Implementation of infection control measures to prevent healthcare-associated transmission of severe acute respiratory coronavirus virus 2 (SARS-CoV-2)

Population and hospital-level COVID-19 measures are associated with increased risk of hospital-onset COVID-19

A review of hospital-onset COVID-19 cases revealed 8 definite, 106 probable, and 46 possible cases. Correlations between hospital-onset cases and both HCW and inpatient cases were noted in 2021. Rises in community measures were associated with rises in hospital-onset cases. Measures of community COVID-19 activity might predict hospital-onset cases.

Lessons learnt for enhancing hospital resilience to pandemics: A qualitative analysis from Italy

The COVID-19 pandemic has outlined the need to strengthen the resilience of healthcare systems. It has cost millions of human lives and has had indirect health impacts too. Hospital buildings have undergone extensive modifications and adaptations to ensure infection control and prevention measures, and, as it is happened following past epidemics, the COVID-19 experience might change the design of hospital buildings in the future. This paper aims to capitalise on the knowledge developed by the stakeholders directly involved with the hospital response during the pandemic to generate new evidence that will enhance resilience of hospital buildings to pandemics. The research adopted qualitative research methods, namely literature review and interviews with Italian experts including doctors and facility managers to collect data which were analysed through a thematic analysis. The findings include the identification of new needs for hospital buildings and the related actions to be taken or already performed at hospital building and service level which are viable for long term implementation and are aimed at improving hospital resilience to pandemics. The results specify how to improve resilience by means of structural modifications (e.g. placing filter zones among different wards, ensuring the presence of airborne infection isolation rooms at least in the emergency departments), technological changes (e.g. oversizing capacity such as medical gases, information technology improvement for delivering healthcare services remotely), and operational measures (e.g. assessing the risk of infection before admission, dividing acute-care from low-care assets). The needs discussed in this paper substantiate the urge to renovate the Italian healthcare infrastructures and they can be considered useful elements of knowledge for enhancing hospital resilience to pandemics in the extended and in the post-COVID-19 era.

COVID-19 Response Among US Hospitals with Emerging Special Pathogen Programs

In February 2015, the US Department of Health and Human Services developed a tiered hospital network to deliver safe and effective care to patients with Ebola virus disease (EVD) and other special pathogens. The tiered network consisted of regional special pathogen treatment centers, state- or jurisdiction-designated treatment centers, assessment hospitals able to safely isolate a patient until a diagnosis of EVD was confirmed and transfer the patient, and frontline healthcare facilities able to identify and isolate patients with EVD and facilitate transport to higher-tier facilities. The National Emerging Special Pathogens Training and Education Center (NETEC) was established in tandem to support the development of healthcare facility special pathogen management capabilities. In August 2020, 20 hospitals that previously received an onsite readiness consultation by NETEC were surveyed to assess how special pathogen programs were leveraged for COVID-19 response. All surveyed facilities indicated their programs were leveraged for COVID-19 response in at least 1 of the following ways: NETEC-sponsored resources and training, utilization of patient isolation spaces, specially trained staff, and supplies. Personal protective equipment shortages were experienced by 95% of facilities, with 80% of facilities reporting that special pathogens program personal protective equipment was used to support facility response to COVID-19 admissions. More than half of facilities (63%) reported leveraging biocontainment unit staff to provide training and education to frontline staff during initial response to COVID-19. These findings have implications for planning and investments to avoid the panic-then-forget cycle that hinders sustained preparedness for future special pathogens.

Viral Sequencing to Investigate Sources of SARS-CoV-2 Infection in US Healthcare Personnel

BACKGROUND

Healthcare personnel (HCP) are at increased risk of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We posit that current infection control guidelines generally protect HCP from SARS-CoV-2 infection in a healthcare setting.

