POST 212. November 9, 2021. CORONAVIRUS. “They went into hospitals with heart attacks, kidney failure or in a psychiatric crisis. They left with covid-19…” “A new report shows the coronavirus pandemic had a direct increase on the number of healthcare-acquired infections in hospitals nationwide.”

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“More than 10,000 patients were diagnosed with covid in a U.S. hospital last year after they were admitted for something else, according to federal and state records analyzed exclusively for KHN. The number is certainly an undercount, since it includes mostly patients 65 and older, plus California and Florida patients of all ages.

Yet in the scheme of things that can go wrong in a hospital, it is catastrophic: About 21% of the patients who contracted covid in the hospital from April to September last year died, the data shows. In contrast, nearly 8% of other Medicare patients died in the hospital at the time…

A KHN review of work-safety records, medical literature and interviews with staff at high-spread hospitals points to why the virus took hold: Hospital leaders were slow to appreciate its airborne nature, which made coughing patients hazardous to roommates and staff members, who often wore less-protective surgical masks instead of N95s. Hospitals failed to test every admitted patient, enabled by CDC guidance that leaves such testing to the “discretion of the facility.” Management often failed to inform workers when they’d been exposed to covid and so were at risk of spreading it themselves…

As the second surge of covid subsided last September, doctors from the prestigious Brigham and Women’s Hospital published a reassuring study: With careful infection control, only two of 697 covid patients acquired the virus within the Boston hospital. That is about 0.3% of patients ― about six times lower than the overall Medicare rate. Brigham tested every patient it admitted, exceeding CDC recommendations. It was transparent and open about safety concerns.

But the study, published in the high-profile JAMA Network Open journal, conveyed the wrong message, according to Dr. Manoj Jain, an infectious-disease physician and adjunct professor at the Rollins School of Public Health at Emory University. Covid was spreading in hospitals, he said, and the study buried “the problem under the rug.”

Before the virtual ink on the study was dry, the virus began a stealthy streak through the elite hospital. It slipped in with a patient who tested negative twice ― but turned out to be positive. She was “patient zero” in an outbreak affecting 38 staffers and 14 patients, according to a study in Annals of Internal Medicine initially published Feb. 9.

That study’s authors sequenced the genome of the virus to confirm which cases were related ― and precisely how it traveled through the hospital.

As patients were moved from room to room in the early days of the outbreak, covid spread among roommates 8 out of 9 times, likely through aerosol transmission, the study says. A survey of staff members revealed that those caring for coughing patients were more likely to get sick.

The virus also appeared to have breached the CDC-OK’d protective gear. Two staff members who had close patient contact while wearing a surgical mask and face shield still wound up infected. The findings suggested that more-protective N95 respirators could help safeguard staff.

Brigham and Women’s now tests every patient upon admission and again soon after. Nurses are encouraged to test again if they see a subtle sign of covid…

CDC guidelines, though, left wide latitude on protective gear and testing. To this day, Shenoy said, hospitals employ a wide range of policies.

The CDC said in a statement that its guidelines “provide a comprehensive and layered approach to preventing transmission of SARS-CoV-2 in healthcare settings,” and include testing patients with “even mild symptoms” or recent exposure to someone with covid.” (A)

“A new report shows the coronavirus pandemic had a direct increase on the number of healthcare-acquired infections in hospitals nationwide.

Increases were attributed to factors related to the COVID-19 pandemic, including more and sicker patients requiring more frequent and longer use of catheters and ventilators as well as staffing and supply challenges, the report said.

With dramatic increases in the frequency and duration of ventilator use, rates of ventilator-associated infections increased by 45% in the fourth quarter of 2020, compared to 2019. The Centers for Disease Control and Prevention analysis found sharp increases in standardized infection rates, indicating that the increases were not simply a reflection of more devices being used.

