 results were posted, COVID-19 was beginning to suck all the oxygen out of the room as far as tabulating infections went. So much so that, in March, CMS “announced unprecedented relief” for the clinicians and providers participating in Medicare quality reporting programs: They would not have to report data on HAIs from January 1 through June 30, the first two quarters of 2020. Announcing the suspension, CMS administrator Seema Verma said CMS was “supporting clinicians fighting Coronavirus on the front lines” and the administration was “cutting bureaucratic red tape so the healthcare delivery system can direct its time and resources toward caring for patients.”

Infection prevention resources have necessarily been diverted to outbreak management, but the impacts on traditional HAI surveillance and prevention efforts “remain concerning,” say clinicians from the Hospital Infection Prevention Program at Virginia Commonwealth University Health System in Richmond. 

 They conducted an informal Twitter poll in April 2020, asking the infection prevention and hospital epidemiology community what percentage of their traditional infection prevention time had been diverted to COVID-19 response efforts. Of the 220 respondents, 79% said they were spending more than 75% of their time.

The potential impacts of the diversion, the authors suggest, are numerous. Surveillance efforts, process measure data collection, and mitigation efforts may be compromised. Moreover, shortages in traditional PPE resources have led the CDC to recommend, for instance, that hospitals with gown shortages stop using isolation gowns for endemic pathogens such as MRSA and vancomycin-resistant Enterococci. Antimicrobial stewardship programs may also divert their attention to Covid-19, meaning that an influx of critically ill patients could drive suboptimal antibiotic uses, putting patients at risk for antibiotic resistance and CDI.

Only 28 states have passed laws to provide the public with hospital infection “report cards,” and it’s only been about six years since CMS began penalizing hospitals that have poor records on hospital-acquired conditions.

 But those are factors in the downward trend for HAIs. The information at Hospital Compare, for example, which is Medicare’s database on quality of care at more than 4,000 Medicare-certified hospitals, “encourages hospitals to improve the quality of care they provide.”

 The teeth in the “encouragement” are the reduced Medicare payments for hospitals that rank in the worst-performing quartile with respect to hospital-acquired conditions, including CAUTI, CLABSI, MRSA bacteremia, CDI, and surgical site infections.

 (CMS’s temporary suspension of penalties, Stevens suggests, is an acknowledgment of the challenges facing the IP community and should be considered and copied by other quality programs.)

Watchdog organizations that allow customers to compare hospitals by ratings have made infection control measures more transparent. The Leapfrog Group, a nonprofit organization that collects, analyzes, and disseminates data on quality and safety of the healthcare system, assigns bi-annual letter grades to general acute-care hospitals to bring patient safety “into the sunlight” and “prove transparency can save lives.” Leapfrog says its safety grade is the nation’s only rating focused entirely on patient safety, including infections.

 According to the 2019 Hospital Safety Grade, 33% of more than 2,600 hospitals earned an “A.”

HAIs are still a serious problem, of course: 1 in 31 hospital patients has at least one.

 And just because hospitals were given a reprieve from reporting for (so far) the first half of 2020 doesn’t mean someone isn’t paying attention. Healthcare providers, infection control experts, and hospital administrators are still noting patterns and doing studies.

Kathleen McMullen, the manager of infection prevention at Christian Hospital and Northwest Healthcare, St. Louis, and lead author on an article about HAIs during the Covid-19 pandemic, writes that the greatest impact is expected to be on CLABSI rates.

 COVID-19 patients are at higher risk for many reasons, she notes, including increased use of femoral lines for central access (away from the mouth and respiratory tract). She and her co-authors, Barbara Smith and Teri Rebman, say two of their hospitals have seen dramatic jumps already: One hospital had a 420% increase; a second had a 327% increase. They also saw a jump in CAUTI for similar reasons: a 179% increase at one hospital, a 57% increase at the other.

One beneficial aspect of COVID-19 is the enhanced environmental cleaning, which reduces organisms spread via contact, like C difficile. McMullen et al say C difficile rates dropped 51% and 45% in the two hospitals. They add, however, that some PPE conservation practices may be concerning, such as reuse of isolation gowns and reduced focus on contact isolation precautions in lower-risk patients.

