Nancy Messonnier, MD, director of the CDC’s National Center for Immunization and Respiratory Diseases, last month 

 that businesses, schools, and government agencies take advantage of telecommuting and telehealth in the face of the COVID-19 outbreak. Judd Hollander, MD, an emergency department physician and the senior vice president for healthcare delivery innovation at 

 in Philadelphia is ready. Under Hollander’s guidance JeffConnect, an umbrella name for 

, in 2015 launched on-demand app allowing patients to connect with Jefferson emergency medicine physicians from home via their cell phones, tablets, or computers with a webcam. Jefferson officials say that the app encourages those who think they may have been exposed to the flu and/or COVID-19 to consult with an emergency medicine physician via a webcam. 

caught up with Hollander recently to ask him about how telehealth can help combat COVID-19 spread.

: Is telehealth in general better positioned to help during the COVID-19 outbreaks than in past outbreaks? If so, how so?

The largest difference with COVID-19 and past disasters or outbreaks is twofold. First, telemedicine is much more advanced and is commonly used in some health systems. For example, Jefferson has done over 150,000 synchronous audio video visits across over 1,000 providers. Thus, when a crisis comes, it is possible to rapidly scale. The second difference is that there is not a problem with infrastructure as might happen after a hurricane so that communications methods are not disrupted.

:Are doctors and patients more inclined to use telehealth than they were even 5 years ago? Are there concerns among physicians about reimbursement for services?

Without a doubt, reimbursement is the main thing that has prevented further adoption of telehealth. Only a few states mandate the payers pay for the services regardless of how they are delivered (in-person or via telemedicine). Thus, when payers prioritize their shareholders and try to avoid paying while physicians try to prioritize their patients, there is a large financial liability to providers and health systems that is not filled by the payers. Thus, fewer systems are using telemedicine than would otherwise use if it was reimbursed. When you do not have a baseline program, you cannot really scale it overnight.

:You say that the telehealth]services have increased in popularity in recent years. Can you give me a better idea of how much that popularity has increased?

At Jefferson, we have a 200-400% increase year over year depending upon which use cases. We are now doing nearly 300 telemedicine encounters per day, and that was before COVID-19.

:Do some conditions/diseases lend themselves to telehealth better than others? For instance, would oncology be something that’s telehealth-friendly?

The best use case for telemedicine is for the patient who is happy to do a telemedicine call. We have been surprised to learn that it can be used and be very well accepted in areas we never would have predicted. A couple examples include post mastectomy care, care following surgical procedures and nutritional consultations for diabetes. We tend to let patients drive the decision to do telemedicine rather than in-person care. 

:How has telehealth been used against the flu?

Jefferson has JeffConnect, a direct to consumer on-demand app that anyone in our service area can download for free, register and within 5 minutes do a visit with an emergency physician-the same people who work in our urgent care centers and emergency departments. We treat a lot of patients with the flu or presumptive flu. Patients that do not meet evidence-based criteria for anti-viral agents can be treated symptomatically. Patients who meet criteria can either be sent for testing or be treated empirically. We have been doing this for years.

:Can a physician actually diagnose COVID-19 via telehealth or does there need to be samples taken?

The approach to COVID-19 via telemedicine begins with screening the patient for risk of COVID-19 using the latest CDC recommendations. Then the approach is much like that with influenza, except for an increased emphasis on social distancing. If patients are stable and have a COVID-19 exposure risk, we have coordinated with the local department of health so that they can go home for home quarantine and the DOH can come to the house to perform testing. Our goal is very much to prevent exposure of anyone else to the person under investigation while providing the best care for the patient, in accordance with the latest CDC guidelines.

: Nancy Messonnier, MD, director of the CDC’s National Center for Immunization and Respiratory Diseases, recently suggested that hospitals and other healthcare facilities use telehealth in dealing with COVID-19. Has this been the biggest CDC push for telehealth use that you recall?

:How can telehealth help infection preventionists and hospital administrators do their jobs better? For IPs especially; that seems to be very much of a hands-on job. Where would telehealth fit in?

We use telehealth in the outpatient setting but we also use it in the in-person setting. Let’s face it, consults give advice over the phone. They don’t need to touch each patient. We try to limit the number of people in the room and leverage telemedicine so the person inside the room can be the eyes and ears of the others. Of course, when procedures are needed, the best person to do the procedure needs to don PPE and go in the room, but the more we can limit exposure the better.

Articles

A Conversation With Judd Hollander, MD: How Telehealth Can Address the COVID-19 Outbreak

As the novel coronavirus COVID-19 continues its logarithmic leaps from person to people, across borders and oceans, trailing jokey and terrifying viral memes, it has triggered an odd assortment of hoarding behaviors in the panicky public: toilet paper, hand sanitizer, soap … and surgical face masks.

Early-and indeed, ongoing-lack of information about the virus’ etiology and pathology meant face masks have become a precious commodity. In early March, health authorities from Washington state (which by that time had announced the first COVID-19–related death in the US) sent an urgent request to the federal Strategic National Stockpile for 233,000 respirators and 200,000 surgical masks.  

They received an answer-but not the one they hoped for. They would get less than half the amount they requested: 93,600 N95 respirators and 100,200 surgical masks.