METHODS

In this retrospective case series, we used viral genomics to investigate the likely source of SARS-CoV-2 infection in HCP at a major academic medical institution in the Upper Midwest of the United States between 25 March and 27 December 2020. We obtained limited epidemiological data through informal interviews and review of the electronic health record and combined this information with healthcare-associated viral sequences and viral sequences collected in the broader community to infer the most likely source of infection in HCP.

RESULTS

We investigated SARS-CoV-2 infection clusters involving 95 HCP and 137 possible patient contact sequences. The majority of HCP infections could not be linked to a patient or coworker (55 of 95 [57.9%]) and were genetically similar to viruses circulating concurrently in the community. We found that 10.5% of HCP infections (10 of 95) could be traced to a coworker. Strikingly, only 4.2% (4 of 95) could be traced to a patient source.

CONCLUSIONS

Infections among HCP add further strain to the healthcare system and put patients, HCP, and communities at risk. We found no evidence for healthcare-associated transmission in the majority of HCP infections evaluated. Although we cannot rule out the possibility of cryptic healthcare-associated transmission, it appears that HCP most commonly become infected with SARS-CoV-2 via community exposure. This emphasizes the ongoing importance of mask wearing, physical distancing, robust testing programs, and rapid distribution of vaccines.

COVID-19 in Health Care Personnel: Significance of Health Care Role, Contact History, and Symptoms in Those Who Test Positive for SARS-CoV-2 Infection

OBJECTIVE

To identify significant factors that help predict whether health care personnel (HCP) will test positive for severe acute respiratory coronavirus 2 (SARS-CoV-2).

PATIENTS AND METHODS

We conducted a prospective cohort study among 7015 symptomatic HCP from March 25, 2020, through November 11, 2020. We analyzed the associations between health care role, contact history, symptoms, and a positive nasopharyngeal swab SARS-CoV-2 polymerase chain reaction test results, using univariate and multivariable modelling.

RESULTS

Of the symptomatic HCP, 624 (8.9%) were positive over the study period. On multivariable analysis, having a health care role other than physician or advanced practice provider, contact with family or community member with known or suspected coronavirus disease 2019 (COVID-19), and seven individual symptoms (cough, anosmia, ageusia, fever, myalgia, chills, and headache) were significantly associated with higher adjusted odds ratios for testing positive for SARS-CoV-2. For each increase in symptom number, the odds of testing positive nearly doubled (odds ratio, 1.93; 95% CI, 1.82 to 2.07, P<.001).

CONCLUSION

Symptomatic HCP have higher adjusted odds of testing positive for SARS-CoV-2 based on three distinct factors: (1) nonphysician/advanced practice provider role, (2) contact with a family or community member with suspected or known COVID-19, and (3) specific symptoms and symptom number. Differences among health care roles, which persisted after controlling for contacts, may reflect the influence of social determinants. Contacts with COVID-19-positive patients and/or HCP were not associated with higher odds of testing positive, supporting current infection control efforts. Targeted symptom and contact questionnaires may streamline symptomatic HCP testing for COVID-19.

Care bundles for improving outcomes in patients with COVID-19 or related conditions in intensive care - a rapid scoping review

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the strain of coronavirus that causes coronavirus disease 2019 (COVID-19) can cause serious illness in some people resulting in admission to intensive care units (ICU) and frequently, ventilatory support for acute respiratory failure. Evaluating ICU care, and what is effective in improving outcomes for these patients is critical. Care bundles, a small set of evidence-based interventions, delivered together consistently, may improve patient outcomes. To identify the extent of the available evidence on the use of care bundles in patients with COVID-19 in the ICU, the World Health Organization (WHO) commissioned a scoping review to inform WHO guideline discussions. This review does not assess the effectiveness of the findings, assess risk of bias, or assess the certainty of the evidence (GRADE). As this review was commissioned to inform guideline discussions, it was done rapidly over a three-week period from 26 October to 18 November 2020.

