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 couple of weeks.

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 HVAC system.

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 nursing home project.

 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.”

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

Pennsylvania Department of Health. COVID-19 Long-term care facilities data for Pennsylvania. 

https://www.health.pa.gov/topics/disease/coronavirus/Pages/LTCF-Data.aspx

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. J Infect Contr 45 (2017): 652-9. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7115276/pdf/main.pdf

Dyer J. Under pressure: Hospitals race the clock to prepare safe spaces for COVID-19 victims. 

. June 2020. ICT website. https://www.infectioncontroltoday.com/view/covid-19-forced-hospitals-build-negative-pressure-rooms-fast

Miller S, Mukherjee D, Wilson J, Clements N, Steiner C. Implementing a Negative Pressure Isolation Space within a Skilled Nursing Facility to Control SARS-CoV-2 Transmission. 

https://doi.org/10.1101/2020.07.04.20143123

Articles

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.” 

Novel Initiative Keeps Nursing Home Residents Safe From COVID-19

As the fight against coronavirus disease 2019 (COVID-19) continues, the consumer market for gadgets to keep you from touching doorknobs and elevator buttons, and gizmos to disinfect your phone, your packages, your groceries, glasses, shoes, and the air you breathe—just to name a few—is mind-boggling. Similarly, lots of new and old technologies are being marketed to the healthcare sector, promising cleaning and disinfection on all kinds of surfaces contaminated with SARS-CoV-2.

Contact with surfaces contaminated with the virus is of great concern even though the primary mode of transmission is through close, prolonged contact (defined as <6 feet for >/=15 minutes

) with respiratory droplets and aerosols. There is possible risk of transmission, albeit low, from inadvertently touching a deposit of these respiratory particles on a surface, and then touching one’s face or eyes. Recently, an article published in 

 spoke about real life SARS-CoV-2 transmission versus laboratory-simulated situations stating “the chance of transmission through inanimate surfaces is very small, and only in instances where an infected person coughs or sneezes on the surface, and someone else touches that surface soon after the cough or sneeze (within 1–2 hours).” Knowing that contaminated surfaces may place patients and healthcare workers at risk, let’s look at some of the technology being marketed for use in disinfection of COVID-19 contaminated surfaces.

Ultraviolet Germicidal Irradiation (UVGI)

 is a type of ultraviolet (UV) light that is composed of 3 types of light—UVA, UVB, and UVC.UVC is the most effective of all germicidal light. It was first used in the early 19th century

 as a method to disinfect air. It was during this time that the spread of airborne infections by droplet nuclei was discovered, and also the bactericidal effects of sunlight (UV) to prevent that spread. Despite early successes in applying UVGI, its use fell out of favor. However, in the 1980s, an increase in infections from tuberculosis (TB) led to renewed interest in UVGI. It was found to be safe and very effective in disinfecting the air, preventing transmission of a variety of airborne infections in addition to TB.

When it comes to disinfecting the air, there are 3 primary methods of applying UVC systems against infectious agents in the air: upper-air, coil irradiation, and airstream disinfection. Upper-air systems are typically installed in room spaces, such as above patient beds, in waiting rooms, corridors and break areas, etc., where they kill airborne microorganisms that inherently circulate into the path of the UVC light.

Coil irradiation and airstream disinfection systems are installed within air handling units or duct runs within HVAC systems, downstream of cooling coils, to keep coils clean and to provide supplemental kill ratios in airstreams and on filter surfaces. Reduction of potential pathogens in the air can help prevent resettling onto surfaces, helping to contribute to a reduction in microorganism transmissions.

In healthcare, we hear a lot about UVC being used to disinfect surfaces more so than air or water. It relies on a short wavelength of light to break down microorganisms by naturally damaging their DNA and RNA, rendering them unable to replicate. Since viruses are not considered microorganisms, UVC does not actually “kill” viruses. Instead, it inactivates the virus and prevents any illnesses it might spread.

UVC has been shown to be effective in reducing pathogenic microorganisms present on frequently touched surfaces and is already being used in some hospital settings for disinfecting rooms, surfaces, and equipment. Interestingly, the US 

Centers for Disease Control and Prevention

 lists UVC as one of the most promising methods of disinfecting air-filtering face masks, such as the N95, for reuse when there is a shortage of personal protective equipment (PPE).UVC devices are an effective means of reducing concentrations of airborne and surface microorganisms that can lead to healthcare-associated infections (HAIs).

Until very recently, UVC wavelength devices for disinfection of surfaces had not yet been proven effective against COVID-19. There were only data to support effectiveness against other coronaviruses with fairly similar RNA structures to the virus that causes COVID-19. However, on May 21, 2020, Xenex recently tested its LightStrike™ robot specifically on SARS-CoV-2 in a biomedical lab in Texas, and found that, in 2 minutes, it was able to achieve a reduction of the virus greater than 99.99% within about a 3-foot radius.

So, the effectiveness of UVC for reduction of microorganisms including bacteria, viruses, and fungi has been proven time and again. But using UVC radiation to disinfect is not simple and requires lots of protocols to use safely. The radiation must be contained, often in a device of some kind, be it a light box, robot, or tower. When UVC light is used to disinfect a room, people must be cleared from the room before the device is turned on because it can be harmful to eyes and skin. Sometimes the robots need to be repositioned to eliminate “shadowing,” which blocks the UV light from touching the surface intended for disinfection. Installing UVC lights to irradiate a room or determining the placement of mobile devices is also a complicated process and must be appropriately validated to work effectively. Some systems are very costly. Lastly, and most importantly, all surfaces need to be free of any soil or bioburden in order for the UV light to touch the surface and for disinfection to occur, therefore, it does not replace cleaning. It can be a powerful tool used as an adjunct to a thorough cleaning process.

Misters, foggers, fumigation, or electrostatic spraying

are technologies used to apply disinfectants, like hypochlorous acid and hydrogen peroxide, to entire rooms such as empty public waiting rooms, operating rooms, and patient care spaces. Misters work by using a pressure pump that operates under pressure (ex, 1000 psi) and pushes water and any other product through small orifices that atomize the substances and turn them into a mist. Foggers work almost the same way but turn the mist into fog by allowing for flash evaporation. Electrostatic sprayers work by charging liquids (ie, cleaners, sanitizers, disinfectants) as they pass through a sprayer nozzle.