In late February, when US Department of Health and Human Services Secretary Alex Azar said the US needed at least 300 million N95 respirators for healthcare workers, the US had only 30 million.

As of March 5, Prestige Ameritech, one of the few manufacturers still making face masks and respirators in the US, had received requests for 1.5 billion masks.

As of March 10, the US had a national stockpile of 12 million N95 masks and 30 million surgical masks for a healthcare workforce of about 18 million, according to an article in 

, which notes “[i]f only 6 million of them are working on any given day (certainly an underestimate) they would burn through the national N95 stockpile in two days if each worker only got one mask per day, which is neither sanitary nor pragmatic.”

The US Centers for Disease Control and Prevention (CDC) in mid-March posted new guidelines, saying surgical masks are now an acceptable alternative for N95 respirators because “the supply chain of respirators cannot meet demand.”

The mismatch between demand and supply has opened questions about what actually is the best way to protect against infections like COVID-19, and who will benefit most from them. The World Health Organization (WHO) has said wearing masks may create a false sense of security among the general public.

US Surgeon General Jerome Adams, MD, tweeted in exasperation: “Seriously people-STOP BUYING MASKS! They are NOT effective in preventing general public from catching #Coronavirus, but if healthcare providers can’t get them to care for sick patients, it puts them and our communities at risk!” 

Shortfalls in protective masks have put a spotlight on 2 concerns in particular: utility and compliance. Experts agree that not every situation requires a face mask, even in this world of drug-resistant bacteria-although it isn’t always definitively clear which situations do. 

In an interview with BBC News, David Carrington, MD, of the University of London, said although routine surgical masks could help lower the risk of contracting a virus via the “splash” from a sneeze or cough, and provide some protection against hand-to-mouth transmission, they aren’t effective against airborne viruses or bacteria because they’re too loose, have no air filter, and leave the eyes exposed.

Face masks have come a long way since the 1800s, when they were basically gauze strips placed over the mouth. Originally developed to minimize the risk of transmitting microorganisms from clinician to patient, they’re now intended to protect both patients and clinicians from drug-resistant pathogens transmitted by blood or other body fluids. 

Masks come in different shapes, with different features, intended for different purposes: flat-fold tie-on, duckbill with or without shield, cone shaped, flat-fold with shields…theoretically, there should be something for everyone. But they’re only effective when worn properly, and not everyone can-or does-wear them properly. Most guidelines suggest changing a surgical mask any time it becomes wet. A mask wet with exhaled moisture has increased resistance to airflow, is less efficient at filtering bacteria, and vents more.

It’s not uncommon, though, says Dianne Rawson, RN, MA, in 

, to see masks poorly fitted, placed below the nose, or wet with blood or body fluids.

Even the correct mask can put clinicians at risk if not worn correctly: with nose and mouth completely covered to create a seal and prevent gaps. But fit can be an issue for anyone whose face doesn’t follow the median contours, or someone who has a beard or mustache. A 2000 study found that bacterial shedding from people with beards was increased (although an analysis of that study called it “an example of contamination being extrapolated to infection without measuring the endpoint of infection”).

One National Health Service hospital in England has responded to the coronavirus pandemic by asking staff to “consider” shaving their beards. “I recognize,” Derek Sandeman, MD, the medical director, said, “for some this is a big ask, that beards are so popular at present. However, I do believe it is the right thing to do.” He added that alternative types of respiratory equipment are available for people who have a good reason to keep their beards, including for religious reasons.

The CDC has helpfully published a visual aid for the kinds of facial hair that work, or don’t work, with mask use.

Some styles, such as soul patches, pencil mustaches, and “the Zappa” made the cut. 

The current health emergency (like other pandemics) has also put a new spotlight on compliance, a complicated subject. Studies have demonstrated that healthcare workers are generally poorly compliant with respiratory guidelines.

But compliance studies often run into the Hawthorne effect: Knowing they’re being observed, staff tend to improve their adherence. 

Interestingly, a 2019 study found that following hospital protocol for using N95 respirators was a given-until it wasn’t. Discussions with focus groups of nurses and nursing assistants at 4 Veterans Administration and academic medical centers revealed that discomfort was not the main issue. People wanted to follow respiratory protective equipment (RPE) protocol, the investigators said, but RPE misuse was driven by “personal” protocols, such as when people did not trust the protocol and instead relied on their experience. Generally, the misuse amounted to overuse-staff didn’t trust the safety protocols and wanted to protect themselves and patients. The overuse, of course, is a factor in supply shortages.

Moreover, according to researchers who reviewed studies on facial protection, healthcare workers may view standard precautions as adversely affecting job performance and their relationships with patients: They cite insufficient time, interference with job duties, reduced dexterity, and discomfort.

But the investigators also found peer pressure and attitudes of family members who were afraid of contracting infection influenced the actions of the healthcare workers, making them more likely to adhere to safety procedures.

One health professional said, “I think the fear of contracting the disease was palpable, very real. Nobody was trying to cut corners.”

The CDC has issued interim recommendations, tempered with reality: When possible-given the current shortages-patients with confirmed or possible infection should wear surgical masks, and healthcare workers treating potentially infected patients should wear N95 respirator masks and goggles. N95 respirators are more protective, reducing exposure to small particles, filtering out at least 95% of airborne particles, and, because of the tight fit, allowing minimal leaking

(the National Institute for Occupational Safety and Health recommends fit assessment during the initial selection of a respirator and periodically as part of a respiratory protection program.)

