A novel disease comes with novel problems and in this new era of coronavirus disease 2019 (COVID-19), there have been so many things challenging infection prevention efforts. From personal protective equipment (PPE) roadblocks to changing isolation precautions, this has been a minefield not only for infection prevention, but also public health. As of this writing, the United States is facing a backlog in testing, delaying results for up to 10 or even 14 days in some areas. Concurrently, there is unabated transmission through many southern states, worrying many that significant second waves are already in play.

As the United States works to increase testing capacity and hospitals adjust to ensure they can handle surges, one of the biggest pieces to COVID-19 response is contact tracing. This function of public health works to reduce the potential for secondary transmission following the identification of a single case. Resource intense, contact tracing is a cornerstone of public health and outbreak response.

Contact tracing is not new, but rather a tried-and-true measure of public health response to outbreaks and infectious diseases. When someone tests positive for SARS-CoV-2/COVID-19, contact tracers work to interview the positive person and identify who they may have come into contact with so they can then be informed and quarantine for 14 days if needed. Contact tracing is an approach that has been successfully used for outbreaks ranging from Ebola to foodborne illnesses, like salmonella. More recently, it’s been used in response to COVID-19 and has been extremely successful in countries that have opted to heavily invest in such efforts from the beginning.

notes: “Large-scale contact-tracing programs in places such as South Korea and Germany have been instrumental in suppressing the novel coronavirus, SARS-CoV-2. Within days of detecting its first case on January 20, South Korea created an emergency response committee that quickly developed wide-scale virus testing, followed by an extensive scaling up of the nation’s network of contact tracers.”

In the United States though, we have struggled with contact tracing, with efforts woefully under-resourced. Estimates have put the needs of the United States at 100,000 contact tracers. Sadly though, this has not been the case, with states like Arkansas having 900 contact tracers for the whole state. Florida, which is experiencing a large surge in cases, has 291 tracers per 100,000 residents.

In the conversations about contact tracing, many may not realize that infection preventionists have been doing this for decades within the walls of healthcare facilities. There is often an assumption that public health departments solely do contact tracing, but when healthcare workers or patients have infections like tuberculosis, pertussis, or varicella, the IP works to identify exposed patients and staff to notify and work with occupational health regarding quarantine or post-exposure prophylaxis. From measles outbreaks to staff working with pertussis, I have done contact tracing as an infection preventionist since the day I began in the profession. Public health efforts tend to come into play when there are community-based exposures beyond the hospitals, or if we need assistance with larger exposures. Joint efforts are often employed for large exposures, such as measles.

In hospitals, it is common to have infection preventionists manage contact tracing and COVID-19 has been no exception. Especially in the early days of the disease when testing was more challenging to obtain, it was not uncommon to have patients hospitalized for several days without consideration for the disease, especially when we were learning about the range of symptoms.

When a patient is identified as having COVID-19, review of their movement throughout the hospital and the use of isolation precautions comes into play. Infection preventionists review and trace the patient’s movements, when isolation precautions were employed, and work to identify potential points of time when there could have been exposures due to a lack of isolation. This was more common in the beginning and prior to many hospitals moving to mandated universal masking for entire healthcare facilities. Once these points in time are reviewed, identifying staff interacting with the patient during periods without isolation becomes key. Pulling a “line list” of those staff who cared for or interacted with the patient during this timeframe is important as it not only allows for notification, but also coordination with occupational health. For COVID-19, this means following the US Centers for Disease Control and Prevention (CDC) definition of exposure and identifying those staff who interacted with the patient without PPE (mask and eye protection) within six feet and for more than fifteen minutes. From there, it comes down to identifying those staff exposed and ensuring they’re aware of the potential exposure. While the CDC allows healthcare workers to continue working post-exposure as they are essential, they are to quarantine for the 14 days following the exposure. For many though, the critical need for healthcare workers is vital and ensuring they are vigilant in masking following this exposure is vital.

In the event that a healthcare worker or staff member is found to be positive, the same processes apply. Ultimately, contact tracing is about building relationships and trust to ensure that people feel comfortable discussing potential exposures and feel safe about discussing times they might have been unmasked.

 Contact tracing occurs within their department/unit and then any patients they interacted with. Since the use of universal masking in healthcare facilities, this has greatly diminished those meeting the definition for exposure.