Although a low number of studies have been published so far, the rates of bacterial infection in COVID-19 patients are “considerable and probably underestimated,” says Patrizia Spigaglia, from the Istituto Superiore di Sanità, the leading technical-scientific body of the Italian National Health Service that’s located in Rome. In part, this is due to the complexity of bacterial infection diagnosis during the current health emergency. She also warns about a higher risk of C difficile infections, because of the connection with antibiotics. She cites estimates that 72% of COVID-19 patients have been treated with broad-spectrum antibiotics, and about 75% of residents in long-term-care facilities (LTCFs, and hardest hit by COVID-19) receive at least one course of antibiotics during 6 or more months.

The mid-pandemic studies have the immediacy of ongoing research, because the patients who survive usually have only recently had COVID-19, or still have it. And the findings vary—not surprising since the studies are often observational, in individual hospitals, with small patient populations.

For instance, a single-center study in northern Italy found a high incidence of bloodstream infections in the study group of 78 critically ill patients with COVID-19.

 The cumulative risk of developing BSI was almost 25% after 15 days in the ICU, potentially surpassing 50% after 30 days. On the other hand, researchers who analyzed 88,201 blood cultures from 28,011 patients at New York-Presbyterian hospitals found the rate of bacteremia, which can lead to bloodstream infections, low among COVID-19 patients.

 In fact, bloodstream infections, the researchers said, are “very rare” in COVID-19 patients.

All the usual suspects of HAI are now compounded by this new one—COVID-19 itself. Zhou et al conducted a meta-analysis of 40 studies and found the proportions of nosocomial Covid-19, SARS and MERS were relatively similar: 44%, 36% and 56%, respectively. Of the confirmed patients, the medical staff and other HAIs accounted for 33% and 2% of Covid-19 cases, 37% and 24% of SARS cases, and 19% and 36% of MERS cases.

Despite the heavier workload of dealing with COVID-19, it’s more important than ever to provide data feedback by surveillance on Enterococcus, S aureus, Klebsiella, Acinetobacter, Pseudomonas and Enterobacter spp., according to Dexter et al. Cleaning and other processes, these physicians write, significantly reduce the transmission of pathogenic bacteria and viruses—particularly important for a virus like SARS-CoV-2, which can survive for at least three days on a variety of materials, including stainless steel and plastic.

Two categories—patients with hospital-acquired COVID-19 infection and healthcare personnel with occupationally acquired COVID-19—are new metrics that require monitoring, say McMullen and her co-authors. The definitions are not clear yet, they add, due to the mass of unknowns swirling around COVID-19, but determining the definitions should be a priority for the infection prevention field. Infection preventionists should take action now, they urge, to prevent some of these anticipated health outcomes. They should encourage continual focus on proven best practices for CLABSI and CAUTI prevention, and prioritize IP observation of invasive procedures.

As the pandemic seems not to abate, patients will start to present to the hospital after delaying crucial primary and preventive care visits, meaning sicker non– COVID-19 infected patients, with the potential for increased CLABSI and CAUTI rates. Patients selected for the first non-emergent surgeries will also be at higher risk of infection, which may lead to higher rates of SSIs.

In other words, despite this new threat, and despite the reprieve from data reporting, now is not the time to let surveillance of the “old familiar” HAIs slip.

US Department of Health and Human Services. National HAI targets & metrics. HHS website. https://health.gov/our-work/health-care-quality/health-care-associated-infections/targets-metrics. Accessed 07-20-20.

Centers for Medicare and Medicaid Services. CMS announces relief for clinicians, providers, hospitals and facilities participating in quality reporting programs in response to COVID-19. CMS website. https://www.cms.gov/newsroom/press-releases/cms-announces-relief-clinicians-providers-hospitals-and-facilities-participating-quality-reporting. Accessed 07-20-20.

Stevens MP, Doll M, Pryor R, et al. Commentary: Impact of COVID-19 on traditional healthcare-associated infection prevention efforts. Infect Control Hosp Epidemiol 2020; 1–2. doi:10.1017/ice.2020.141.

Committee to Reduce Infection Deaths. Hospital Infection Reporting. https://hospitalinfection.org/resources/state-infection-laws/state-law-summary/. Accessed 07-20-20.