This generates charged droplets that repel one another and, when applied to environmental surfaces, they stick to and even wrap around them to coat all sides. This “whole room” approach to disinfection can help eliminate some of the human error that may occur from the repetitive and tedious task of repeatedly cleaning patient care spaces as often as needed in a healthcare environment. Whole room disinfection devices also limit the use of chemicals which benefit the environment as well as the employees who are exposed to harmful cleaning products on a regular basis. Some of these devices, in addition to disinfecting surfaces, have been proven to clean the air as well.

Since disinfectants are considered pesticides, they are reviewed and regulated by the US Environmental Protection Agency (EPA). Unless the disinfectant product label specifically includes disinfection directions for fogging, fumigation, or electrostatic spraying, the EPA does not recommend using these methods to apply disinfectants because the EPA has not evaluated the product’s safety and efficacy for methods not addressed on the label. Also, a disinfectant’s safety and effectiveness may change based on how it is used. Currently, the CDC recommends cleaning contaminated surfaces with liquid disinfectant products to prevent the spread of disease. However, the EPA announced the 

 of certain Pesticide Registration Improvement Act (PRIA) submissions for products already on List N that are effective against COVID-19 and applied for use using alternate application methods such as misters, foggers, fumigation and electrostatic spraying.

 One such product, Spore Defense applied through the Clorox Total 360® electrostatic sprayer, may be an effective way to eliminate SARS-CoV-2 from complex surfaces and is eligible for use against SARS-CoV-2, based on the EPA’s emerging Viral Pathogen Policy.

No doubt more and more makers of disinfectants will consider submitting an application to use these alternate methods for “whole room“ disinfection. Keep in mind all of these technologies still require cleaning of the surfaces prior to their use. They also have some time constraints for application and re-occupancy of the area. Fogging, for example, is typically carried out for a minimum of 15 to 30 minutes to enable the fog to disperse and the chemical action to occur. After fogging, an additional 45 to 60 minutes is required for the droplets to settle from the air onto the surfaces. During this “aeration” period, no one should enter the area. Also, when fogging, the equipment in the space being addressed should be limited, and the remaining equipment should be powered off and covered so that the disinfectant does not penetrate the sensitive electronic circuitry. If powering off and covering the equipment is not an option, fogging should not be considered. A final, very important consideration should also include the health and safety of staff and patients in areas where this technology is being routinely used.

 technologies range from antimicrobial agents for medical devices and surgical implants such as silver and copper to coatings that ensure surfaces are disinfected. They prevent the growth and spread of bacteria on surfaces such as medical instruments, walls, counters, door handles, and other high-touch areas. Silver ions prevent bacteria from reproducing. Copper destroys bacteria by damaging bacterial DNA and cell proteins. Copper is also effective against viral and fungal pathogens. Now there is an EPA-approved surface coating with antiviral properties effective for use against SARS-CoV-2 and proven to provide long-term, non-toxic surface protection within 2 hours of application for up to 7-90 days.

 The non-toxic coating “SurfaceWise2” is applied via an electrostatic spray to provide always-on protection on treated surfaces.

These long-lasting surface coatings may help provide persistent reduction in environmental contaminants, potentially improving patient outcomes. One thing to consider might be what are the long-term effects of coating, then recoating hospital equipment and surfaces? Much more to come as the surface coating race continues.

obtained by a achieving a temperature of 100 °C, 5% relative humidity for 50 minutes was found to effectively decontaminate 3 million N95 masks, allowing for reuse by healthcare workers during shortages, based on a study by the University of Illinois. It did not alter their integrity or fit and was least likely to reduce the filtration efficiency when compared with other available decontamination methods such as moist heat, ethanol, isopropanol solution, bleach, and ultraviolet light. The study found that “...dry heat decontamination generated by an electric cooker, like rice cookers, instant pots, and ovens could be an effective and accessible decontamination method for the safe reuse of N95 respirators.”

The mask should be enveloped in a towel or dishcloth to prevent it from touching the side of the pot and melting.

If an oven is being used to decontaminate the mask, it should be placed in a paper bag and no part of the mask should come in contact with the heating element to prevent a fire. We may scoff at this now, but continuing increases in COVID-19 infections leading to increased hospitalizations may again causes PPE shortages, so keep your eye on that instant pot.

During the trial and evaluation of any technology for disinfection, infection preventionists, environmental services (EVS) crew, and other stakeholders should undertake a comprehensive evaluation of the item under consideration.

For example, any new device being considered for purchase and implementation in a healthcare organization should be evaluated for its cost-effectiveness; whether the technology demonstrates a reduction in infection rates that justifies the cost associated with the purchase and maintenance of the device; whether the claims made by the manufacturer, such as spectrum of activity or dwell for disinfectants, are pertinent to your hospital and doable by your staff. Evaluators should identify the ongoing costs involved in use, education and training, staffing, and sustainability. Finally, any new technology should be evaluated for its relevance of use once the COVID-19 pandemic has passed.

Even now the need for enhanced cleaning surrounding COVID-19 is being questioned. Is it really needed and sustainable? Ask yourself a couple of questions before jumping feet first into any of these technologies. Will this technology also help with reduction of multidrug-resistant organisms or other problem organisms seen at my facility? Is my current level of cleaning and disinfection acceptable? Are there other things that could be done to improve cleaning and disinfection at my facility without adding to current practices? No matter the answer, know these technologies are available to add to your “toolbox” of best cleaning and disinfection practices when you need them but be aware of the caveats for their use.

Sharon Ward-Fore, MS, MT(ASCP), CIC, is an infection prevention consultant located in Chicago. She is also a member of Infection Control Today®’s Editorial Advisory Board.

CDC Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19) Health Departments, Public Health Guidance for Community-Related Exposure. 

Current guidance based on community exposure, for people exposed to people with known or suspected COVID-19 or possible COVID-19. 