Unfortunately, one piece we’re seeing more of are exposures during interactions with coworkers in breakrooms, walks to the coffee shop, etc. Too often we focus on the risk from patient interactions, which means we fail to really communicate the risk of interaction with our coworkers without masks on.

Perhaps one of the biggest challenges in contact tracing is pulling these line lists and identifying anyone who interacted with that staff member or patient. Chart review and emailing leaders of departments that might not be documented in the medical record, such as environ- mental services (EVS), is time intensive. Moreover, as much as we’d like electronic medical records to be able to rapidly pull such data, it’s often imperfect and still requires reaching out to leaders of those other departments.

This presents an opportunity though, for technology to perhaps innovate a new approach to tracking interactions and movements within healthcare. Some suggestions have ranged from using Bluetooth identification badges to log employees going in and out of the patients’ room. This is a challenge I’m hoping the COVID-19 pandemic has brought to light and will spark innovative approaches that can be utilized far beyond the pandemic. While many are focusing on PPE efforts to help drive change and establish more sustainable supply chains, contact tracing is one that also needs re-vamping. The importance of privacy shouldn’t be ignored
and hopefully approaches that focus on patient-facing interactions can help support that.

As the COVID-19 pandemic continues to surge, it is unlikely that contact tracing within healthcare will become anything less than critical. While it may be easier with the universal masking efforts, it becomes increasingly difficult as more healthcare workers become positive.

For many of us in surging areas like Arizona or Texas, keeping above the water can be a full-time task. There are ranges of how we approach this as well—do we cease con-tact tracing in COVID-19 cohorts with the assumption that the proper measures are taken? Allow self-reporting? Ultimately, hospitals pose a unique environment for contact tracing and heavily rely on infection preventionists to perform it. As we move to a sustainable COVID-19 response and potentially living with it in a more endemic nature, what will contact tracing look like?

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.

Aschwanden, C. Contact tracing, a key way to slow COVID-19, is badly underused by the U.S. 

https://www.scientificamerican.com/article/contact-tracing-a-key-way-to-slow-covid-19-is-badly-underused-by-the-u-s/

Centers for Disease Control and Prevention. Notes from the field: lack of measles transmission to susceptible contacts from a health care worker with probable secondary vaccine failure — Maricopa County, Arizona, 2015.” Accessed February 12, 2017. 

https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6430a5.htm

Centers for Disease Control and Prevention. Contact Tracing. CDC website. 

https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/contact-tracing.html

Articles

As the COVID-19 pandemic continues to surge, it is unlikely that contact tracing within healthcare will become anything less than critical. 

Contact Tracing for COVID-19? Infection Preventionists Can Get it Done 

Bug of the Month helps educate readers about existing and emerging pathogens of clinical importance in healthcare facilities today. Each column explores the Bug of the Month's etiology, the infections it can cause, the modes of transmission, and ways to fight its spread. The pathogen profiles will span bacterial, viral, fungal and parasitic species. We encourage you to use Bug of the Month as a teaching tool to help educate healthcare personnel and start a dialogue about microbiology-related imperatives.

Coronavirus disease 2019 (COVID-19) has made hand hygiene all the rage. That’s too bad. Because hand hygiene doesn’t only help to slow the spread of COVID-19, but a slew of other dirty bugs, as well. 

Bug of the Month: I’m Downright Nasty And Clever to Boot

Thinking of teleworking? Not in a million years, we would have guessed, but yes, it is happening. Infection preventionists (IPs) are boots on the ground and people think we’re everywhere, but this morning as I write this, I am at home, in my office, getting ready to start my day. How will the units survive? How will I survive?

I begin my day just as if I were in my “hospital” office. I have my coffee and fire up my computer. Will start to look at emails and then dive right into surveillance and reporting, only stopping for the occasional Skype meeting or call from the hospital. I know my teammates (all incredibly bright master’s prepared nurses) at the hospital will take care of rounding and putting out fires, and when I return next week and someone else works from home the roles will be reversed. While some may have questioned our ability to telework, the reassurance of support provided comfort. We also had to deal with the very real possibility if one member went into quarantine, we could lose the entire team.

