Evidence from whole genome sequencing of aerosol transmission of SARS-CoV-2 almost 5 hours after hospital room turnover

Experimental evidence suggests that Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) remains viable within aerosols with a half-life of approximately 3 hours; however, it remains unclear how long airborne SARS-CoV-2 can transmit infection. Whole genome sequencing during an outbreak suggested in-room transmission of SARS-CoV-2 to two patients admitted nearly 2 and 5 hours, respectively, after discharge of an asymptomatic infected patient. These findings suggest that airborne SARS-CoV-2 may transmit infection for over 4 hours, even in a hospital setting.

Sickness presenteeism in healthcare workers during the coronavirus disease 2019 (COVID-19) pandemic: An observational cohort study

Sickness presenteeism among healthcare workers (HCW) risks nosocomial infection, but its prevalence among HCW with COVID-19 is unknown. Contemporaneous interviews revealed a sickness presenteeism prevalence of 49.8% among 255 HCW with symptomatic COVID-19. Presenteeism prevalence did not differ among HCW with and without specific COVID-19 symptoms or direct patient care.

Concordance of SARS-CoV-2 RNA in Aerosols From a Nurses Station and in Nurses and Patients During a Hospital Ward Outbreak

IMPORTANCE

Aerosol-borne SARS-CoV-2 has not been linked specifically to nosocomial outbreaks.

OBJECTIVE

To explore the genomic concordance of SARS-CoV-2 from aerosol particles of various sizes and infected nurses and patients during a nosocomial outbreak of COVID-19.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included patients and nursing staff in a US Department of Veterans Affairs inpatient hospital unit and long-term-care facility during a COVID-19 outbreak between December 27, 2020, and January 8, 2021. Outbreak contact tracing was conducted using exposure histories and screening with reverse transcriptase-polymerase chain reaction (RT-PCR) for SARS-CoV-2. Size-selective particle samplers were deployed in diverse clinical areas of a multicampus health care system from November 2020 to March 2021. Viral genomic sequences from infected nurses and patients were sequenced and compared with ward nurses station aerosol samples.

EXPOSURE

SARS-CoV-2.

MAIN OUTCOMES AND MEASURES

The primary outcome was positive RT-PCR results and genomic similarity between SARS-CoV-2 RNA in aerosols and human samples. Air samplers were used to detect SARS-CoV-2 RNA in aerosols on hospital units where health care personnel were or were not under routine surveillance for SARS-CoV-2 infection.

RESULTS

A total of 510 size-fractionated air particle samples were collected. Samples representing 3 size fractions (>10 μm, 2.5-10 μm, and <2.5 μm) obtained at the nurses station were positive for SARS-CoV-2 during the outbreak (3 of 30 samples [10%]) and negative during 9 other collection periods. SARS-CoV-2 partial genome sequences for the smallest particle fraction were 100% identical with all 3 human samples; the remaining size fractions shared >99.9% sequence identity with the human samples. Fragments of SARS-CoV-2 RNA were detected by RT-PCR in 24 of 300 samples (8.0%) in units where health care personnel were not under surveillance and 7 of 210 samples (3.3%; P = .03) where they were under surveillance.

CONCLUSIONS AND RELEVANCE

In this cohort study, the finding of genetically identical SARS-CoV-2 RNA fragments in aerosols obtained from a nurses station and in human samples during a nosocomial outbreak suggests that aerosols may have contributed to hospital transmission. Surveillance, along with ventilation, masking, and distancing, may reduce the introduction of community-acquired SARS-CoV-2 into aerosols on hospital wards, thereby reducing the risk of hospital transmission.

Six Moments of Infection Prevention in Injection Drug Use: An Educational Toolkit for Clinicians

BACKGROUND

Injection drug use-associated bacterial and viral infections are increasing. Expanding access to harm reduction services, such as safe injection education, are effective prevention strategies. However, these strategies have had limited uptake. New tools are needed to improve provider capacity to facilitate dissemination of these evidence-based interventions.

METHODS

The "Six Moments of Infection Prevention in Injection Drug Use" provider educational tool was developed using a global, rather than pathogen-specific, infection prevention framework, highlighting the prevention of invasive bacterial and fungal infections in additional to viral pathogens. The tool's effectiveness was tested using a short, paired pre/post survey that assessed provider knowledge and attitudes about harm reduction.