Updated July 31, 2020, Accessed August 30, 2020. 

https://www.cdc.gov/coronavirus/2019-ncov/php/public-health-recommendations.html

Goldman E. Exaggerated risk of transmission of COVID-19 by fomites.

 2020; 20(8):892-893. doi.org/10.1016/ S1473-3099(20)30561-2.

Reed N. The History of Ultraviolet Germicidal Irradiation for Air Disinfection 

. 2010; Jan-Feb; 125(1):15–27.doi:10.1177/003335491012500105.

CDC Centers for Disease Control and Prevention. Healthcare Workers-Implementing Filtering Facepiece Respirator (FFR) Reuse, Including Reuse after Decontamination, When There Are Known Shortages of N95 Respirators. Updated August 4, 2020. Accessed August 27, 2020. 

https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/decontamination-reuse-respirators.html

Xenon LightStrike™ pulsed xenon disinfection robot. Product information. Accessed August 28, 2020. 

https://www.go.xenex.com/SARs-CoV-2-Results

US Environmental Protection Agency Pesticide Registration. Expedited Review for Adding Electrostatic Spray Application Directions for Use to Antimicrobial Product Registrations. Accessed August 30, 2020. 

https://www.epa.gov/pesticide-registration/expedited-review-adding-electrostatic-spray-application-directions-use

Allied BioScience’s SurfaceWise2 Press release. August 24, 2020. Accessed August 28, 2020.

Oh C, Araud, E, Puthussery J, Bai H, Clark G, Wang L, Verma V, Nguyen T.Dry Heat as a Decontamination Method for N95 Respirator Reuse.

 2020; 7, 9, 677–682. doi: 10.1021/acs.estlett.0c00534.

Infection preventionists should know that these technologies are available to add to their toolboxes of best cleaning and disinfection practices when they need them, but be aware of the caveats for their use. 


When It Comes to COVID-19 Disinfectants: Use With Care

Infection preventionists (IPs) know personal protective equipment (PPE) better than anyone and now is the time that their knowledge and skills should partner with efforts to bring PPE into the future so that we can avoid supply chain interruptions, while also addressing new challenges and requirements brought about by the coronavirus disease 2019 (COVID-19). Sustainable, reusable, and safe are all strategies that need to be a part of the infection prevention and PPE future. Unfortunately, until there is a more significant push for this, innovation may not occur. Innovation seems to be occurring in community-based measures addressing the public’s need for wanting to venture outside in rather fascinating ways. For example, the Micrashell, which was created to allow people to attend music concerts.

 Looking at some of the more ridiculous aspects of this suit, it does reinforce the notion that if people want to return to a more normal state in the face of a pandemic, innovators will try to find a way. Why can’t this be said for healthcare PPE?

Use of gowns, gloves, and masks have stayed mostly the same while the public has adapted a whole new approach to masks and PPE. This is a stark reminder of why the healthcare sector often struggles with innovation in areas that might not provide profit. Unlike a new robotic surgical tool, PPE doesn’t quite have the same pizzazz or the potential for new profit, which means selling the importance of independence and staff safety is something we must all collectively work on.

Perhaps now is the time for healthcare, infection prevention, and the tech geniuses of Silicon Valley to partner and develop a new approach to PPE. Consider face shields. There is considerable knowledge about their ability to protect the wearer, but what about source control?

 There is a desperate need to understand not only the efficacy of various non-traditional PPE, but also push for innovation in the name of sustainability and in the face of a pandemic.

Up until COVID-19, the term PPE was most commonly thrown around in healthcare and industrial environments, but it has quickly become a common phrase across the globe. From bandanas to half-face respirators, our daily lives are now integrated with respiratory protection. For some, this means finding the most comfortable or stylish approaches to face protection out in the community. For those of us in infection prevention and healthcare, it’s been an uphill battle that will likely evolve with the ebb and flow of COVID-19, but also the evolution of PPE.

Currently, recommendations focus on N95 respirators being ideal but surgical masks are acceptable if no aerosol-generating procedures are being performed on the patient. Part of the challenge though, as we saw with supply chain issues, was in how we approach extended use and re-use. These are phrases that were never considered in US infection prevention efforts—we’re a “single-use” sort of culture and frankly, never did we think we’d be facing a pandemic in which we had to deal with supply chain issues so early on in that pandemic. But that’s what happened, as IPs know all too well.

As a result of this, we’ve seen a few things happen—first, the allowance of KN95s, which meant a review of respirator safety and efficacy to allow for these to be used in emergencies.

 KN95 respirators are manufactured in China and, as a result of shortages in N95s, the National Institute for Occupational Safety and Health (NIOSH) approved specific types of KN95 respirators for use in the United States. As time went on though, concerns grew about KN95 variances or efficacy in ability to filter out small particulates. They have been worn more by the public than by the healthcare system, however. What this pandemic has really shown us is that we ultimately need to approach the PPE problem in innovative ways and not focus solely on respiratory protection.

That focus on respiratory protection emphasizes a lot of innovations and revisions to guidelines from the US Centers for Disease Control and Prevention (CDC) and NIOSH. First, the use of masks with exhaust valves. This has not been something we’ve traditionally seen or utilized much, but ultimately required significant review. Upon deeper analysis, masks with exhaust valves were discouraged by the CDC due to the lack of filtration from the valve, which could potentially be spreading infectious droplets/aerosols if the wearer was infectious every time he or she exhaled. This change impacted both healthcare and the community, as those healthcare workers in non-patient-facing roles were wearing cloth or personal masks in certain settings. This awareness reinforced the role of evaluating novel masks and those that increasingly become popular for perceived enhancements. Moreover, the recent review of various cloth masks has shed light on a further need to truly assess and test the efficacy and limitations of community masks. This especially comes into play as infection preventionists have to determine whether fabric masks are acceptable for those employees who are not in patient-facing roles.

A secondary piece to respiratory protection, though, has emphasized the need to re-use and extend use.