I can tell you; we have all admitted it takes a little getting used to. It’s a different routine yet we remain intensely focused even when we are not there, I know (as do my staff) that I am protecting and serving our valuable customers. I was asked last week “what made it difficult to get used to” and I think it’s the sense of releasing some control. I know when I am there I can respond quickly and can be there to help if things get out of control. There’s also a sense of comfort for myself and my staff knowing we have each other’s backs Infection prevention is a hands-on, eyes-on-the-hospital job. The idea of working from home may fill you, the hard-working IP, with anxiety. I know I have an incredibly strong team and becoming anxious about something I cannot control remotely is wasted energy.

What will they do when they know you can’t appear around any corner? How can you provide just-in-time advice? The coronavirus disease 2019 (COVID-19) pandemic has upended so much about our lives and ways of conducting business, everything is vulnerable to change. Though potentially an afterthought to the busy IP, the IP’s health and well-being is critical during this marathon pandemic. Furthermore, a telework-ready IP is an IP that continues to support their facility if they also end up in quarantine. Teleworking like so many other aspects of nursing are something we just needed to jump into. No training, no guidebook, no manual. We take our daily routine and model it into practice from our homes and offices. Like so many other things in life, attitude is everything. As nurses we must be flexible and fluid in our practice. Our primary mission is to save lives and to adjust to what may get in our way.

At the beginning of the pandemic we were all working “inside” the hospital. As information and guidelines became available, we quickly realized we would not be able to sustain social distancing within our current space.

And did we all need to physically enter the hospital every day? Especially when we were asking other departments to minimize the staff (and therefore exposures) in the hospital? Being outside felt kind of odd at first, but again we must focus on our mission to protect our patients and staff. It can’t be about us, really a no-brainer.

Technology today connects us not only to each other, but to the hospital intranet and, with it, the patient’s electronic health record. It enables us to still maintain important meetings electronically from the comfort of our desk or home (when thinking about the meetings we are no attending in person—there are many). We start the day with the morning IP huddle to discuss calendars, important meetings or rounds that might need to be covered. Other meetings include hospital incident command, construction updates, meetings with environmental services, surgical processing, and facilities. Meetings are led by who would have led them in person, making do from their home office.

When preparing for the pandemic, nursing leadership and top officials discussed how we can keep our doors open and provide the highest level of care safely. Since standing up a COVID-19 ward and locking down the hospital (restricting visitors and cancelling all non-urgent surgical cases), we meet to discuss “reopening.” This term is a bit misleading, more of a calculated and planned phasing to develop a “new normal.”

The level of collaboration or questions presented depends on the party asking and on the meeting. Some may just need updates on CDC guidelines, others need advice on proper containment for a construction project, and environmental services may ask if a specific chemical can be used as a substitute for something harder to obtain. Routine business is conducted, like the storing of surgical trays and purchasing storage solutions.

Even at the hospital, most meetings are telemeetings. Face-to-face meetings are not recommended unless absolutely necessary.

Payroll and administrative functions can be completed remotely, electronic training modules are the norm, and policies can be updated from home—perhaps with fewer distractions. The IP’s teleworking would update policies to decrease the workload of the staff at the hospital. Hospital staff are rounding and putting out the daily fires that crop up even more with the coming of COVID-19. Surveillance and reporting of hospital-acquired infections (HAI’s) has long held the IP captive to their computer, and thus is easily accomplished at a home work station. If in-house, the split would be about 50/50. Teleworking is 100%; so you need to get used to that.

The ideal balance may be to have a portion of the IP staff working within the brick and mortar facility, responsible for face-to-face interactions, environment of care rounds, assessment of construction sites, perform daily rounds, assess compliance with infection control policies (hand hygiene, precautions), and provide hands-on staff education. The physically present IP can answer questions, offer reassurance, and provide comfort in a way that a remote presence cannot. As much as people say they “dread” seeing the IP, they rely on us as experts to provide guidance on critical decisions related to COVID as well as other infectious diseases. Talking with staff in person (while maintaining social distancing) helps staff know they are supported and heard.

Our current process is to rotate staff weekly to telework. Each Friday we review who will be working from home the following week and what is included in their responsibilities. To date it is working.

Our world has changed significantly, and the IP is not immune to a new paridigm. In our facility a hybrid model of telework and face-to-face infection prevention is the best balance between allowing social distancing and safety while maintaining the same high standards we expect from the tireless, essential IP. Our colleagues rely on our expertise and we cannot let them down.