But the tight fit that makes respirators safer than masks also makes them uncomfortable, especially when worn for long stretches. Julie Feuer, an oncology nurse practitioner in a large county hospital in Westchester County, New York, says she wears a mask for about half the day, depending on how many of her patients are on droplet isolation. Although she prefers the N95 for safety reasons, especially during this pandemic, “it’s pretty tight on my face, leaving marks-and it’s hot under there!” It’s a little claustrophobic, she says. “Regular surgical masks are easier to deal with and looser fitting.” 

Kathy Manelis, RN, agrees. Recently retired after 37 years, she worked with critically ill patients and usually wore a mask for 20 to 30 minutes at a time. She, too, found the masks claustrophobia-inducing-and they steamed up her glasses.

Alessia Bonari, a young nurse in Italy, posted a photo of the chafe marks from the respirator, saying, “I’m afraid because the mask might not stick properly to the face…I’m physically tired because the protective devices hurt…”

Respirators have also been associated with mild adverse effects, including acne, skin rashes, dehydration, and headaches. About one third of healthcare providers in one study reported headaches, which could be due to hypoxemia, hypercapnia, or stress, the researchers say.

It’s also possible, they note, that the pressure from the strap on the neck over the superficial nerves might aggravate neck strain. 

Researchers who surveyed healthcare workers about respirator use said the respondents were looking for respirators that are more comfortable, interfere less with breathing, diminish heat buildup, are disposable, and permit the user to have facial hair.

Healthcare workers have also said time constraints related to donning, doffing, and changing masks frequently are very real: “…In triage, you change your goggles, gloves, mask and gown between every patient and it’s 100% not feasible,” said one. “Patients would be dying waiting at the triage desk.”

The CDC offers alternatives to N95 respirators, such as other classes of filtering facepiece respirators, elastomeric half-mask and full facepiece air-purifying respirators (which can be repeatedly disinfected, cleaned, and reused), all of which provide equivalent or higher protection than N95 respirators (“when properly worn,” the CDC cautions).

Crisis strategies also include using respirators beyond the manufacturer-designated shelf life, and “limited” re-use.

Health authorities have a double-pronged problem to tackle: The pandemic-driven urgency for enough protection and the daily-use desire for more comfortable protection. The CDC has come under fire for not planning for a shortfall during the current crisis, and for not acting quickly and forcefully enough when the crisis began to expand. The result? Workers are not sure day to day whether they’ll have the supplies they need, leading to a breakdown in a crucial bond of trust. 

“…[I]f workers had more confidence in their employers’ commitment to worker health and safety,” Yassi notes, “employees would have more confidence in the messages and directives they received during a crisis.”

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

1.    Sun LH, Goldstein A. Washington state asked the U.S. stockpile for coronavirus masks. The response raises concerns. 

https://www.washingtonpost.com/health/2020/03/05/washington-state-asked-us-stockpile-coronavirus-masks-response-raises-concerns/

2.    Secon H. People are racing to buy face masks amid the coronavirus outbreak, but they probably won't protect you from illness. 

https://www.businessinsider.com/wuhan-coronavirus-face-masks-not-entirely-effective-2020-1

3.    Not enough face masks are made In America to deal with coronavirus. NPR Morning Edition. 03-03-20. 

https://www.npr.org/sections/health-shots/2020/03/05/811387424/face-masks-not-enough-are-made-in-america-to-deal-with-coronavirus

4.    Specht L. What does the coronavirus mean for the U.S. health care system? Some simple math offers alarming answers

https://www.statnews.com/2020/03/10/simple-math-alarming-answers-covid-19/

5.    Centers for Disease Control and Prevention. Interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease 2019 (COVID-19) in healthcare settings. CDC website. 

https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Finfection-control.html

6.    World Health Organization. Advice on the use of masks the community, during home care and in health care settings in the context of the novel coronavirus (2019-nCoV) outbreak. Interim guidance 29 January 2020.www.who.int › docs › default-source › documents › advice-on-the-us... Accessed Mar. 14, 2020.

7.    Can wearing masks stop the spread of viruses? BBC.com. 01-23-20. 

8.    Lipp A. The effectiveness of surgical face masks: what the literature shows. 

https://www.nursingtimes.net/clinical-archive/infection-control/the-effectiveness-of-surgical-face-masks-what-the-literature-shows-30-09-2003/

9.    Rawson D. The basics of surgical mask selection. 

https://www.infectioncontroltoday.com/personal-protective-equipment/basics-surgical-mask-selection

10.Lipp A. The effectiveness of surgical face masks: what the literature shows. 

11.Russell P. COVID-19: NHS staff face a close shave to ensure face masks work. 

https://www.medscape.com/viewarticle/925882

12.Centers for Disease Control and Prevention. To beard or not to beard? That’s a good question! CDC website. https://blogs.cdc.gov/niosh-science-blog/2017/11/02/noshave/. Accessed March 14, 2020.