RESULTS

Seventy-five respondents completed the paired surveys. At baseline, 17 respondents (22.6%) indicated that they had received no prior training in harm reduction and 28 (37.3%) reported discomfort counseling people who inject drugs (PWID). Sixty respondents (80.0%) reported they had never referred a patient to a syringe service program (SSP); of those, 73.3% cited lack of knowledge regarding locations of SSPs and 40.0% reported not knowing where to access information regarding SSPs. After the training, 66 (88.0%) reported that they felt more comfortable educating PWID (P < .0001), 65 respondents (86.6%) reported they planned to use the Six Moments model in their own practice, and 100% said they would consider referring patients to an SSP in the future.

CONCLUSIONS

The Six Moments model emphasizes the importance of a global approach to infection prevention and harm reduction. This educational intervention can be used as part of a bundle of implementation strategies to reduce morbidity and mortality in PWID.

Vaccination Status and the Detection of SARS-CoV-2 Infection in Health Care Personnel Under Surveillance in Long-term Residential Facilities

This cohort study examines the association of vaccination status and detection of SARS-CoV-2 infection in health care personnel at long-term residential facilities.

Front-Line innovation: Rapid implementation of a nurse-driven protocol for care of outpatients with COVID-19

Aims and objectives

Our objective was to rapidly adapt and scale a registered nurse‐driven Coordinated Transitional Care (C‐TraC) programme to provide intensive home monitoring and optimise care for outpatient Veterans with COVID‐19 in a large urban Unites States healthcare system.

Background

Our diffuse primary care network had no existing model of care by which to provide coordinated result tracking and monitoring of outpatients with COVID‐19.

Design

Quality improvement implementation project.

Methods

We used the Replicating Effective Programs model to guide implementation, iterative Plan‐Do‐Study‐Act cycles and SQUIRE reporting guidelines. Two transitional care registered nurses, and a geriatrician medical director developed a protocol that included detailed initial assessment, overnight delivery of monitoring equipment and phone‐based follow‐up tailored to risk level and symptom severity. We tripled programme capacity in time for the surge of cases by training Primary Care registered nurses.

Results

Between 23 March and 15 May 2020, 120 Veterans with COVID‐19 were enrolled for outpatient monitoring; over one‐third were aged 65 years or older, and 70% had medical conditions associated with poor COVID‐19 outcomes. All Veterans received an initial call within a few hours of the laboratory reporting positive results. The mean length of follow‐up was 8.1 days, with an average of 4.2 nurse and 1.3 physician or advanced practice clinician contacts per patient. The majority (85%) were managed entirely in the outpatient setting. After the surge, the model was disseminated to individual primary care teams through educational sessions.

Conclusion

A model based on experienced registered nurses can provide comprehensive, effective and sustainable outpatient monitoring to high‐risk populations with COVID‐19.

Clostridium difficile Screening for Colonization During an Outbreak Setting

A rapidly deployed ward-based screen and isolate initiative for Clostridium difficile carriers during an outbreak averted 5 of 10 expected hospital-acquired infections without identified harms. Each infection avoided required screening 197 and isolating 4.4 patients. Targeted C. difficile screening resulted in outbreak mitigation.

1173. Expanding the MAGIC: Engagement of Frontline Nursing Staff in Device Stewardship

Background

Nearly 40% of all peripherally inserted central catheter (PICC) placements may be inappropriate. Validated appropriateness criteria (Michigan Appropriateness Guide for Intravenous Catheters or MAGIC) were developed to improve patient safety and decrease adverse events from PICC line use. Recent studies have demonstrated the impact of MAGIC implementation with success but involve multimodal interventions that may not be sustainable. We evaluated the effect of a nursing-driven MAGIC-derived triage tool online utilization.

Methods

We conducted a quasi-experimental before and after study evaluating the effect of a MAGIC-derived triage tool including all patients for whom a PICC consult was ordered. The triage tool was implemented January 1, 2018 as part of the consult order and required providers to identify an indication for placement. All consults were reviewed by the IV Team Nurses who collaborated with ID providers when warranted. Providers were contacted if MAGIC criteria suggested alternate access was more appropriate and encouraged to either place a mid or peripheral line or to consider an oral medication. Rates of line utilization and line infections pre-intervention and post-intervention were compared.

Results

Overall, 242 consults for PICC lines were placed during the one year intervention period January 1, 2018 to December 31, 2018. Indications included: antibiotics (54%), TPN/chemo (21%) difficult access (17%), no response (8%). Thirty-five PICCs were averted directly related to the intervention. Appropriate indication of PICC placement with the tool was 88%. During this same time period, the line utilization ratio (lines/1,000 patient-days of care) decreased from a mean of 3.8 (range 3.3 to 4.2 for years 2015–2017) to 2.6, a 32% reduction (IIR 0.72; P < 0.05). Central line bloodstream infection rates (infections/1,000 line days of care) also decreased from a mean of 0.81 (range 0.56 to 1.18 for years 2015–2017) to 0.37, a 54% reduction (IIR 0.4; P = 0.10).