JODY FEIGEL, RN, MSN, is the Nurse Manager of Infection Prevention at VA Pittsburgh Healthcare System in Pittsburgh.

A telework-ready infection preventionist is an IP who continues to support their facility if they also end up in quarantine. Teleworking like so many other aspects of nursing is something we just needed to jump into. No training, no guidebook, no manual.

During COVID, Telehealth Can Be an Infection Preventionist's Friend

Currently, the United States Environmental Protection Agency (EPA) registered products that claim long-lasting effectiveness are limited to those that control odor-causing bacteria on hard non-porous surfaces. The agency is currently reassessing changes that may allow such claims in response to the current coronavirus disease 2019 (COVID-19) pandemic. Unfortunately, standard procedures for testing and registration by regulatory agencies of continuously active sanitizers or disinfectants (CADs) as disinfectants useful in preventing exposure to disease causing microorganism transmission has only taken place in recent years.

The EPA developed a protocol for evaluating bactericidal activity on nonporous copper containing surface alloys and one-for-one for claiming a residual self-sanitizing activity of dried chemicals on hard, non-poroud surfaces. These methods also simulate contact and touching by incorporating “wear” of the test surface as well as re-inoculation of the test microorganism. However, more progress is needed in this area to develop standard procedures that would also allow a better reflection of the advantages in terms of benefits in reducing the risk of infection with treated surfaces.

Quantitative microbial risk assessment is an approach that has been used to demonstrate reduced risk of infection from a continuous acting hand sanitizer over time. Using this approach, it was demonstrated that four hours after hand application the sanitizer reduced the probability of infection if the hand was re-contaminated with 

Recent epidemiological studies have suggested that CADs can reduce the bacterial bioburden on surfaces in healthcare environments and hospital acquired infections. Assessment of a quaternary ammonium polymer coating in intensive car units was found to result in the absence of antibiotic resistant bacteria on surfaces for three months in one study and in a follow-up study a 36% decline in hospital-acquired infection (HAI) 

. Several studies with copper surfaces have also shown similar results and suggested a reduction in HAIs in 

The potential for CADs has taken on new importance with the Covid-19 pandemic. Protecting exposure via surfaces in facilities used by large numbers of individuals becomes challenging. This is especially true in schools, universities, mass transport, recreational facilities, etc. The amount of resources and practicality of disinfecting facilities between use by different individuals appears insurmountable in many cases. Recent studies have shown that SARS-CoV-2 that CADs can be effective against this virus both on hard surfaces and fabrics and may be useful in filling 

CHARLES P. GERBA, PhD, is a professor of environmental microbiology in the Department of Environmental Science, and Environmental and Community Health at the University of Arizona. He serves on the Advisory Boards of PDI and Allied Bioscience.

Charles P. Gerba, PhD: “Unfortunately, standard procedures for testing and registration by regulatory agencies of CADs (continuously active sanitizers or disinfectants) as disinfectants useful in preventing exposure to disease causing microorganism transmission has only taken place in recent years.”

Continuously Active Disinfectants Can Keep COVID at Bay

Standard precautions have a long history in healthcare, being practiced in some form since the Middle Ages. The Centers for Disease Control and Prevention (CDC) formalized these precautions into what was then called universal precautions in response to the HIV epidemic in the late 1980s. Universal precautions were focused on protecting healthcare workers from blood borne pathogens, focusing on the use of personal protective equipment (PPE) such as gowns and gloves. The concept treats all blood and body fluids as potentially infectious. Universal precautions were revised and became standard precautions in 1996 and became more inclusive of an overall infection prevention aspect when engaging in patient care. Respiratory hygiene was added to standard precautions in 2007, in recognition of the increasing risk of respiratory spread of illnesses such as pandemic influenza.

Transmission based precautions were developed in the 1970s, and were revised to be a next higher level of precautions for those infectious diseases that were spread through contact, droplet and airborne transmission. The emergence of antimicrobial resistant pathogens drove the need to update standard precautions so that healthcare environments could prevent transmission as well as keep providers safe. Just as the need for transmission-based precautions was driven by emergence of pathogen resistance, it is now time to look again at the concept of standard and transmission-based precautions and determine if additions or changes are needed in the wake of the COVID-19 pandemic.

