key: cord-268935-4obwu75u
authors: Lepak, Alexander J.; Shirley, Daniel K.; Buys, Ashley; Stevens, Linda; Safdar, Nasia
title: Implementation of infection control measures to prevent healthcare-associated transmission of severe acute respiratory coronavirus virus 2 (SARS-CoV-2)
date: 2020-10-12
journal: Infection control and hospital epidemiology
DOI: 10.1017/ice.2020.1262
sha: 
doc_id: 268935
cord_uid: 4obwu75u

Care of SARS-CoV-2-positive patients in healthcare institutions is challenging because of potential risk of transmission to other vulnerable patients. We describe infection control measures which were associated with no instances of hospital transmission. Adoption of the infection control bundle described may be helpful to prevent SARS-CoV-2 spread within healthcare institutions.

(EUA)-approved RT-PCR testing methods. Patients who were tested as outpatients, those tested in the emergency room or urgent care clinics, and those tested within the first 24 hours of an admission were excluded. Notably, repeated inpatient testing of individuals was, in general, directed toward those undergoing procedures, those in whom signs or symptoms suggested possible COVID-19, those with acute changes in status requiring intensive care unit (ICU) or intermediate (IMC) care, and/or based on provider judgment.

In total, 720 patients were tested >24 hours after admission to an inpatient unit, and the total number of inpatient SARS-CoV-2 tests was 1,007. The median age was 59 years (IQR, 40-69) and 52% were male. The reason for testing was skewed toward asymptomatic screening preceding procedures (71%). This finding was expected because repeat preprocedural testing was directed to be done within 48 hours prior to any aerosol-generating procedure. Of 1,007 inpatient tests, 59 tests (5.9%) were positive and 58 were known to be positive prior to inpatient testing (eg, positive prior to admission or as part of admission work-up). Thus, only 1 patient (0.1%) tested positive during an inpatient stay in which that patient was not known to have a history of a positive test. Over the study period, we had a sizeable COVID-19 inpatient population (112 inpatients with 1160 inpatient days) and a large at-risk pool of inpatients without COVID-19 (37,096 inpatient days).

For the single positive inpatient without a prior history of SARS-CoV-2, chart review revealed that this adult patient lived in a community setting, had mild symptoms (sinus congestion, eye pain, and cough) that started 10 days prior to admission, and was self-isolating at home. The patient presented with a myocardial infarction before universal admission testing was instituted, and the prior mild respiratory symptoms were not noted. On hospital day 4, the patient tested positive as part of pre-procedure screening. We believe that infection was present from community exposure prior to admission; therefore, we did not find any laboratory-confirmed cases suggestive of possible nosocomially acquired SARS-CoV-2 infection despite a substantial inpatient population with and without COVID-19. It has been suggested that false-negative results may occur, but negative-to-positive conversion has rarely occurred at our institution (<1%). 10 we were able to achieve these results without routine, serial testing of asymptomatic healthcare workers (HCWs), and we had a low threshold for testing HCWs with symptoms with a 1% rate of infection in our HCWs.

Our study has several limitations. First, this was a retrospective observational study. Second, because testing was limited to inpatient setting, we were not able to ascertain symptom onset after discharge, which may have resulted in testing elsewhere. However, we examined all positive ambulatory tests and did not find any positive results in patients within 7 days of discharge from our hospital. Finally, we were unable to examine the relative effect of each individual infection control measure. Our study has a number of strengths. As the single positive case we found demonstrates, it can be difficult to identify all potential positive patients by history taking alone. Thus, we strongly believe that universal testing of patients admitted to the hospital should be performed. This testing should be followed by targeted testing based on daily, protocol-driven screening questions to determine whether any symptoms have changed that suggest possible COVID-19. These first 2 measures aim to rapidly identify patients that should be placed in transmission-based isolation and to help prevent inadvertent spread. However, additional measures are obviously necessary to prevent nosocomial spread from known SARS-CoV-2-positive patients who may need complex medical care including intensive care, multiple-specialty care, invasive procedures or surgery, and intrahospital transport. These measures include meticulous infection control measures described here. In conclusion, using iterative implementation of infection control measures we were able to care for numerous COVID-19-infected and -uninfected patients without any cases of nosocomial spread.

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Acknowledgments. The content of this articles is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.Financial support. This research was supported by the National Institute of Allergy And Infectious Diseases of the National Institutes of Health Office of the Director (grant no. DP2AI144244).

All authors report no conflicts of interest in relation to this study.