13.Baig AS, Knapp C, Eagan AE, Radonovich LI Jr. Health care workers' views about respirator use and features that should be included in the next generation of respirators. 

2010;38:18-25. doi: 10.1016/j.ajic.2009.09.005. Epub 2009 Dec 29.

14.Fix GM, Reisinger HS, Etchin A, McDannold S, Eagan A, Findley K et al.Health care workers' perceptions and reported use of respiratory protective equipment: A qualitative analysis. 

2019 Oct;47(10):1162-1166. doi: 10.1016/j.ajic.2019.04.174. Epub 2019 Jun 7.

15.Yassi A, Moore D, FitzGerald JM, Bigelow P, Hon C-Y, Bryce E and other members of The BC Interdisciplinary Respiratory Protection Study Group. Protecting the faces of health care workers: knowledge gaps and research priorities for effective protection against occupationally-acquired respiratory infectious diseases. 

16.Yassi A, Moore D, FitzGerald JM, Bigelow P, Hon C-Y, Bryce E and other members of The BC Interdisciplinary Respiratory Protection Study Group. Protecting the faces of health care workers: knowledge gaps and research priorities for effective protection against occupationally-acquired respiratory infectious diseases. 

17.Yassi A, Moore D, FitzGerald JM, Bigelow P, Hon C-Y, Bryce E and other members of The BC Interdisciplinary Respiratory Protection Study Group. Protecting the faces of health care workers: knowledge gaps and research priorities for effective protection against occupationally-acquired respiratory infectious diseases. 

18.Centers for Disease Control and Prevention. Interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease 2019 (COVID-19) in healthcare settings. CDC website. 

https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html

19.National Institute for Occupational Safety and Health. Filtering out confusion: frequently asked questions about respiratory protection. CDC website. 

https://www.cdc.gov/niosh/docs/2018-129/default.html

20.Reneau A. We owe a huge thanks to the heroes on the front line of the coronavirus pandemic. Upworthy.com. 

https://www.upworthy.com/doctors-nurses-heroes-coronavirus

21.Lim EC, Seet RC, Lee KH, Wilder-Smith EP, Chuah BY, Ong BK. Headaches and the N95 face-mask amongst healthcare providers. 

22.Baig AS, Knapp C, Eagan AE, Radonovich LI Jr. Health care workers' views about respirator use and features that should be included in the next generation of respirators. 

23.Yassi A, Moore D, FitzGerald JM, Bigelow P, Hon C-Y, Bryce E and other members of The BC Interdisciplinary Respiratory Protection Study Group. Protecting the faces of health care workers: knowledge gaps and research priorities for effective protection against occupationally-acquired respiratory infectious diseases. 

24.Centers for Disease Control and Prevention. Strategies for optimizing the supply of N95 respirators: conventional capacity strategies. 

https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/conventional-capacity-strategies.html

25.Centers for Disease Control and Prevention. Strategies for optimizing the supply of N95 respirators: crisis/alternate strategies. 

https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/crisis-alternate-strategies.html

26.Yassi A, Moore D, FitzGerald JM, Bigelow P, Hon C-Y, Bryce E and other members of The BC Interdisciplinary Respiratory Protection Study Group. Protecting the faces of health care workers: knowledge gaps and research priorities for effective protection against occupationally-acquired respiratory infectious diseases. 

One hospital has asked workers to consider shaving their beards.

When It Comes to Fighting Covid-19, Some Problems Can’t Be Masked

It’s a matter of demographics, say the authors of an article in press in the Journal of Post-Acute and Long-Term Care Medicine.1 COVID-19 will disproportionately hit nursing homes and other long-term care facilities because the disease is particularly lethal to the elderly. With that in mind, investigators with Brown University and the Veterans Administration are putting out a call against the blame game. Under a subtitle in the article that is, in fact, labeled, “The Blame Game,” they write: “In recent years, negative outcomes in nursing homes during disaster situations have led the media, public health officials, and politicians to find fault with nursing home providers.” Investigators cite the case in which 4 nursing home workers were charged with criminal homicide in Florida during Hurricane Irma. Without commenting on the particulars of that case, the “historical reality is chilling” given that the epicenter of COVID-19 in the United States is the Life Care Center in Kirkland, Washington where, as of this writing, COVID-19 was found in 81 residents, 34 staff members, and 14 visitors; and 23 people died. “Quite clearly, mortality within long-term care environments related to COVID-19 will be significantly higher than among the general population as a function of resident advanced age and comorbidity rather than substandard care,” the article states. “Some understanding of this fact will certainly be welcomed by the long-term care industry, who are often responsible for delivering difficult care under suboptimal circumstances.” The fatality rate in China for those 70 to 79 is estimated at 8%, and for patients over 80, that shoots up to 14%. “Even as the overall case fatality rate drops, the risk of death among older adults may be 10-fold higher than for younger individuals,” the article states. Mortality rates also increase with the presence of heart or chronic respiratory disease, which are common in long-term care facilities. Rates of heart disease exceed 30% and, for chronic obstructive pulmonary disease, it exceeds 20% in long-term care facilities, say investigators. “Further, extreme functional impairment within long-term care facilities makes close contact between health care workers and residents inevitable,” the article states. “Additionally, cognitive impairment among residents may make contact precautions and isolation a practical impossibility.” Workers should wear gowns, gloves, facemask, and eye protection, but…  “This may be challenging in the nursing home environment, where supplies of these items may be limited and are prioritized for acute care hospitals,” the article states. “In long-term care settings, few of which have negative pressure (airborne isolation) rooms, simple measures like pulling room-dividing curtains and closing doors are helpful.” Even the admonishment that workers with symptoms need to stay home can be problematic, as most of the workers live paycheck to paycheck and long-term care facilities are often understaffed. Workers are used to being pressured to work even when sick. “Providing a work environment that allows healthcare workers to call out without repercussion will be critically important,” the study states. Whether to admit someone who has been diagnosed with COVID-19 will be another concern. “Long-term care facilities are a key component of our healthcare system, and we can anticipate significant pressure to receive discharged hospitalized patients for convalescence or to accommodate sicker patients arriving from the community,” the article states. “We do not yet know how long individuals shed transmissible levels of virus, whether older individuals shed virus longer, nor whether cohorting confirmed cases can reduce risk of spread within a facility or contributes to disease severity among those cohorted.”  -------------------------------- 