Recent outbreaks and epidemics have shown that infection prevention needs to become more sophisticated with standard precautions, travel history and general awareness of national and international epidemiology and diseases of public health concern. Over the last two decades, the majority of the significant outbreaks was due to viral respiratory illnesses (severe acute respiratory syndrome (SARS), middle eastern respiratory syndrome (MERS), avian influenza). The SARS epidemic in part prompted the CDC to update the standard precautions to include respiratory etiquette.

In these recent outbreaks, and the current pandemic, healthcare workers (HCWs) are at increased risk for acquiring the infections purely as a result of doing their jobs. Data has shown that HCWs made up roughly 20% of cases in the SARs outbreak and 18% in the MERS outbreak.

 It is still unknown how many HCWs have become infected in the COVID-19 pandemic, but current estimates as of this writing are greater than 65,000 cases.1 Many factors can contribute to HCW infections, but often early in outbreaks and pandemics, lapses in infection control practices play a major role. Not having the appropriate type or amount of PPE, lack of isolation of infectious patients, and lack of awareness of epidemiological risk factors, such as recent travel or congregate living status, all play a part. With any type of outbreak, there is always an initial gap in awareness and understanding of the pathogen, transmission factors, and virulence. At this time is when HCWs can be most vulnerable and the outbreak has the potential to grow from a local or regional level. It is during this time when traditional application of standard precautions may not be enough.

Recent articles in the press have been debating the role of airborne transmission in COVID-19 spread.

 While there is not a clear consensus, what does appear to be clear is the need to develop more nuanced definitions of droplet and airborne transmission. The desire to have a very mutually exclusive and clear separation of the types of transmission makes it easier to educate, implement, and monitor. However, science shows that it is more of a continuum that is impacted by many variables, which leaves much up to the bedside practitioner to evaluate and assess risk levels.

Environmental factors, such as humidity level, air exchanges, pressure differentials, can all impact the amount of aerosolization that can occur with respiratory droplets.

 Patients themselves impact, with activity levels, cough etiquette and other host factors that can potentially impact communicability of the virus. The strain of the virus can be more infectious than others, which is not known at the time of admission to the healthcare facility. Manipulations and treatments that are done to the patients also impact the ability of aerosolization, such as oxygenation modalities, endotracheal intubation, bronchoscopies or nebulizing medication treatments.

 All of these factors make the isolation precautions for diseases like COVID-19 more complex than typical droplet or airborne definitions.

With the knowledge that respiratory illnesses have been the greatest international impact on recent outbreaks, it is time to again review the items included in standard and transmission-based precautions and potentially include some variation of universal masking for patient encounters. In particular, this may be most essential in frontline areas, such as emergency departments, urgent care centers, ambulances and first responders, where there is no known history for the patient and unknown exposure risks. Also, in areas where many aerosol generating procedures are occurring, such as intensive care units, procedural areas, respiratory care units and dental clinics.

Another difficult lesson learned from the COVID-19 pandemic is the inadequate supply of respirator options that are available across the healthcare continuum for staff. Traditional N95 masks that require fit testing were in short supply as the pandemic ratcheted up. In even shorter supply were other types of respirators that did not require fit testing, such as PAPRS, CAPRS and other full-face respirator options.

And with almost all of these types of respirators, there are still contraindications for use, such as facial hair, eyeglasses, severe asthma, or other health conditions of the worker. This has revealed a long feared weak link in the ability of a facility to provide adequate protection to all its healthcare workers at the most crucial time it is needed. Efforts to increase not only the availability of current respirators, but also develop new technologies that offer the same level of protection, but have more universal fit and application to a wide variety of users, should be a push from manufacturers and vendors for healthcare and other essential workers.

More research is needed in the field of disease transmission, and in particular for respiratory illnesses. Many studies are based on animal models, which have limitations with human physiology, or are lab-based, which have limitations in real-world scenarios. Understanding of how effective the airborne or aerosol spread is for various respiratory diseases would provide much needed information on how best to develop transmission-based precautions that are effective. A review of the current recommendations of airborne precautions would also elucidate which components are most effective in breaking the chain of disease spread.

And based on these types of data, precautions for specific viral illness could be more specific and also more customizable based on transmission factors. However, until that time comes, and with the continued threat of emerging viral respiratory pathogens, consideration of universal masking guidelines as part of standard precautions may be the beginning of another evolution of how we approach infection prevention practices in healthcare organizations.