 This in particular is one that weighs heavy on the healthcare industry and we are inherently wasteful. Medical waste and pollution are increasingly topics of concern. The healthcare system struggles to move to more sustainable options for supplies. Consider PPE— as a result of the pandemic, many of us are moving toward half-face respirators that can be reprocessed, or even the reprocessing of N95 masks to extend use and re-use. Really, what this means is that in terms of PPE innovation, the direction we need to move toward is one of sustainability and reduced waste.

Ultimately, this would drive not only a reduction in having to haphazardly fit test people when we run out of one type of mask but reduce the dependence on a fragile international supply chain. COVID-19 has shed light on the utter dependence hospitals and healthcare facilities have on temperamental supply chain systems. Moving toward a model that would allow for reprocessing, like the half-face respirators, would of course create a new workflow and impact infection prevention efforts. Determination of how to store masks, which disinfectants to use, and general movements of masks between staff or units are all things that need to be considered. Determining a process for reprocessing, collection and returning of the masks, ensuring that people are aware of the need to have them reprocessed, and ability to train on cleaning/disinfecting after use and throughout a shift are all things the infection preventionist would need to consider. Despite these barriers, it seems that creating this process could help ultimately prevent a situation where our respiratory protection is intrinsically linked to vulnerable suppliers.

Masks and respiratory protection aren’t the only PPE we worry about though—gowns have increasingly become a hot topic. Reuse and extended use quickly became the topic of conversation after masks were no longer at the forefront of public discourse. Many have turned to gowns that can be laundered. In fact, the CDC put together crisis capacity strategies that include extended use of isolation gowns, reuse of cloth isolation gowns, and methods for prioritizing gowns, which included the recommendation: “During care activities where splashes and sprays are anticipated, which typically includes aerosol-generating procedures, during the following high-contact patient care activities that provide opportunities for transfer of pathogens to the hands and clothing of healthcare providers, such as: Dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, wound care.”

These recommendations point to a growing realization that we simply must establish a new approach to PPE in healthcare. Truly, IPs know the nuances of PPE better than most. We know how to train and educate on them, evaluate them, but we also know the challenges that occur with a novel production or process. This points to a critical need for infection preventionists to be part of this product evaluation and innovation moving forward in not only the COVID-19 response, but also larger pandemic preparedness.

For IPs, this also means we should be refining our evaluation process for PPE—not just in terms of if it works and protects staff, but how well it’s functioning in the work environment. Is it challenging to disinfect? Uncomfortable and prone to misuse? Pulling on this knowledge and the role of infection prevention in educating, perhaps now is the time that innovation begins to rely more heavily on infection preventionists and our valuable insight into the world of healthcare PPE. The changes we help guide now can help make healthcare safer and infection prevention easier.

SASKIA V. POPESCU, PHD, MPH, MA, CIC, is a hospital epidemiologist and infection preventionist. During her work as an infection preventionist, she performed surveillance for infectious diseases, preparedness, and Ebola-response practices. She holds a doctorate in biodefense from George Mason University where her research focuses on the role of infection prevention in facilitating global health security efforts. She is certified in infection control and has worked in both pediatric and adult acute care facilities.

Abby Haglage, “Is this neon hazmat suit designed to protect concertgoers a game changer for live events? Epidemiologists weigh in” Yahoo Money. May 4, 2020. https://money.yahoo.com/is-this-neon-hazmat-suit-designed-to-protect-concertgoers-a-game-changer-for-live-events-epidemiologists-weigh-in-165225644.html?guccounter=1&guce_referrer=aHR0cHM6Ly93d3cuZ29vZ2xlLmNvbS8&guce_referrer_sig=AQAAAC6-ylvRRMPpAVV3bC1mjyk_0f2AxSa-61f8-T7r-HTApZ-v_7hgs_HB1p7jo5KCps69Y1dh2b9z3CWYN0OhuWgkaeoaANQHW2lUwau0GGzYAE2QSSAynoUrrh3GbliCt_gC7h9wLBT6iCkunGm4T64AJ3BfM5t0POoei4__5Ejy

Perencevich EN, Diekema DJ, Edmond MB. Moving personal protective equipment into the community: face shields and containment of COVID-19. 

 2020;323(22):2252–2253. doi:10.1001/jama.2020.7477

Centers for Disease Control and Prevention. NPPTL Respirator assessments to support the COVID-19 response. July 16, 2020. https://www.cdc.gov/niosh/npptl/respirators/testing/NonNIOSH.html

Centers for Disease Control and Prevention. Implementing filtering facepiece respirator (FFR) reuse, including reuse after decontamination, when there are known shortages of N95 respirators. August 4, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/decontamination-reuse-respirators.html

Centers for Disease Control and Prevention. Strategies for optimizing the supply of isolation gowns. March 17, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/isolation-gowns.html

Perhaps now is the time that innovation begins to rely more heavily on infection preventionists and our valuable insight into the world of healthcare PPE. The changes we help guide now, can help make healthcare safer and infection prevention easier.

Innovations Needed for Personal Protective Equipment

The disinfecting process for endoscopes can use some oversight from infection preventionists (IPs), says Melinda Benedict, MS, CIC, CFER, the global senior manager of infection prevention at Olympus, a company that manufactures endoscopes. Benedict tells 

 that “there’s a lot of room in endoscope reprocessing for infection preventionists to really come in and offer their really unique perspectives and form this multidisciplinary team that is really needed and really helps to promote patient safety.” Benedict says that she’s noticed a shift in which this relatively new idea to expand an IP’s job description seems to be gaining more traction in hospitals. For instance, she’s seen a “very noticeable increase in the number of lectures and programs specifically geared toward infection preventionists to teach them about flexible endoscopy and reprocessing flexible endoscopes….”

In what ways you see infection professionals becoming more involved with sampling and culturing in the future?