Q&A: A Conversation with David Dosa, MD, MPH

 reached out to the study’s corresponding author, David Dosa, MD, MPH, an associate professor of medicine and health service, policy & practice at Brown University’s School of Public Health. 

 Your article seems to be a preemptive attempt to dissuade experts and the public for blaming the spread of COVID-19 on long-term care facilities. Is that a fair assessment? 

 I have worked in the area of disaster preparedness and nursing homes since 2003. The universal theme throughout this time is that nursing homes are often ignored by public health officials and at times unfairly held to standards in the post-disaster dialogue (eg, Monday morning quarterbacking) that they were never financially equipped or staffed to handle. Bottom line-nursing homes are not hospitals, yet they are asked to take care of some of our sickest patients. The point of the article was to raise awareness that there are a lot of unanswered questions that are not necessarily first and foremost on the minds of public health officials and politicians. As you have seen in the Washington state case, they really will need to be a key focus in this epidemic. 

 You touch on many aspects of what makes dealing with COVID-19 especially difficult in long-term care facilities. Your point, as far as I can tell, is that LTCs are the most vulnerable institutions and yet they have the least to work with? True? 

 Nursing homes do have some experience with outbreak situations such as influenza. Nevertheless, they are not set up with negative pressure rooms and staff members are not trained in most circumstances to gown up in full protective gear. In fact, most nursing home residents live in rooms with more than one resident, making infection control extremely difficult. Coupled with the intense functional needs that most nursing home residents require, this makes infection control challenging under optimal circumstances. 

 Immediate recognition that infection control in the nursing home remains a challenging situation to address. Help from infection control professionals in preparing these facilities to address the COVID-19 crisis. Some additional financial resources from federal and state governments to allow nursing homes to temporarily increase their staffing levels, acquire the necessary equipment, and allow for enhanced screening of staff, vendors, and visitors (if they are allowed) would also be important. 

 It starts with making the public aware, correct? 

 The public really does need to be aware of why some of the draconian policies related to visitation are going into effect in this environment. The experience in Washington state and the newly announced case in New Orleans makes this all the more apparent. 

 One of the key factors in preventing outbreaks within nursing homes will be paid sick leave for employees-often those with the most contact with patients (LPNs, aides, etc) work multiple jobs at hourly wages. If they don’t work, they don’t eat and that prompts many to come to work even when they don’t feel well. Nursing homes really do need to institute plans to check all who enter for symptoms and send those who are sick home. Paid leave would help in this situation.  

Dosa D, Jump RLP, LaPlante K, Gravenstein S. Long-term care facilities and the coronavirus epidemic: practical guidelines for a population at highest risk. 

. 2020;Mar 13. pii: S1525-8610(20)30249-8. doi: 10.1016/j.jamda.2020.03.004. [Epub ahead of print].

The media, public health officials, and politicians are accused of being too quick to find fault with nursing home providers.

Long-Term Care Facilities Particularly Vulnerable to COVID-19 (and Criticism)

A lot of it comes down to education and communication. That’s the primary takeaway from a studyin 

Antimicrobial Resistance & Infection Control

saying that the effectiveness of link nurses in helping to bolster infection prevention and control (IPC) efforts very much depends on the support those nurses and the programs they’re associated with have from hospital management, and the quality of interaction between link nurses and infection control personnel.

A link nurse is a professional more common in Europe; in the United States they’re sometimes referred to as “nursing infection control champions,” according to Saskia v. Popescu, PhD, MPH, a nationally known infection preventionist and a member of 

’s Editorial Advisory Board. “They are often rare, but they’re a wonderful resource if hospitals can encourage and support link nurse programs,” says Popescu.

Popescu speaks from a wealth of experience, but hard evidence on the effectiveness of link nurses is spotty. In January 2019, 

reportedon a study that concluded that there’s just not enough data to determine how well link nurse programs work. The authors of that studyconcluded that “available studies have methodological issues, small sample size or lack the consideration of the implementation process or patient outcomes.”

and both studies have the same corresponding author, Mireille Dekker, of the department of medical microbiology and infection prevention with Amsterdam UMC, Vrije Universiteit Amsterdam. Last year’s study-January 2019-was titled “Infection Control Link Nurses in Acute Care Hospitals: A Scoping Review.” 