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.

Xiao J, Fang, M, Chen Q, He B. SARS, MERS and COVID-19 among healthcare workers: A narrative review. 

World Health Organization. Modes of transmission of virus causing COVID-19: implications for IPC precaution recommendations.WHO website.https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations#.XxIWGGzGYPA.email

Klompas M, Baker MA, Rhee C. Airborne transmission of SARS-CoV-2:theoretical considerations and available evidence. JAMA Network. Published online July 13, 2020. doi:10.1001/jama.2020.12458

Shiu EYC, Leung NHL, Cowling, B. Controversy around airborne versus droplet transmission of respiratory viruses: implication for infection prevention. 

Many factors make the isolation precautions for diseases like COVID-19 more complex than typical droplet or airborne definitions. 

Revamp Standard Precautions for Infection Preventionists

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Giving birth can be difficult in even the best of circumstances. But what happens if the infant needs to be taken to the neonatal intensive care unit? And what happens if a mother or father tests positive for COVID-19? What if there are not enough isolation rooms? These are just some of the issues that have been confronted by NICUs across the country in the face of the COVID-19 pandemic. Jenny Hayes, MSN, RN, CIC, CAIP, CASSPT, is the infection prevention leader at the Hospital of the University of Pennsylvania. Hayes says that it all comes down to strategy. She recently sat down with 

 to explain what she considers to be the best approaches to NICU care under the shadow of COVID-19. For instance: “All of our mothers are tested upon admission. They all come in whether they’re symptomatic or not symptomatic, they are all tested. Not all hospitals may have that capacity.”

Two-part question. Could you tell us a little bit about the challenges of infection prevention in NICUs in general? And has COVID-19 presented a unique challenge there?

In the neonatal intensive care population, you can’t look at this population as a single entity. This is a combined population of maternal health, both prior to birth and after birth. You have your triage for labor and delivery. You have your labor and delivery staff and that setting. And then you have the birth of a child who perhaps needs emergent resuscitation. Is born prematurely and needs to go to the infant resuscitation bay and is subsequently admitted to the neonatal intensive care unit. Once that happens, you still have to have that consideration for the postpartum setting where the mother will be recovering from the delivery. So, remembering that delivery can take place as a vaginal birth in a labor and delivery room, or perhaps in an operating room as a C-section. Both of those settings have unique considerations for safety as far as COVID-19 is concerned.

In labor and delivery, mom’s in labor. There may be heavy breathing involved. You may have more close contact with the face. Perhaps you’re holding the patient’s hand and assisting them in breathing. It can be a heavier breathing. Asking the patient to wear a mask, which is something that we do in our facility, can be challenging at that point, especially as labor progresses, and you’re to the point of pushing. That right there offers a set of unique challenges for both the patient and the staff in the room. And when you talk about aerosolization, sometimes you’re talking about if perhaps a mom screams during that delivery. She may aerosolized some particles that wouldn’t normally take place in a routine patient care setting. The patient in labor is going to have unique needs, as opposed to the patient who delivers by C-section. Now you’re looking at a perioperative setting. Now you have to consider the airflow exchange in an operating room. You want to make sure that you are meeting the correct guidelines for that.

We allow one partner in the room. One coach in the room with the parent. In the past, you could have more than one person, but with COVID-19 we are now have one person to assist with that labor. And yes, they would be masked as well. Everyone in the room is universally masked.

 They’re wearing a paper surgical mask and they are wearing a face shield to protect them in addition to the mask, because that offers eye protection as well. The point of the mask, as I’m sure as you hear in the media, helps prevent transmission at the source. OK? Your patient is protecting you by wearing the mask. You’re protecting the patient by wearing a mask. That face shield is going to help you protect your eyes.

Do you test the babies after they’re born for COVID?