OBJECTIVES

To identify and describe the available evidence on the use of care bundles in the ICU for patients with COVID-19 or related conditions (acute respiratory distress syndrome (ARDS) viral pneumonia or pneumonitis), or both. In carrying out the review the focus was on characterising the evidence base and not evaluating the effectiveness or safety of the care bundles or their component parts.

SEARCH METHODS

We searched MEDLINE, Embase, the Cochrane Library (CENTRAL and the Cochrane COVID-19 Study Register) and the WHO International Clinical Trials Registry Platform on 26 October 2020.

SELECTION CRITERIA

Studies of all designs that reported on patients who are critically ill with COVID-19, ARDS, viral pneumonia or pneumonitis, in the ICU setting, where a care bundle was implemented in providing care, were eligible for inclusion. One review author (VS) screened all records on title and abstract. A second review author (DR) checked 20% of excluded and included records; agreement was 99.4% and 100% respectively on exclude/include decisions. Two review authors (VS and DR) independently screened all records at full-text level. VS and DR resolved any disagreements through discussion and consensus, or referral to a third review author (AN) as required.

DATA COLLECTION AND ANALYSIS

One review author (VS) extracted the data and a second review author (DR) checked 20% of this for accuracy. As the review was not designed to synthesise effectiveness data, assess risk of bias, or characterise the certainty of the evidence (GRADE), we mapped the extracted data and presented them in tabular format based on the patient condition; that is patients with confirmed or suspected COVID-19, patients with ARDS, patients with any influenza or viral pneumonia, patients with severe respiratory failure, and patients with mixed conditions. We have also provided a narrative summary of the findings from the included studies.

MAIN RESULTS

We included 21 studies and identified three ongoing studies. The studies were of variable designs and included a systematic review of standardised approaches to caring for critically ill patients in ICU, including but not exclusive to care bundles (1 study), a randomised trial (1 study), prospective and retrospective cohort studies (4 studies), before and after studies (7 studies), observational quality improvement reports (4 studies), case series/case reports (3 studies) and audit (1 study). The studies were conducted in eight countries, most commonly China (5 studies) and the USA (4 studies), were published between 1999 and 2020, and involved over 2000 participants in total. Studies categorised participant conditions patients with confirmed or suspected COVID-19 (7 studies), patients with ARDS (7 studies), patients with another influenza or viral pneumonia (5 studies), patients with severe respiratory failure (1 study), and patients with mixed conditions (1 study). The care bundles described in the studies involved multiple diverse practices. Guidance on ventilator settings (10 studies), restrictive fluid management (8 studies), sedation (7 studies) and prone positioning (7 studies) were identified most frequently, while only one study mentioned chest X-ray. None of the included studies reported the prespecified outcomes ICU-acquired weakness (muscle wasting, weight loss) and users' experience adapting care bundles. Of the remaining prespecified outcomes, 14 studies reported death in ICU, nine reported days of ventilation (or ventilator-free days), nine reported length of stay in ICU in days, five reported death in hospital, three reported length of stay in hospital in days, and three reported adherence to the bundle.

AUTHORS' CONCLUSIONS

This scoping review has identified 21 studies on care bundle use in critically ill patients in ICU with COVID-19, ARDS, viral influenza or pneumonia and severe respiratory failure. The data for patients with COVID-19 specifically are limited, derived mainly from observational quality improvement or clinical experiential accounts. Research is required, urgently, to further assess care bundle use and optimal components of these bundles in this patient cohort. The care bundles described were also varied, with guidance on ventilator settings described in 10 care bundles, while chest X-ray was part mentioned in one care bundle in one study only. None of the studies identified in this scoping review measured users' experience of adapting care bundles. Optimising care bundle implementation requires that the components of the care bundle are collectively and consistently applied. Data on challenges, barriers and facilitators to implementation are needed. A formal synthesis of the outcome data presented in this review and a critical appraisal of the evidence is required by a subsequent effectiveness review. This subsequent review should further explore effect estimates across the included studies.