: “I am indeed on a bit of a mission to study the effects of link nurse programs and ways to improve their impact. I started out as a link nurse myself. Nowadays, I am a clinical epidemiologist working in infection control. In our hospital, this two-way communication between the infection control team and the nurses in the ward is vital, especially in these hectic times.”

The study published this year in February 2020 was titled “Infection Control Link Nurse Programs in Dutch Acute Care Hospitals: A Mixed-Methods Study.” 

It examines ways to make link nurse programs more effective and although it too bemoans the dearth of data about such programs, it suggests ways hospitals can find out more. “To evaluate the contribution of ICLN [infection control link nurse] programs to the implementation of IPC guidelines it is necessary to audit the program effects and to perform well-designed effectiveness studies,” the study states. “Social network analysis could contribute to understanding how knowledge on infection control and prevention is transferred best.” 

The link nurse provides just that-a link-between IPC and hospital wards and/or departments. Ideally, they increase awareness of infection control issues and motivate colleagues to improve in that regard, keeping patients and themselves safer by limiting the spread of healthcare-acquired infections (HAI). To be most effective, link nurses need to receive training from the infection control team. Although infection control link nurse programs exist throughout the world, there’s wide variation on how the programs are organized and implemented. 

In the study, Dekker and associates write that “the few studies that have evaluated effectiveness of these programs revealed that compliance with hand hygiene guidelines and incidence of MRSA infections indeed improve when ICLN are active. However, these studies do not describe their ICLN program in detail nor elaborate on the contextual factors that may have contributed to these improvements. Contextual factors include factors that are not part of the ICLN program such as cultural, organizational and management characteristics of the hospital, but do play a role in the implementation of IPC practices.” 

Nearly 90% of the hospitals made education a bulwark of ICLN efforts. That usually included 2-hour sessions given about 6 times a year. These sessions were conducted in-house.

Dekker and associates collected data through a mixed-methods process combining a survey and semi-structured interviews with infection control practitioners. Seventy-two infection control practitioners from 72 different hospitals participated in the survey (the Netherlands has 74 hospitals). 

Investigators also conducted in-depth interviews with 4 of the infection control practitioners. Snippets of these interviews pepper the study and offer a snapshot of the challenges and rewards of ICLN efforts.

The survey was divided into five parts and asked whether their institution had an ICLN program or intended to set one up, what were the tasks of the link nurses, what infection prevention professionals felt ICLNs needed to be able to do a better job, what sort of education was provided and how respondents rated the programs. In the final part of the survey, respondents were asked to what extent they were able to accomplish their IPC goals through the help of ICLN, the study states. This was expressed on a 10-point Likert scale. 

Forty-eight (66.7%) completed surveys came from hospitals with an ICLN program; 18 (25%) from hospitals planning to implement one in the near future. Six (8.3%) said that their ICLN programs had been abandoned due to lack of support from the ward and/or hospital management. 

The ICLN programs had been in operation from 3 to 8 years in the institutions that had them. In the hospitals where the infection control team initiated the program, the IP teams did so from an effort to disseminate IPC knowledge, and often in response to an infection control problem.

“The actual start of these programs was related to a more positive overall attitude of hospital management and healthcare workers towards IPC; it was sparked by threats such as a recent Ebola outbreak and the rise of antimicrobial resistance,” the study states. 

As an interviewee put it, “We needed this outbreak of vancomycin-resistant 

to convince our hospital management that we needed to implement an ICLN program” (the interviewees were not identified).

The top 3 goals of the ICLN programs were to increase an awareness of infection prevention, create a liaison between the wards and the IPC team, and to make the ICLN a source of information for peers. “Some infection control practitioners were able to described these program goals in a clear manner and incorporated knowledge and skills from other departments (e.g. quality department, training and education department) to supplement their own and ICLN’ competences whereas others found it challenging to prepare a plan of action,” the study states. 

As an interviewee put it, “As an infection control practitioner I am obliged to support link nurses, but I don’t know how to do that best.” 

The relationship between the ICLN and the IPC team was give-and-take, but exactly who was giving what and in what amount varied. “Some infection control practitioners focused their efforts on providing support for the ICLN in implementing IPC policies, where others focused more on receiving support from the ICLN in monitoring the compliance with IPC measures,” the study states. 

Many times, the programs were created on the run. “Infection control practitioners described that they developed their programs while implementing them at the same time,” the study states. “Programs were adapted as IPC teams searched for an optimum strategy to collaborate with their link nurses to improve practice. Adjustments to the program were based on lessons learned during implementation and the dynamic IPC priorities. Infection control practitioners query what sort of training to provide, what topics to educate on and how to stimulate ICLN to be proactive.” 

Communication doesn’t always flow freely. One interviewee said that, “Our link nurse meetings must become a bit more interactive. We need to ask: What did you learn? What will you do differently tomorrow? What is the next issue you will address?” 

When it came to making ICLN program goals, the buck stopped with the IPC team in two thirds of the hospitals.  

“The IPC teams perceived the introduction of ICLN networks and the activities of ICLN as important assets that helped them to achieve their infection control goals,” the study states. “They scored this importance with a median of 7.0 (IQR 6.0–7.0) on a 10-point Likert scale.” 