Centers for Medicare and Medicaid Services. Hospital-Acquired Condition Reduction Program (HACRP). CMS website. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/HAC-Reduction-Program. Accessed 07-20-20.

6.	Medicare.gov. Hospital Compare CMS website. https://www.medicare.gov/hospitalcompare/About/What-Is-HOS.html. Accessed 07-20-20.

Leapfrog Group. 20 years after “To Err Is Human,” Leapfrog Hospital Safety Grades prove transparency can save lives. Leapfrog Group website. https://www.hospitalsafetygrade.org/about-our-movement/newsroom/display/807485. Accessed 07-20-20.

Centers for Disease Control and Prevention. HAI Data. CDC website. https://www.cdc.gov/hai/data/index.html. Accessed 07-20-20.

McMullen KM, Smith BA, Rebman T. Impact of SARS-CoV-2 on hospital-acquired infection rates in the United States: Predictions and early results. Am J Infect Control. 2020 Jul 2 doi:10.1016/j.ajic.2020.06.209 [Epub ahead of print].

Spigliaga P. COVID-19 and Clostridioides difficile infection (CDI): Possible implications for elderly patients. Anaerobe. 2020;64. Published online 2020 Jun 25. doi:10.1016/j.anaerobe.2020.102233.

Giacobbe DR, Battaglini D, Ball L, et al. Bloodstream infections in critically ill patients with COVID-19. Eur J Clin Invest. 2020;46(2): 266–284. doi.org/10.1111/eci.13319.

Sepulveda J, Westblade LF, Whittier S, et al. Bacteremia and blood culture utilization during COVID-19 surge in New York City. J Clin Microbiol. doi:10.1128/JCM.00875-20.

Zhou Q, Gao Y, Wang X, and others. Nosocomial infections among patients with COVID-19, SARS and MERS: A rapid review and meta-analysis. Ann Transl Med. 2020; 8(10): 629. doi:10.21037/atm-20-3324.

Dexter F, Elhakim M, Loftus RW, Seering MS, Epstein RH. Strategies for daily operating room management of ambulatory surgery centers following resolution of the acute phase of the COVID-19 pandemic. J Clin Anesth. 2020;64 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7188624/pdf/main.pdf. Accessed 07-20-20.

As the pandemic seems not to abate, patients will start to present to the hospital after delaying crucial primary and preventive care visits, meaning sicker non–COVID-19 infected patients, with the potential for increased CLABSI and CAUTI rates.

HAIs Didn’t Go Away When COVID-19 Came Along

During the Middle Ages, people tried to escape the plague by sequestering themselves-not an easy task (then or now). Dealing with infectious diseases still comes down to containing the spread. 

Modern hospitals have isolation down to a science, literally. Nowadays, it means having a room or unit in which the infected air is rerouted, away from other patients and hospital staff. One way to do this is with a negative pressure room, in which a lower air pressure allows outside air into the room; any air that flows out of the room has to pass through a filter. By contrast, a positive pressure room maintains a higher pressure inside the treated area than that outside it. Clean filtered air is pumped in; if there’s a leak, the air is forced out of the room. Positive pressure rooms are usually used for patients with compromised immune systems; negative pressure rooms are common in infection control, to ensure infectious germs don’t spread via the heating, ventilation, and air conditioning (HVAC) system. 

A negative pressure room is particularly crucial when something like coronavirus disease 2019 (COVID-19) strikes-this new virulent killer is too much of an unknown quantity to take even the smallest chances of spreading. But the need for such rooms can put extreme stress on hospitals, which are not always ready to handle influxes of infected patients-let alone in the massive numbers of the COVID-19 pandemic. In New York, the current epicenter of the pandemic, total cases crested to 75,000 in early April-and the peak hadn’t even been reached yet.

In the case of a pandemic, says Nick Clements, PhD, an investigator at the University of Colorado, Boulder, wrote in a 2014 blog post, hospitals should be prepared for at least a 300% to 500% increase in ICU and isolation room capacity.

 But despite the increasing need for negative pressure rooms, Saskia Popescu, PhD, MPH, MA, CIC, and a member of 

’s Editorial Advisory Board, says most hospitals are not equipped to handle the high volumes of patients requiring them. Popescu, a hospital epidemiologist and infection preventionist, has researched the role of infection prevention in facilitating global health security efforts. 