 I think any infection preventionist who has oversight of an area in their facility that uses flexible endoscopes, reusable flexible endoscopes, will, if they aren’t already involved in this, will eventually be pulled into this area. Really, the reason for that is patient safety. Infection preventionists are always cognizant of patient safety, and that is really their role in the hospital. So, the purpose of an endoscope sampling and culturing program is really to detect possible microbial contamination on an endoscope. This is most often performed on a type of endoscope that performs specialty procedures called a duodenoscope. And a lot of facilities that use duodenoscopes are interested in sampling and culturing. It really is possible to do this with any type of endoscope. And it may seem simple enough. There’s endoscope sampling and culturing protocol, but it really is a multi-step process. And above all, it’s a learning experience. If you haven’t ever done sampling or had experience with this, it really takes a multidisciplinary team to come together and design and manage and implement these types of programs and infection preventionists…. I always recommend that a facility pull in their IPs because the IPs really fill a knowledge gap that other areas and other people in your facility may not have, especially when it comes to microbiology. What are harmful bugs? What are bugs that may be environmental, and not so harmful? And really, how to take a laboratory report and read it and analyze it and understand what it says. And I think that’s why IPs are so important in this type of program.

There have been some breakthroughs with duodenoscopes recently. Isn’t there a push to make them, or at least parts of them, disposable?

That sounds like it’s from an FDA communication and they did state that there should be a gradual movement either toward single-use duodenoscopes or duodenoscopes with single-use components. Olympus has really filled that role. We just came out with a new model that has a disposable end cap that sort of allows the person that is cleaning the duodenoscope to uncover some of the smaller mechanic portions of that scope in order to really get in there and visualize what they’re cleaning with a brush. Kind of in order to improve human factors really in reprocessing scopes. So, at no point does the FDA say you must use a single-use scope. Reusable endoscopes, and reprocessing reusable endoscopes using high-level disinfection or sterilization should a facility have that capability or already be doing that is so absolutely acceptable. I think another way infection preventionists can really play a role in getting more involved in their endoscopy department is by going in and seeing if they can help with the reprocessing of reusable endoscopes. Whether that’s a duodenoscope or any other model. There are opportunities to go in and audit that process to make sure all of the reprocessing technicians are really using best practices as far as society guidelines and the manufacturer’s guidelines.

Are hospitals more and more inviting infection preventionists to be a part of this process?

If the departments that are handling endoscopes aren’t inviting the IPs in, I think the IPs should really be proactive and seeing if they can reach out to help. Right now, as far as who’s actually cleaning, reprocessing, disinfecting, decontaminating endoscopes, it really seems to be different depending on which facility you go into. So, you have ambulatory surgical centers where everything is really right there—centralized—and one usually smaller location where the reprocessing is done by a tech or a nurse or maybe a medical assistant kind of right next door in a room. All the way through to larger hospital systems that may be sending their flexible endoscopes down into central sterile to be reprocessed or even off site. We’ve heard of some larger facilities really centering all of their medical device reprocessing into one facility that may be down the street or across town and those endoscopes have to move over to that location. One of the benefits in doing something like that is that you centralize all of these same types of tasks and you can have a more specialized workforce really doing those kinds of duties and becoming their experts in their jobs in cleaning and reprocessing medical devices.

Is there a national guideline for how to actually do this?

There are actually several national guidelines. Professional societies will put out guidelines on endoscope reprocessing. Facilities really should be not only taking into account the endoscope manufacturers IFU [instructions for use] but also the manuals on how to use any other equipment they may be using during that reprocessing journey. There are smaller pieces of equipment like flushing pumps, or they’re actually automated endoscope reprocessors, you can think of them as endoscope washing machines. All of those instructions need to be built into the internal protocol at the facility level. But then also we always recommend that the facility follow at least one professional society guidelines specifically written about endoscope reprocessing. And there are four or five of these, and they’re very similar in nature. The CDC has one. Then we have organizations such as 

 [Association for the Advancement of Medical Instrumentation]. They put out a lot of standards and 

 [International Organization for Standardization] documents on medical device reprocessing and sterilization. They have one specific to endoscope reprocessing. And then you can get more into the societies that really focus in on one type of endoscopy use. For example, 

 [Society of Gastroenterology Nurses and Associates] is for gastrointestinal endoscopy. It’s their nurses’ association. You have 

 [Association of periOperative Registered Nurses] that has one. That’s perioperative nursing. And there are a few others as well. But the one good thing that the society guidelines give you is that they go above and beyond what the endoscope manufacturer suggests. So, no matter where you’re doing your reprocessing, whether you’re in a very small room within your unit and your scope never leaves your unit or whether you’re in a bigger center who’s decided to centralize reprocessing, and maybe those scopes go to a different department—as long as the best practices that are within not only the instructions for use from the manufacturers, but also in these guidelines you choose to follow, should be being followed. And as long as you can do that logistically and work through that, then I think it doesn’t really matter, necessarily, where the reprocessing is being done physically, but who’s doing it. Are they trained? Are you using the correct equipment? Are those people following the steps as they should?

What made you conclude that it might be a good idea to have infection preventionists involved in this process?

I think infection preventionists offer a different perspective. Often reprocessing technicians, they’re not typically nurses. They’re essentially sterile reprocessing type of employees. And depending on who oversees them, it may be a nurse manager who really focuses on the procedural aspect of endoscopy or an SPD manager that may have a lot of expertise in medical device manufacturer or medical device reprocessing. But the infection preventionist can really go in almost as a consultant and consult on is the IFU being followed as written. Are people using good aseptic or sterile techniques should that be needed? And that is something that really comes into play specifically for an endoscope sampling and culturing program. In order to get a good sample from an endoscope, it is a little bit of a logistically difficult process because you’re trying to take a microbiological sample from a five-foot-long tube. And depending on who is actually taking the sample, whether they are technicians and may not have ever had good training in aseptic and sterile technique, this is where infection preventionists—because most of them not only have that IP background, but a nursing background or lab background or something similar—can come in as a third party, as a third third set of eyes, and really see things from a different perspective and put their unique expertise to use.

Have you actually seen this work on the ground?

Yes. So, Olympus does do sampling and culturing studies out there, with we’re gearing up for one right now on duodenoscopes. And many of the facilities have agreed to work with us on these studies. The infection preventionist is the most integral player in these studies.

Is that new or has that always been the case?