The study concludes” “Although programs vary widely, education is an overall core component. Efforts to improve the uptake of IPC guidelines through ICLN programs should focus on enhancing infection control practitioners’ and link nurses’ knowledge on implementation science and designing these link nurse programs as multimodal interventions.”

1. Dekker M, van Mansfeld R, Vandenbroucke-Grauls C, De Bruijne M, Jongerden I. Infection control link nurse programs in Dutch acute care hospitals; a mixed-methods study. Antimicrob Resist Infect Control. Published online Feb 27, 2020. doi: 10.1186/s13756-020-0704-2

2. Dekker M, et al. Infection control link nurses in acute care hospitals: a scoping re-view. Antimicrob Resist Infect Control. 2019;8:20

										Ideally, link nurses increase awareness of infection control issues and motivate colleagues to improve in that regard, keeping patients and themselves safer by limiting the spread of HAIs.						 

Searching for the Missing Link (Nurse)

Despite nursing homes becoming a nidus of multi-drug resistant organisms (MDROs), the regulations for staffing infection preventionists (IPs) at nursing homes are far too lax. Nursing homes should have a full-time IP. Presently the regulations only specify a part-time IP without a specific required time commitment. In view of the large number of nursing home residents and the high drug-resistant carriage rate, a full-time position is certainly needed.

That’s especially true these days, as COVID-19 hits nursing homes with particularly devastating results. At the now-infamous Life Care Center, a 130-resident nursing home facility in King County, Washington, COVID-19 infected 81 residents, 34 staff and 14 visitors, causing 23 deaths (22 of them residents).

More recent updates place the total deaths at 35; 34 of whom were residents. As of March 23, 127 of the 15,000 nursing homes in the United States had at least 1 resident who tested positive for COVID-19.

Mortality rates also increase with the presence of heart or chronic respiratory diseases, which are common in nursing homes and other long-term care facilities. Rates of chronic obstructive pulmonary disease are greater than 20%, and for heart disease they are greater than 30% in long-term care facilities. 

So, expect mortality from COVID-19 to be significantly higher at nursing homes and other long-term care environments than among the general population just as a function of advanced age and comorbidities of the residents. In China, the case fatality rate (CFR) is estimated to be 8.0% for those 70 to 79 years of age, and for patients over 80, that shoots up to 14.8%.

Even as the CFR drops with improved treatment, it is expected that those over the age of 80 will have a 10 times higher fatality rate than younger patients.

Many nursing homes around the nation have suspended all visitations, which hopefully will increase the awareness of the importance of controlling the microbiome in nursing homes. Most hospitals routinely screen patients admitted from nursing homes for MDROs, but nursing homes seldom engage in similar action.

Nurse staffing in nursing homes is also all too often inadequate, although state requirements may vary. The federal government relies on the requirement to have “sufficient nursing staff.” The definition of “sufficient” is largely in the eyes of the facility.

In addition to low staffing, salaries for nursing home nurses are lower than they are at hospitals. According to payscale.com, the average RN and certified nursing assistant are paid $28 and $12 per hour, respectively, as those in hospitals are paid $29 and $13 per hour. Even at these salaries, coverage of living expenses can be difficult.

In terms of quality of care, none of the US Centers for Disease Control and Prevention’s 5 most “urgent threats”

are mandated to be reported on a national basis by nursing homes. The only nationally reported data on infectious disease which can be found on Nursing Home Compare are for urinary tract infection. State requirements vary widely. Nursing homes need to have a comprehensive mandatorily reported national tracking system for infectious disease.

Even before the COVID-19 virus refocused the nation’s attention on nursing homes, there were severe deficiencies in infection control. A recent study in California found that over 50% of nursing home residents harbor MDROs.

Of course, extrapolating this data to the entire nation needs to be done with caution, but California has one of the lowest rates of antibiotic usage in the nation.

Some states in Appalachia, such as my home state of Kentucky, have over twice the utilization. At the very least, this study raises grave concerns.

Required antibiotic stewardship programs are all too often ineffective. The CDC estimates that up to 75% of antibiotics in nursing homes are not prescribed correctly.

One study found that 42% of the residents in nursing homes are carriers for methicillin-resistant 

(MRSA) and 34% carry extended-spectrum Î²-lactamase-producing organisms.

Both of these organisms are defined as “serious threats” by the CDC. CMS tolerates a medication error rate of 1 in 20 prescriptions.

There are few requirements for antibiotic prescription oversight. The CDC recommends antibiotics administered for sepsis be rechecked by a professional within 48 to 72 hours after initiation. This standard should also be applied for all antibiotics given in nursing homes. A common failing is the unnecessary continuation of antibiotics in newly admitted residents, since a facility physician visit is not required for up to 30 days post admission and if requested, it is considered timely if it occurs within 10 days.

In response to this threat, the US Centers for Medicare & Medicaid Services (CMS), in collaboration with the CDC, will be initiating targeted infection control inspections with streamlined checklists. During this time standard inspections of nursing homes will be suspended. However, the current CMS suspension of standard inspections indicates a temporary shifting of resources and unless a permanent commitment of new resources is made, there may well be a rapid return to the status quo.