“Hospital ventilation systems are designed and engineered to handle a handful of these rooms per unit,” she wrote in a 2017 article, “and so response plans often include moving these patients to designated areas like gymnasiums or tented-care areas built in parking lots.” 

Most hospitals, small and large, have some form of negative pressure space. But a pandemic with a fast-spreading mystery virus has meant many facilities are having to come up-quickly-with more places to keep the COVID patients safely isolated. Some, like Humber River Hospital, in Toronto, built in 2015 with “SARS foremost in our mind,” according to president and CEO Barbara Collins, are purpose-built to be “pandemic safe.” She told Toronto’s 

  that her hospital is capable of isolating entire departments under negative pressure. Moreover, the ambulance bay and an adjoining “hazmat room” are tailored for “seamless transformation” into a pandemic-ready area.

In an interview with WCMH-TV, Jo Henman, director of infection prevention at OhioHealth, in Columbus, said her facility has 85 inpatient negative-pressure rooms and, thanks to portable high-efficiency particulate air (HEPA) filters, the ability to create more if needed.

At Westchester Medical Center, an 895-bed regional system in the New York metropolitan catchment area, every ICU is negative pressure, and can swap out as needed (except with oncology and other high-risk patients, of course). Minnesota-based Alomere Health, which estimates its surge volume at 20 COVID-19 patients at full capacity, plans to use its negative pressure medical/surgical rooms if the ICUs overflow.

The 1500-bed Cleveland Clinic has converted a 4-story health education building into a surge hospital, with 327 beds for low-acuity patients who don’t need ventilators and accommodating up to 1000 hospital beds if needed.

 California spent $30 million to lease short-term space.

 In late March, Detroit and Chicago were both planning to turn convention centers into temporary COVID-19 hospitals.

Or, a hospital might, like Brigham & Women’s Faulkner Hospital in Boston, just decide to do a large-scale conversion-in double-quick time.

 Faulkner rapidly transformed 2 negative pressure wards for COVID-19 patients. The initial plan went from concept to development within just a few days, with a project that included converting the existing HVAC systems to 100% outside air to eliminate the risk of recirculated air, revising the system controls by rewriting its code, and rebalancing the air distribution components.

Older hospitals, or those with budgets that won’t support major conversions, can still prepare quickly. The American Society for Health Care Engineers says that standard patient rooms can be retrofitted as negative pressure isolation rooms.

 The American Society of Heating, Refrigerating and Air-Conditioning Engineers’ Standard allows for using recirculated room air, provided the air first passes through a HEPA filter. This can be accomplished with a recirculating HEPA filter unit, the association says. 

In a real time-crunch, a temporary isolation area can be set up surprisingly fast. Investigators from University of Colorado, Boulder and the VA’s National Center for Occupational Health and Infection Control got a temporary 30-bed negative pressure ward up and running in less than an hour.

They tested it in a fully functioning hospital in the San Francisco Bay Area. The existing ward had its own dedicated air-handling unit, dedicated bathroom exhaust system, a separate dedicated exhaust system for return registers in the isolation rooms, and a firewall separating the ward from the rest of the hospital. 

The research team used 2 heating, ventilation, air conditioning HEPA-filtered negative-air machines to establish the pressure. Performing pressure measurements at 22 locations, they found they maintained negative pressure that was actually higher than recommendations by the US Centers for Disease Control and Prevention (CDC), and there was no pressure reversal when medical staff entered or exited. They did find that some rooms became neutrally or slightly positively pressured, so they advise staff to use personal protective equipment at all times.

The infection prevention and control team “was heavily involved and present at every meeting,” hospital administration was very supportive, and the nursing staff were especially interested and engaged, Shelly Miller, PhD, the team leader, says.

And the research team proved that it could all be done in approximately 40 minutes-including installation and troubleshooting of the anteroom. “We wanted to get it up fast, it was duct tape and plastic,” says Miller.

Their solution could be lifesaving for smaller or rural hospitals. Miller points out that according to the Institute of Medicine’s report on medical surge capacity, the cost of pandemic preparedness is important to consider-tents, temporary housing materials, disaster response trailers, and HEPA-filtered negative-air machines are expensive. In their study, choices such as plastic sheeting with zippered openings helped lower costs.