I think it’s relatively new in the last few years. I think typically in the past infection preventionists were very concerned about operating room sterility. Things like catheters and central line infections, things like that. Almost population epidemiology within their facility. But I think as the world of endoscopy kind of grows in itself…. Concerns tend to pop up over reprocessing of endoscopes. There are studies that are coming out looking at that. I think as a function of that, infection preventionists get pulled in because there is a very large kind of infection prevention idea behind reprocessing medical devices and reusable medical devices, especially a flexible endoscope. I think it’s a natural transition. And I’ve been to a few 

 [Association for Professionals in Infection Control and Epidemiology] conferences over the years and I have seen a very noticeable increase in the number of lectures and programs specifically geared toward infection preventionists to teach them about flexible endoscopy and reprocessing flexible endoscopes and what that looks like and how they can become involved.

Do you think infection preventionists will be greeted with open arms or might there be some kind of turf problem? There’s always turf problem, right?

I know and, honestly, I’m not sure. I think everybody would like to think that it’s a very harmonious relationship between IPs and the departments they oversee. I am hoping it is like that for everybody.

Any final words for infection preventionists?

I think for infection preventionists: If you’re not already involved in your endoscopy department or you haven’t been invited in, see if you can get in and just continue to check it out and see what’s going on, especially if the reprocessing and cleaning of the scope is actually done within that clinic. If it’s done in another location, and you may already be involved in something else there, see if you can take a peek over there. I think there’s a lot of room in endoscope reprocessing for infection preventionists to really come in and offer their really unique perspectives and form this multidisciplinary team that is really needed and really helps to promote patient safety.

This interview has been edited for clarity and length.

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Melinda Benedict, MS, CIC, CFER:  “I think for infection preventionists: If you’re not already involved in your endoscopy department or you haven’t been invited in, see if you can get in and just continue to check it out and see what’s going on, especially if the reprocessing and cleaning of the scope is actually done within that clinic.”

Q&A: IPs Need to Get More Involved in Endoscope Disinfection

Even in the midst of the coronavirus disease 2019 (COVID-19) pandemic, we should not forget that about 500 people in the United States die each day from antibiotic-resistant organisms. That was one of the points stressed by Admiral Brett Giroir, the nation’s Assistant Secretary of Health at the US Department of Health and Human Services (HHS) during the 2020 Fall Presidential Advisory Council on Combating Antibiotic-Resistant Bacteria. The public portion of the meeting was held online September 9 and 10.

One difference between COVID-19 and multidrug-resistant organisms (MDROs) is that the MDRO is a silent epidemic, comparatively. However, headway is being made.Amanda Cash, DrPH, MPH, a senior health policy analyst at HHS pointed out that from 2012 to 2017, overall deaths from MDROs dropped 18%, and in hospitals they dropped 30%.

It was evident to me that all of this may have changed with the advent of the COVID-19 pandemic.

Arjun Srinvasan, MD, the associate director for healthcare-associated infection prevention programs for the US Centers for Disease Control and Prevention (CDC), pointed out that there are bacterial coinfections that occur with COVID-19 along with antibiotic usage patterns. Preliminary CDC analysis indicates that, COVID-19 leads to a much longer hospital length-of-stay than influenza-like illnesses, 8.44 days compared with 5.88 days, respectively, a finding which was echoed by a number of presenters. Patients with COVID-19 experience a similar number of positive bacterial cultures as they do influenza-like illnesses, 12% in each group. However, during the pandemic, preliminary data reviled that, patients with COVID-19 were more likely to contract healthcare-acquired infections (HAIs), possibly due to longer hospital stays. The most common MDRO infecting patients with COVID-19 was methicillin-resistant 

(MRSA), followed closely by extended spectrum beta-lactamases (ESBL)-producing organisms. MRSA caused just under half of the COVID-19 hospital-acquired antibiotic resistant infections.

CDC preliminary data also found that during the pandemic, total hospitalizations in the United States decreased by approximately 25%. However, inpatient antibiotic usage did not markedly change. The most common types of antibiotics prescribed were ceftriaxone for presumptive community acquired pneumonia, which increased by 22% in April and then fell during the summer, and azithromycin, possibly used in conjunction with hydroxychloroquine, the rate of which increased by 55% in April and then also fell. It was evident to me that in both cases the usage pattern represents changes in both diagnostic ability and treatment recommendations.

Outpatient visits fell by 60%, with antibiotic prescriptions falling by 40%. Azithromycin has been the most commonly prescribed outpatient antibiotic and, with the exception of the COVID-19 hotspots New York or New Jersey, its use also decreased.

From this presentation and others, I concluded that the fall in outpatient visits may have been due to not only a reluctance to seek care, but also to fewer respiratory infections as a result of implementing public health preventive measures.

Emily Heil, PharmD, a board member of the Society of Infectious Diseases Pharmacists, reported similar findings with only 3.5% of patients with COVID-19 having a bacterial coinfection on admission and overall, 14.3% of patients developing a coinfection. However nearly three quarters of all patients were prescribed an antibiotic, usually broad spectrum. Seventy-four percent of the time a fluoroquinolone or cephalosporin was prescribed, which are often the targets of stewardship programs.

Kalvin Yu, MD, the medical director at Becton Dickinson & Co., also reported that COVID-19 hospitalized patients have a higher death rate, higher intensive care unit (ICU) utilization, and longer length-of-stay than COVID-19–negative patients. Mortality for those in the ICU was 38.2% for COVID positive vs. 13% for COVID-19–negative patients and even more pronounced mortality differences were observed for non-ICU admissions, with mortality rates of 10.9% and 1.8%, respectively. Twenty-four percent of COVID-19–positive patients were admitted to the ICU compared with 17% of COVID-19–negative patients. Length-of-stay was 8.7 days and 5.1 days, respectively.

Antibiotics were used in 68% of COVID-19–positive patients, compared to 46% of COVID-19–negative patients. Antibiotics used in COVID-19–positive patients were already those with antibiotic resistance problems including, Ceftriaxone, macrolides, and vancomycin. Finally, Yu presented data regarding COVID positive patients havinga high rate of 

 occur more frequently in COVID-19–positive than COVID-19–negative patients.

