Saskia v. Popescu, PhD, MPH, MA, CIC

For many states with a growing number of coronavirus disease 2019 (COVID-19) cases, a real issue has been the challenge of understanding exposures. With surging cases in Arizona, California, Texas, and Florida, this means that exposure risks for healthcare workers are growing in the community. For those of us in healthcare, this adds to the challenge of identifying when healthcare workers become sick. Checking against exposures we know might have happened, this can be problematic. How many of us truly know when we’ve been exposed? The knowledge we have in healthcare can be both a gift and burden. We know who has COVID-19, but once we leave the hospital, that knowledge of potential exposures likely goes right out the window.

 from the Centers for Disease Control and Prevention (CDC) 

 (MMWR) has shed light on how many people truly know where their exposure to SARS-CoV-2 occurred. Interviewing 364 participants during March 9-27 across Colorado, the researchers found some interesting sources for these COVID-19 cases.

The authors noted that “among the 265 (73%) participants without known contact with a laboratory-confirmed COVID-19 patient, 30% (79 of 265) reported contact with a person they knew who had fever or respiratory symptoms. The most commonly reported activities in the 2 weeks before becoming ill included attending gatherings of >10 persons (116; 44%), traveling domestically (76; 29%), working in a healthcare setting (75; 28%), visiting a healthcare setting not as a healthcare worker (61; 23%), and using public transportation (57; 22%).”

Moreover, nearly 30% reported contact with at least one person who had laboratory confirmed COVID-19. A majority of this group reported that their exposure was related to a household member, whereas 25% noted that exposure to a confirmed case occurred in the workplace. These two types of exposures represented the majority of those reported from people with known exposures to confirmed cases. Of those with workplace exposures, a majority stated that this contact occurred in healthcare settings (60% were in healthcare personnel), followed by public administration or military.

While these findings are important, perhaps the most concerning is that so many of newly diagnosed cases aren’t aware where their infection stemmed from – where the exposure occurred. This is an increasingly important trend as infection preventionists work to respond to surges of COVID-19 cases. While healthcare worker exposures can and do occur, so many also occur out in the community. It’s easy to assume the greatest risk is in the hospital, where cases occur. This is also where the greatest protection occurs though – the near universal masking, presence of enhanced isolation precautions, and intense focus on isolation precautions. It’s when we leave the hospital or go to get a coffee in the cafeteria, our behaviors can become lax. We opt to take breaks from masking, exhausted from it all. Communicating these risks are important though. Since it’s so easy to focus on those high-risk exposures, we may not realize how frequent those small moments occur. It’s a helpful to remind staff about the risk in the community and how they can protect themselves while still living their lives. Discussing risk spectrums and harm reduction measures can go a long way and help staff stay safe beyond the walls of the healthcare facility, which is ultimately our goal.

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It’s when infection preventionists leave the hospital or go to get a coffee in the cafeteria, that behaviors can become lax. We opt to take breaks from masking, exhausted from it all. 

Low-Risk Exposures to COVID-19 Can Sometimes Pack Deadly Punch

As the United States sees a steep rise in cases across several states like Arizona, California, Florida, and Texas, there is increasing concern for long-term implications within healthcare. Perhaps one of the most challenging aspects of healthcare’s response to coronavirus disease 2019 (COVID-19), is the ongoing fatigue and readiness as cases rollercoaster.

For so many of us, one rather odd piece to infection prevention in the time of COVID-19 is the more quiet moments when elective surgeries are cancelled, but COVID-19 units are busy and the hospital is a mixture of chaotic and quiet. When hospitals cancel elective surgeries to hold for surge capacity, it creates a unique situation in which we are busy while simultaneously being emptier.

In Arizona, this was the case and the stress of the COVID-19 units was drastically different than the quiet areas in the hospital that would normally be teeming with people due to have surgeries. Another piece to this though is that during the spring, many people avoided hospitals for two reasons. First, there was fear of catching COVID-19, which is always a misconception during outbreaks. Second, they hear on the news that hospitals are stressed and don’t want to add to it or were worried about quality of care.

 from the Center for Disease Control and Prevention (CDC) 

(MMWR) points to this very issue by looking to the indirect effects of the pandemic on use of emergency departments for acute life-threatening conditions. By utilizing national syndromic surveillance data, they found that in the ten weeks following the declaration of COVID-19 as a national emergency, those emergency department visits were significantly impacted.