We do if the mom tests positive. All of our mothers are tested upon admission. They all come in whether they’re symptomatic or not symptomatic, they are all tested. Not all hospitals may have that capacity. And in that case, they need to prioritize their testing and they may want to prioritize that based on symptomatology. We did that initially, we only tested symptomatic patients. But then we discovered with the increases in the COVID rates that there was a lot of asymptomatic cases that were not being identified in the community at large. One of the challenges with testing with just symptomatic patients was that some of the patients were refusing testing because they were afraid of being separated from their baby. When we went to universal testing, that became part of their pre-admission education when they’re being followed by their obstetrician. They would understand that universal testing was required for all patients admitted to labor and delivery, whether you had symptoms or did not have symptoms. There was more education in the prenatal setting, so that they would understand what the signs and symptoms of COVID are. Practitioners, we’re following them for that, assessing them for that, doing telemedicine visits. In the last month of pregnancy, you would require ultrasounds or an internal exam. You would be coming into the office. And of course, there are outpatient settings, trying to really limit the volume of patients in the practices. Again, to prevent the spread of COVID-19. Part of that education through telemedicine or inpatient visits is universal testing protocols. So, it’s not a surprise when they come in that, yes, we’re going to test you for COVID-19. Fortunately, in our hospital, we’re able to get the results pretty quickly. If the mom tests positive, then yes, we will test the baby. When the patient delivers in labor and delivery, as I described some of the unique scenarios with that, as opposed to a C-section that’s a perioperative setting. Now that’s a little bit different. Your air exchanges need to be higher. In a normal patient room, you’re looking at a greater than 6 air exchanges per hour. In a perioperative setting, greater than 12. You really want to ensure that your air balancing is correct.

That would be facilities. There’s air direction. They usually have a contractor who can do their air balancing reports for them. Usually done annually. But if there’s any concern that there’s a change in the airflow, then they can always have their contractors come in and check it again. There’s filtration that takes place and there’s directional airflow that takes place. You have to have the correct checks and balances. And you do this really normally in a perioperative setting, but then you have to consider, “Oh mom tested positive.” So now this OR is isolated as a COVID OR. We have our supplies isolated in that OR. Some things stay outside of the room. Some things are inside of the room, depending on your policy and your hospital, how you want to handle that based on a risk assessment. And that risk assessment will be performed with nursing staff and leadership, physicians, anesthesia. What is it that you have to have in the room absolute at hands reach? What is it that occasionally you may use, that may say in a cart outside of the room?

What concerns you the most about COVID-19 and the neonatal intensive care units?

Open bay settings. A lot of intensive care units are designed with open bay settings, and limited isolation rooms. You may have seven or 10 beds in an open bay, and maybe only have one or two isolation rooms. But now what happens when you limit the number of isolation rooms you have? Perhaps you have two isolation rooms. Perhaps you have two babies whose mothers tested positive for COVID. So now they have to go into isolation. But now you have another mom who comes in and she’s a person under suspicion you have a pending test, and she delivers promptly. So now you have a baby who maybe…. You have to strategize where you’re going to place that baby. Perhaps at the end of the bay, closer to the isolation rooms. Waiting for that test result to come back to see, because they’re under investigation for possible COVID. You really kind of have to strategize placement of patients and prioritize those risks.

What happened when you had more patients who tested positive for COVID-19 then you had isolation rooms? What did you do in that case?

Well, that’s where you have to strategize. You have to really look and see what type of…. Are there any aerosol generating procedures? If the baby’s on CPAP or BiPAP, then that may be a greater concern because that’s an aerosol generating procedure. You’d want to put that baby in the isolation room. A baby that comes to you from the infant resuscitation bay, and they’re already intubated, it’s more of a closed setting. The other thing is you may have an isolette warmer that is closed. That’s going to help prevent some of that aerosolization that will happen. Rather than an open bassinet, you put that baby in an isolette.

I guess in some cases the bonding between a newborn and mother wasn’t able to take place right away?

 That’s correct. We require two tests, 24 hours apart, to take mom out of isolation. The mom may deliver and may not be able to see the baby initially, during that time period, we’re trying to rule in or rule out COVID. And if [the mother has COVID-19 and the baby doesn’t] mom’s going to be going home, and then she’s going to have to follow the quarantine initiatives that are put out by the department of health before she’ll be able to come back and visit with the baby. Because the baby’s in the intensive care unit, their discharge is likely to be delayed due to their health issues. It becomes very challenging. And it’s heartbreaking for some of these families.

This interview has been edited for clarity and length.

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Jenny Hayes, MSN, RN, CIC: “Asking the patient to wear a mask, which is something that we do in our facility, can be challenging at that point, especially as labor progresses, and you’re to the point of pushing. That right there offers a set of unique challenges for both the patient and the staff in the room.”