The CDC has also attempted to strengthen regulations which give little if any firm guidance. The CDC has developed a program for nursing home infection prevention referred to as “enhanced barrier precautions.” Although the name implies strict infection control procedures, it may actually be recommending far too little to control the frequent occurrence of dangerous contagions in nursing homes. 

The premise behind the protection of healthcare workers and residents with enhanced barrier precautions is that some resident encounters have a higher risk of transmission of pathogens than others. And that contact precautions should be reserved for those encounters with the highest risk, thus, helping to preserve the patient’s dignity. However, recommendations need to be effective, since no nursing home resident wishes to preserve dignity by infecting visiting grandchildren with a dangerous contagion. 

Three of the organisms which are targeted for control with enhanced barrier precautions are contained on the CDC’s list of “urgent threats.” MRSA, another common nursing home pathogen, is also targeted and is on the CDC’s list of “severe threats.”

There are 2 concerns. The first is that although lower risk encounters carry a relatively low risk of transmission, some encounters, such as passing meds, occur so frequenty that the risk to the healthcare worker over time can be high. For example: The passing of meds to a MRSA carrier is defined as a low-risk activity. Each encounter was found by Roghman, et al., to contaminate healthcare workers’ gowns and gloves with MRSA 8% and 16% of the time, respectively.

The study found a 25% MRSA carrier rate in nursing home residents and if one assumes a healthcare worker passes meds to 25 patients 3 times a day, they would be expected to contaminate their clothes 11 times a week.

Another study by Blanco, et al., evaluated the risk of contamination with gram negative bacillus.

Using the same methodology, it can be predicted that the passing of meds would result in the contamination of a healthcare worker’s clothes once a week.

The second is that enhanced barrier precautions do not restrict the movements of a carrier within a facility, which is problematic. The CDC notes that environmental colonization with MDROs can last longer than 6 months.

In the case of MRSA, one study has found colonized patients contaminated the environment more frequently than those with an active infection.

MRSA carrier contamination of the environment can occur very rapidly with 35% of carriers contaminating their environment within 33 hours

and the contamination may last as long as 2.33 to 8.35 years.

We need to start fostering an optimal patient microbiome, but the United States does not even adequately screen for MDROs. 

, for example, is a major cause of post-operative infections. The WHO recommends that in affluent countries, all patients undergoing surgery be screened and decolonized for 

However, in the US we do not even do this for MRSA.

In nursing homes, we need to develop and implement a strategy based upon the existing microbiome of the facility and the compatibility with the resident’s microbiome. The average resident resides in a nursing home for over two years and determining the resident’s microbiome before admission should become standard. If the resident carries dangerous contagions, then decolonization should be attempted. Some organisms such as carbapenem-resistant

 (CRE) may have very long durations of colonization (over a year) and how to best decolonize is not known.

In such cases, admission into a compatible facility or zone isolation should be implemented.

Finally, the health and wellbeing of infection preventionists along with all healthcare workers needs to be safeguarded. At a minimum, workers should be periodically screened for dangerous contagions and a national registry created for acquisitions. In addition, a healthcare worker’s economic safety net needs to be established. Decolonization of healthcare workers should be undertaken. For MRSA this has been found to have up to an 88% success rate.

There can be no doubt that COVID-19, along with other MDROs, pose unacceptable risks to nursing home residents, IPs and all healthcare workers, along with their families. Correction will require a sustained commitment to invest in infrastructure, new technologies and implement resource intense strategies. 

These pathogens are relentless, they are evolutionarily programed to win, and they are currently doing just that.

(1)  (9)   42 CFR § 483.80 - Infection control. Cornell Law Scholl Legal Information Institute.   42 CFR § 483.30(b)    

https://www.law.cornell.edu/cfr/text/42/483.80

(2) McMichael TM, et al. Centers for Disease Control and Prevention.   COVID-19 in a Long-Term Care Facility - King County, Washington, February 27–March 9, 2020.   MMWR / March 18, 2020 / Vol. 69   

http://www.documentcloud.org/documents/6812675-CDC-Life-Care-Center-of-Kirkland.html


	  
	(3)  CMS Announces Findings at Kirkland Nursing Home and New Targeted Plan for Healthcare Facility Inspections in light of COVID-19    

https://www.cms.gov/newsroom/press-releases/cms-announces-findings-kirkland-nursing-homeand-new-targeted-plan-healthcare-facility-inspections

 
	    
	(4)  The Epidemiological Characteristics of an Outbreak of 2019 NovelCoronavirus Diseases (COVID-19) - China, 2020.   China CDC Weekly.    

Infection Control Today, May 2020 (Vol. 24 No. 4)

A Conversation With Judd Hollander, MD: How Telehealth Can Address the COVID-19 Outbreak

When It Comes to Fighting Covid-19, Some Problems Can’t Be Masked

Long-Term Care Facilities Particularly Vulnerable to COVID-19 (and Criticism)

Searching for the Missing Link (Nurse)

When COVID-19 Knocks on Nursing Homes’ Doors, Systemic Problems Welcome It

Breaking the Chain: How to Better Contain Infection Risk During Hospital Construction

Establishing Vascular Access Teams for Patient Safety

May 2020 Bug of the Month