Overall, emergency department visits dropped 42% during the initial months of the outbreak. Their analysis focused primarily on myocardial infarction (MI), stroke, and hyperglycemic crisis, that occurred before and after the declaration. While this list is not exhaustive, it provides a good representation of the impact the pandemic had on emergency departments and thus hospitals. The authors note that “in the 10 weeks following the emergency declaration (March 15–May 23, 2020), ED visits declined 23% for MI, 20% for stroke, and 10% for hyperglycemic crisis, compared with the preceding 10-week period (January 5–March 14, 2020). EDs play a critical role in diagnosing and treating life-threatening conditions that might result in serious disability or death.”

Interestingly, the decline of these ED visits was similar across all age groups for MI and stroke, but for hyperglycemic crisis, those younger who were female tended to avoid the emergency departments. When looking across all ages and conditions, the researchers found that the largest differences were in those adults over 65 years of age going to the emergency department for MI or stroke, those between 18-44 and less than 18 years of age who would visit for hyperglycemic crisis.

While these findings aren’t particularly surprising, they do shed light on the implications for people experiencing medical crises and their willingness to seek care during a pandemic. It is critical that efforts be made to communicate to the public the safety of hospitals and not to avoid seeking care during events, like the COVID-19 pandemic. Delays in seeking care can result in potentially avoidable severe illness or death.

While the rest of the hospital bustles with energy as healthcare workers fight COVID-19, emergency departments have been oddly quiet because of the drop in elective surgeries.

Emergency Departments Now the Quiet Eye of the COVID Hurricane

While cases in New York City have been on the decline and many states are reopened or in the process of reopening, across the United States, 6 states are seeing record high cases. Arizona, Florida, Oklahoma, Oregon, and Texas are all seeing major spikes in their cases of COVID-19. For many, this is 

 of rapid reopening efforts, but also Memorial Day weekend events and gatherings possibly paid a part. In fact, 17 states saw their new cases rises within the last week. (Oklahoma saw cases rise by 68%.)

With well over 2 million cases in the United States, the question then becomes has the second wave begun or are we still experiencing the first wave? Or has the first wave been so rough that it’s blending into the second wave? 

For many, it seemed like the first wave of COVID-19 cases was mild and didn’t feel as chaotic as what we saw across some U.S. cities, while others experienced deeply traumatizing, overwhelmed hospitals. That so many of us were in different periods of the outbreak often lends itself to many thinking we’re through the first wave … or even the pandemic. Cheer down. As we’re seeing in many states, that’s just not the case. For many, 

Those of us in healthcare and infection prevention must focus on sustainable efforts to combat COVID-19. How do we maintain readiness and response without burnout? There’s no solid answer to this, but a big piece really goes into the establishment of plans and education. 

For those scaling down, what are your indicators for scaling back up? Sometimes the hardest thing is recognizing when we need to start looking again at personal protective equipment (PPE) re-use efforts, surge capacity, and all the other aspects of pandemic response that had to be implemented initially. 

The good thing is that we have knowledge on our side, both in terms of lessons learned and hopefully having some more processes already in place; processes that don’t need to be created or revised. Having COVID-19 plans, like information on extended use of N-95 masks, or duration of isolation, available online on intranets can be immensely helpful. 

Another piece to this is reiteration of training and screening. While most are using universal masking practices for all hospital employees, how confident are we in their compliance or habits? Now is the time to do educational roadshows on PPE and isolation precautions. They don’t have be long, but it’s a nice way to stop by units not treating COVID-19 patients and discuss proper masking practices. (For instance, wearing PPE all day is rather novel for most of us.) 

Moreover, this is the time to chat with staff about hospital plans and address questions they might have. Using those quiet moments to invest in sustainable COVID-19 infection prevention goes a long way and helps to reduce the long-term burden on the infection preventionists. Giving staff the skills to not only be safe, but also critically think through infection prevention situations, is critical to their safety and that of the patient. 