Multiple presenters, including Hana Balkhy, MD, the executive director for infection prevention and control atthe World Health Organization, and Andrew Singer, PhD, UK Centre for Ecology & Hydrology, also stressed that less than 10% of COVID-19–hospitalized patients had or developed a bacterial coinfection, but approximately 70% were on antibiotics.

However, of the patients who die, the incidence of coinfections may be higher. Cornelius Clancy, MD, the chief of the infectious diseases section at VA Pittsburgh Health Care System, reviewed nearly 500 published autopsy reports and concluded that between 35% to 40% of patients who die with COVID-19 have histopathological findings consistent with a pulmonary coinfection.

Heil stressed that the above observations underscore the need for antibiotic stewardship programs. But stewardship activities decreased as pharmacists were shifted to COVID-19–related activities such as writing new therapeutic guidelines and updates, overseeing clinical trials, emergency use authorizations, and the administration of novel medications. To compound matters, in many institutions, staff were also laid off for budgetary considerations. “This loss of personnel may have long-term consequences,” Heil warned.

The impact of telehealth on antibiotic stewardship was discussed by Gail Golab, the chief veterinary officer, scientific affairs and public policy at the American Veterinary Medical Association. Several peer-reviewed reports have found that antibiotics for respiratory and ear infections are prescribed at a higher rate in human telemedicine than in-person visits. This appears to be a consequence of not being able to perform a physical exam or laboratory evaluation, making antibiotic prescription clinical guidelines more difficult to follow. However, it has also been shown that telehealth can help implement antibiotic stewardship programs which have led to lower antimicrobial use.

All of this points to the need for an effective COVID-19 vaccine and innovative strategies to expand testing.

Sean O’Leary, MD, a professor specializing in pediatric infectious diseases at the University of Colorado, stressed that vaccines that sit in refrigerators do not save lives, vaccinations given to suspectable patients do. And all is dependent upon public vaccination acceptance. Childhood vaccines are well accepted with 94.7% of children receiving the measles, mumps, and rubella vaccinations. However, influenza vaccination has only a 45% compliance rate. O’Leary reviewed research from Yale

, which examined acceptance of a SARS-CoV-2 vaccine: More respondents reported they would receive a COVID-19 vaccine compared with a flu vaccine.The one exception was the Black population who had the lowest acceptance, even though their communities are severely impacted by COVID-19.

O’Leary reviewed an August 25 to 27, 2020 STAT/Harrris poll

found that the majority of the respondents (78%) from both political parties feel the COVID-19 vaccine is driven more by politics than science. Both the CDC and US Food and Drug Administration setting possible goals before the election fueled this paranoia along with the initiative’s name of Warp Speed. O’Leary stressed that messaging regarding the safety of vaccines needs to be done carefully so as not to create a “backfire effect,” where the message, although accurate, further entrenches the antivaccination beliefs of the recipient.

It is exceedingly difficult to remove misinformation from the minds of those who are not willing to be vaccinated. You may actually reinforce the myth by making it more familiar, by providing too many arguments, or threatening the holder’s world view.

O’Leary described 3 components of a message designed to debunk a myth: Focus on core facts, explicitly say the myth is false, and offer an explanation as to why the misinformation has occurred.

The most important way to encourage vaccination is to have the vaccine recommended by the provider.

An important advance in monitoring the spread of COVID-19 is the pool testing of multiple samples using a single test. This technique conserves resources and efficiently identifies carriers.

This concept was elevated to a new level by Sean Norman, MSc, PhD, the director of the molecular microbial ecology lab at the University of South Carolina, who described the utility of pool testing sewage. This innovative approach allows an unbiased testing of SARS-CoV-2 levels in the community, which includes both symptomatic and asymptomatic carriers. Results from such testing can guide community decisions on how to reopen activities in our society. In addition, a more targeted application is the monitoring of individual office buildings or university dorms. A positive test can then be used to identify carriers with targeted case tracking.

COVID-19 is a severe illness and stressor on our healthcare system that is rapidly changing the practice of medicine. Patients afflicted with COVID-19 have an increased susceptibility to antibiotic-resistant infections both from prolonged hospitalizations and the use of immunocompromising agents such as dexamethasone. MRSA was found to be the most common antibiotic-resistant organism in these patients. A finding arguably produced by a culmination of ineffective past strategies to control MDROs let alone prepare for a pandemic.

The United States has endured both supply shortages and disruptions in the antibiotic supply chain, affecting availability of antibiotics for tuberculosis and sexually transmitted infections, a result of ineffective preparation and a slow and anemic response at the beginning of the pandemic.

As aptly stated by Srinvasan: “The pandemic laid bare the fact that our healthcare-associated infections and antibiotic use and resistance programs at both the state and facility level are both significantly underfunded and understaffed, in too many instances where one meets in this area a challenge set up for failure.”

The most important consensus which was echoed throughout the conference was that social distancing and wearing a mask cannot only help with COVID-19, but may also profoundly decrease the flu season.

Rawson TM, Moore LSP, Zhu N, et al. Bacterial and fungal co-infection in individuals with coronavirus: A rapid review to support COVID-19 antimicrobial prescribing [published online ahead of print, 2020 May 2]. 

Malik AA, McFadden SM, Elharake J, Omer SB. Determinants of COVID-19 vaccine acceptance in the US [published online ahead of print, 2020 Aug 12]. 

. 2020;100495. doi:10.1016/j.eclinm.2020.100495

Silverman E.Poll: Most Americans believe the Covid-19 vaccine approval process is driven by politics, not science.STAT.Aug. 31, 2020.Accessed Sept. 14, 2020. 

https://www.statnews.com/pharmalot/2020/08/31/most-americans-believe-the-covid-19-vaccine-approval-process-is-driven-by-politics-not-science/

Patients afflicted with COVID-19 have an increased susceptibility to antibiotic resistant infections both from prolonged hospitalizations and the use of immunocompromising agents such as dexamethasone.

Taking Aim at Antibiotic-Resistant Bacteria During COVID

The monitoring and tracking of healthcare-acquired infections (HAIs) has evolved over time based on national and local guidelines and regulations. Formal standard definitions for HAIs were first developed by the Centers for Disease Control and Prevention (CDC) through the network of hospitals that participated in the National Nosocomial Infection Surveillance (NNIS) program.