A portable anteroom can be used as an extra layer of protection between the isolation space and the rest of the hospital. A positively pressured anteroom, for instance, lets staff don PPE in a protected environment. A drawback is that because the anteroom is less pressurized than the isolation room, there’s a risk of infectious particles carrying from the movements of healthcare workers into the patient’s room.  

Further, because the pressure in these specialized rooms has to be so carefully nuanced, maintenance is important. Citing a 2001 long-term assessment of isolation room performance, Nick Clements notes in his blog post that isolation room operating conditions may “shift away from optimal” for a variety of reasons, and operating conditions are “somewhat temporally variable.”

 A loose air handling unit fan-belt or accidental changes made during maintenance could, he says, result in “sharp changes” in the room pressure.

There are few studies as yet testing the effectiveness of establishing temporary isolation wards during a surge, cautions Clements, who was on the team that established the Bay Area temporary ward. Before including a temporary isolation ward in a hospital surge capacity plan, he advises conducting a (successful) full-scale demonstration to uncover any logistical and engineering issues.

Caring for patients in negative pressure rooms can amplify the usual constraints and stresses for staff. Guangdong Second Provincial General Hospital, in China, came up with a way to help lessen some of the stress.

By February 2020, the hospital had admitted more than 30 confirmed cases of COVID-19 and more than 200 suspected cases. It’s not uncommon, clinicians from the hospital report in 

 that medical personnel in negative pressure wards are not fully aware of their exposure while caring for patients. So, the hospital set up an innovative infection-control system called the observing system. Cameras cover the entire ward except for the privacy area. Infection control observers, who are appointed by the hospital’s Department of Infection Control and Nursing and undergo intensive training to become familiar with the requirements for infection control in the negative pressure wards, monitor the wards via computers. 

Their responsibilities include maintaining the normal operation of the isolation wards, supervising the implementation of disinfection, ensuring a sufficient supply of protective materials, arranging specimens for inspection and-not least-they “relieve anxiety of the medical personnel while treating patients.” 

They also watch to make sure healthcare providers don’t omit or overlook steps in putting on or taking off PPE. In one case a patient’s zipper unexpectedly ripped a nurse’s glove. Discovering the situation, the observer “immediately soothed the nurse and sent another staff member into the ward to assist,” assessed the risk for the nurse, and arranged a quarantine room to ensure full safety before the nurse returned to the ward.

The frontline medical staff highly recommend the new system, the authors say. 

Whether caring for a few or thousands of infectious patients, healthcare facilities must be both proactive and flexible. Most recently, Miller and her team have been conducting another pop-up test, this one in a nursing home, depressurizing an entire wing. Given that nursing homes have all along been hotspots of COVID-19, fast, secure response is key. Until we know more about this deadly intruder, protection is the strongest weapon.

Janet Dyer is a writer and editor specializing in clinical topics. She lives in Suffern, NY.

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https://microbe.net/2014/10/04/temporary-isolation-rooms-and-their-application-to-hospital-surge-capacity-for-infection-control/

2.     Popescu S. Building airborne isolation units during emergent times. ContagionLive. 08-25-17. 

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8.     Brigham & Women’s Faulkner Hospital: negative pressure wards for COVID-19 treatment. Fitzemeyer & Tocci. 04-07-20. 

https://www.f-t.com/post/brigham-women-s-faulkner-hospital-negative-pressure-wards-for-covid-19-treatment

9.     Herrick M. Retrofitting an existing room for negative isolation. 

https://www.hfmmagazine.com/articles/2672-retrofitting-an-existing-room-for-negative-isolation

10.  Miller SL, Clements N, Elliott SA, Subhash SS, Eagan A, Radonovich LJ. Implementing a negative-pressure isolation ward for a surge in airborne infectious patients. 

https://www.sciencedirect.com/science/article/pii/S0196655317300925

11.  Chen X, Tian J, Li G, Li G. Initiation of a new infection control system for the COVID-19 outbreak. 

https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30110-9/fulltext

										A portable anteroom can be used as an extra layer of protection between the isolation space and the rest of the hospital. A positively pressured anteroom, for instance, lets staff don PPE in a protected environment.						 

Author | Jan Dyer

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