Conclusion

Even in a setting of low line infection and line utilization rates, further reductions in potential device harm can be achieved using point of care feedback tools. This intervention empowers nursing involvement in device stewardship, thus expanding the range of their involvement in stewardship activities.

Disclosures

All authors: No reported disclosures.

C. difficile Screening for Colonization among Surgical Ward Admissions Is Feasible and Useful

Background

Identification of patients colonized with C. difficile (CDcol) upon admission and initiation of precautions has been shown to decrease hospital-acquired C. difficileinfection (HA-CDI) in a recent study. We implemented a quality improvement program screening new admissions to a surgical service and evaluated risk factors and outcomes associated with CDcol.

Methods

Prospective cohort of all patients admitted to the surgical wards including ICU over a 6 month period 10/16–4/17. Upon admission, a perirectal swab was sent for C diff PCR. Patients with positive screens were placed on contact precautions. CDcol patients were not treated. Testing for CDI was done as usual practice only in patients with diarrhea. Main outcome was prevalence of CDcol and relationship to HA-CDI.

Results

Of 708 surgical admissions, 585 (82.6%) patients were screened, 543 were eligible based on first admission; 19 (3.5%) were colonized. Recent surgical hospitalization (OR 13.2, 95% CI 3.4;52.1) and prior CDI (OR 19.5, 95% CI 2.9;127.7) were independent risk factors for CDcol. Antibiotic and PPI use were not associated. Of those with CDcol, 7 developed CDI (36.8%) compared with 5/524 (0.9%) screen negative patients (adj OR 60, 95% CI 12.6;286). CDcol combined with a prior h/o CDI allowed for detection of 8/12 (75%) cases of HA-CDI compared with 3/12 (25%) if only prior history was available. HA-CDI rates on surgical wards after one month post-implementation were 9.3/10,000 bed days of care compared with 12.2 in 2016 and 12.8 in 2015. No delays in bed flow were identified.

Conclusion

Admission CDcol prevalence was low in our surgical VA population but was strongly associated with development of HA-CDI. Prior CDI was the strongest risk factor for CDcol and HA-CDI. Knowledge of prior CDI and CDcol status identified 75% of patients who developed CDI, 3 times more than knowledge of prior CDI alone. In certain settings, CDcol screening could improve detection and early isolation of potential CDiff spreaders. Implementation required significant support from administration, nursing and the laboratory, and was successful based on screening percentage without impact on bed flow. Impact on facility CDI rates remains to be fully demonstrated.

Disclosures

All authors: No reported disclosures.

Culture if spikes? Indications and yield of blood cultures in hospitalized medical patients

BACKGROUND

Although optimal utilization of blood cultures has been studied in populations, including emergency room and intensive care patients, less is known about the use of blood cultures in populations consisting exclusively of patients on a medical service.

OBJECTIVE

To identify the physician-selected indication and yield of blood cultures ordered after hospitalization to an acute medical service and to identify populations in which blood cultures may not be necessary.

DESIGN, SETTING, AND PATIENTS

A prospective cohort study was performed at a single Veterans Affairs Medical Center from October 1, 2014 through April 15, 2015. Participants included all hospitalized patients on a medical service for whom a blood culture was ordered.

MEASUREMENTS

The main outcomes were the rate of true positive blood cultures and the predictors of true positive cultures.

RESULTS

The true positive rate was 3.6% per order. The most common physician-selected indications were fever and leukocytosis, neither of which alone was highly predictive of true positive blood cultures. The only indication significantly associated with a true positive blood culture was "follow-up previous positive" (likelihood ratio [LR]+ 3.4, 95% confidence interval [CI]: 1.8-6.5). The only clinical predictors were a working diagnosis of bacteremia/endocarditis (LR+ 3.7, 95% CI: 2.5-5.7) and absence of antibiotic exposure within 72 hours of the culture (LR+ 2.4, 95% CI: 1.2-4.9).

CONCLUSIONS

The rate of true positive blood cultures among patients on a medical service was lower than previously studied. Using objective and easily obtainable clinical characteristics, including antibiotic exposure and working diagnosis, may improve the likelihood of true positive blood cultures. Journal of Hospital Medicine 2016;11:336-340. © 2016 Society of Hospital Medicine.