In the beginning, we were rapidly trying to do training and education, acquire PPE, and develop educational materials and processes. Now is the time to regroup and refine our practices, like ensuring staff understand when isolation precautions for COVID-19 patients can be discontinued, or where the information is available to give to patients being sent home, but still requiring isolation. These are a just a few lessons learned and a handful of things that can help guide us to a more sustainable approach to COVID-19.

Infection Preventionists Prepare to Ride the Second Wave of COVID

The supply (or lack thereof) and utilization of personal protective equipment (PPE) has been one of the most frustrating aspects of dealing with COVID-19 for infection preventionists (IPs). Enacting emergency re-use and extended-use policies and protocols is not only a novel situation but something that goes against our natural tendencies. One of the first ways we can work toward more sustainable efforts is to first focus on daily PPE counts. This is something most likely to do with larger, international and national supply chains from manufacturers and distributers, but overall, this is a good measure to establish as a standard IPC practice. 

The COVID-19 pandemic shed light on the dependency we in healthcare and in the United States have on international suppliers and manufacturers of critical items, like PPE.  

 in February, “According to data compiled by the US Department of Health and Human Services, 95% of the surgical masks used in the US and 70% of the respirators-thicker, tight-fitting masks that offer better protection against viruses-are made overseas. That leaves the mask supply vulnerable to labor disruption if a pandemic sickens manufacturing workers, as well as to flat-out diversion if a government decides to keep its own stock at home.” 

As the COVID-19 pandemic fluctuates and might be more severe in some countries, supply chains will likely be impacted. Shortages extend beyond masks and gowns, but also into tubing, Foley catheter kits, disinfecting wipes, hand hygiene, disposable laryngoscope blades, and much more. COVID-19 ultimately represents the bigger issue of hospital preparedness and how we integrate critical aspects, like supply chain and surveillance.

Keeping a continued eye on critical supplies is one piece to addressing a vulnerable supply chain. Moreover, are IPs evaluating days on hand or also considering surges? In many cases, the relationship between IP and the supply chain department is passive and fluctuates with emergencies or new products. What if, though, we worked to have a more proactive relationship that involved weekly meetings regarding the level of supplies, like PPE? Right now, many of us are getting daily reports on the number of supplies we have and how many days of utilization that translates to.

Working with the supply chain department to set up more continuous, proactive check-ins that are measured by days of supplies on hand and how that would fluctuate with varying surges can be immensely helpful. 

In addition, IPs can possibly utilize more sustainable PPE. Full-face respirators have become more common with the COVID-19 pandemic. These offer an alternative to N95 respirators and, in some cases, combine eye protection. A benefit to these devices is that they are re-usable and able to be cleaned and disinfected between use. Like powered air purifying respirators (PAPRs), they offer a long-term alternative for extended use that is often more comfortable for staff. More importantly, they allow staff to re-use them with disinfection protocols that change the traditional disposable notion of PPE. While IPs have traditionally thought of PAPRs for only emergency preparedness situations, perhaps full-face respirators offer a middle ground that can change pandemic preparedness in healthcare. 

Face shields are another piece to this puzzle. More research is being done about the feasibility of utilizing face shields in several environments-for all triage staff as protection measures, but also as a potential alternative for community 

. While these offer protection for eyes, respiratory protection will still be required for those in isolation requiring a mask (e.g. surgical or N95). The use of face shields in the community as an alternative to face masks is an increasing topic of conversation and while changes cannot be made to current PPE protocols at the moment, it will be interesting to see where this research leads.

In many cases, the relationship between IP and the supply chain department is passive and fluctuates with emergencies or new products. What if, though, we worked to have a more proactive relationship that involved weekly meetings regarding the level of supplies, like PPE?

Author | Saskia v. Popescu, PhD, MPH, MA, CIC

Articles

Low-Risk Exposures to COVID-19 Can Sometimes Pack Deadly Punch

Emergency Departments Now the Quiet Eye of the COVID Hurricane

Infection Preventionists Prepare to Ride the Second Wave of COVID

COVID-19 Lesson: How IPs Can Ensure We Never Run Out of PPE Again