 This network was a voluntary group of facilities that used the definitions to standardize the collection of HAI data and also report to a national database where analysis was completed and disseminated. This national data surveillance program provided a method for benchmarking HAI events with the advantage of having consistent definitions and data collection methodologies.

Facilities could determine what HAIs they would actively track and report, leaving it to the discretion of the infection control program, facility leadership, and assessment of specific population risk factors. Therefore, each facility could be tracking different infections, but all would be using the same definitions for data collection and determination of HAI status. Eventually, the NNIS evolved into the National Healthcare Safety Network (NHSN) and the HAI definitions transitioned over to the NHSN division of the CDC. Currently, HAI definitions in the United States are standardized to the NHSN criteria and infection prevention (IP) programs to use those definitions as their surveillance strategy.

Over time, the tracking of HAIs became more regulated. State governments were passing legislation mandating public reporting of select HAIs, thereby forcing IP programs to focus efforts on those particular HAIs that were publicly reported. Each state would have different HAIs required, however the majority focused on device associated infections, such as central line associated bloodstream infections (CLABSIs), or various surgical site infections.

 As the risk and impact of HAIs became more noticed in the public media, the federal government established the reporting requirements through the Centers for Medicare and Medicaid Services (CMS) of several HAIs, starting with CLABSI and adding more indicators.1 Currently there are 6 HAIs that are federally publicly reportable: CLABSI, catheter associated urinary tract infections (CAUTI), surgical site infections (SSI) for colon procedures, SSI for total abdominal hysterectomies, and laboratory based measures for 

 (MRSA) bacteremia infections. The public reporting of these HAIs impacted the way IP programs define their surveillance plans and tied hospital reimbursement directly to performance on these indicators.

As public reporting became a reality for IP programs, the focus of the surveillance shifted from what would be more individualized to each facility to these 6 specific HAIs. The efforts of IP programs had to meet the reporting need, and also were more visible as a financial impact to hospitals. IP programs also were pressured from hospital leadership when reviewing cases to determine if they met NHSN definitions, and would then be reported and potentially result in CMS penalties.

These aspects of the mandatory reporting were new experiences for IP programs, and the task of describing an event as hospital-associated or not, suddenly became much more at the forefront of the role performed by infection preventionists (IPs). Meanwhile, the requirement for public reporting meant that surveillance became more important and a higher priority for IP programs; therefore, other important program functions, such as rounding, education, process improvement projects, construction and biopreparedness all had to be set aside for the time to monitor and report HAI data.

Resources need to be provided for IP programs that can help ease the burden of reporting, and also free up time for IP staff to perform other tasks. Surveillance and data mining systems that can automate much of the reporting requirements would be ideal for IP programs. Also, as mandatory reporting continues, it would be essential to have input from IPs on what items should be included or added to the reporting requirements. IP staff input would allow federal and state legislators to understand the time and resource requirements of mandatory reporting and be a voice to advocate for changes in legislation that would improve reporting.

The coronavirus disease 2019 (COVID-19) pandemic has impacted HAIs across the country. Not only were IP programs stretched during the pandemic as part of the public health response, but also the HAI reporting was still being done. IP staff had to figure out how to manage all the workload of the pandemic response and continue to keep surveillance and data reporting current and active.

The work of HAI prevention was also impacted similarly, with less time for IPs to do rounding and focus on the elements that contribute to HAIs. As the national data is analyzed and released in coming months, it will be interesting to see if HAIs were impacted by COVID-19 and to understand exactly how a pandemic influences HAI prevention efforts. Anecdotally, patients with COVID-19 were seen to be high risk for HAIs, particularly CLABSI and CAUTI, due to long lengths of stay, duration of ICU admissions, proning treatments to help with respiratory function and other unique aspects of care.

As IPs work toward a future that includes COVID-19, there will continue to be a resource pull away from traditional infection prevention work to help focus continued efforts toward pandemic response, vaccination of staff and patients and public health collaboration. Compounding this work is the increased risk for HAI events with COVID patients. IP programs can work with nursing and medical staff to develop COVID-19 pathways for patients to help address concerns around HAIs and other healthcare-associated complications, such as pressure injuries and falls. These pathways can include specific interventions that are based on current best practice, such as chlorhexidine bathing, daily assessment of devices, and use of external urinary catheters, but make modifications that would further help mitigate risk for these patients who are at increased risk.

The impact of COVID-19 on HAI identification and reporting is still to be seen. Perhaps more reporting will be required of other respiratory illnesses, such as influenza or pertussis, as well as hospital onset COVID outbreaks. Perhaps COVID status will be part of routine reporting to NHSN as a risk factor. However, the regulations around reporting may change, IP programs will need to continue to incorporate pandemic response into their daily routines, while working to maintain a presence with HAI prevention. All this puts a strain on IP programs, and increased resources or new collaborations and partnering across programs will be essential for success, and ultimately for patient and staff safety.

REBECCA LEACH, RN, BSN, MPH, CIC, has been an infection preventionist since 2010, with a background in nursing and epidemiology. Leach, a member of Infection Control Today®’s Editorial Advisory Board, currently works at a healthcare system in Phoenix that includes 5 hospitals and more than 100 outpatient treatment centers.

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Bean M. How the pandemic is affecting HAI rates: 5 things to know. Becker’s Hospital Review. Published August 5, 2020. Accessed September 12, 2020. 

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COVID-19 possibly hindered the prevention of healthcare-acquired infections (HAIs) because infection preventionists have less time to do rounding and focus on the elements that contribute to HAIs. 

Infection Control Today, November 2020 (Vol. 24, No. 9)

Novel Initiative Keeps Nursing Home Residents Safe From COVID-19

When It Comes to COVID-19 Disinfectants: Use With Care

Innovations Needed for Personal Protective Equipment

Q&A: IPs Need to Get More Involved in Endoscope Disinfection

Taking Aim at Antibiotic-Resistant Bacteria During COVID

Tracking of Healthcare-Acquired Infections Continues to Evolve

Bug of the Month: I’m Riding the Anti-Vax Wave in My Comeback