“Infection control practices in COVID-19 wards often adapted to shortages of personal protective equipment, responded to fear of healthcare personnel, and did not always lend themselves to better infection prevention,” said Drs. Tara N. Palmore and David K. Henderson of the National Institutes of Health, in an editorial accompanying the study. “The success of the previous several years, with steady declines in rates of these (healthcare-associated) and device-related infections, further accentuated the upswings that occurred in 2020.”

The largest increases were for bloodstream infections associated with central line catheters that are inserted into large blood vessels to provide medication and other fluids over long periods. Rates of central line infections were 46% to 47% higher in the third and fourth quarters of 2020, compared to 2019, according to the study.

From 2019 to 2020, major increases were also found in catheter-associated urinary tract infections, ventilator-associated events and antibiotic resistant staph infections…

“COVID-19 created a perfect storm for antibiotic resistance and healthcare-associated infections in healthcare settings. Prior to the pandemic, public health – in partnership with hospitals – successfully drove down these infections for several years across U.S. hospitals,” said Dr. Arjun Srinivasan, the CDC’s Associate Director of Healthcare Associated Infection Prevention Programs.

The increase comes after years of steady reductions in healthcare-associated infections.

“In a coronavirus disease ward in 2020, preventing a catheter-associated urinary tract infection was probably not always the foremost consideration of healthcare staff,” the report said.

All available resources were directed at minimizing the risks of COVID-19 transmission in the hospital, they said.

“Nurses and doctors were trying to save the lives of surges of critically ill infectious patients while juggling shortages of respirators and, at times, shortages of gowns, gloves and disinfectant wipes as well,” the authors said in their commentary. “Sometimes these efforts went terribly wrong.” …

As of 2018, the percentage of hospitals achieving zero infections had declined dramatically since 2015, according to a 2018 Leapfrog report.” (B)

“More than 1 in 10 COVID-19 patients from 314 UK hospitals acquired their infection from the hospital early in the pandemic, according to a research letter in The Lancet yesterday.

“There are likely to be a number of reasons why many patients were infected in these care settings,” said study author Chris A. Green, MBBS, DPhil, in a Lancaster University press release.

“These include the large numbers of patients admitted to hospitals with limited facilities for case isolation, limited access to rapid and reliable diagnostic testing in the early stages of the outbreak, the challenges around access to and best use of [personal protective equipment], our understanding of when patients are most infectious in their illness, some misclassification of cases due to presentation with atypical symptoms, and an under-appreciation of the role of airborne transmission.”…

“Unlike at the beginning of the pandemic,” the researchers conclude, “there are [now] opportunities to pre-empt hospital-acquired infections and break chains of transmission through regular patient, resident, and staff testing including point-of-care diagnostics, as recently introduced for [National Health Service] staff, coupled with robust hospital infection prevention and control policies that include staff vaccination, environmental disinfection, and appropriate isolation, all supported by sentinel monitoring systems.”” (C)

“Patients with COVID-19 who are critically ill may be at increased risk for hospital-acquired infections (HAI), especially ventilator-associated pneumonia (VAP) and bloodstream infections (BSI) caused by multidrug-resistant (MDR) bacteria, according to study findings published in Chest.

Few studies have characterized HAIs in patients with COVID-19. To address this knowledge gap, a team of investigators in Italy conducted a multicenter retrospective analysis (ClinicalTrials.gov Identifier: NCT04388670) of prospectively collected data to assess the characteristics and outcomes of patients hospitalized with severe COVID-19 who develop an HAI…

The most frequently observed HAIs were VAP (51%; 26.0/1000 intubation days), BSI (34%; 11.7/1000 ICU patient-days), and catheter-related BSI (10%; 4.7/1000 ICU patient-days). Of the VAP cases, 64% were caused by Gram-negative bacteria and 28% were caused by Staphylococcus aureus. The variables independently associated with infection were age, positive end expiratory pressure, and treatment with broad-spectrum antibiotics on hospital admission….

“Patients with [HAIs] complicated by shock showed almost double mortality, and infected patients experienced prolonged [IMV] and hospitalization,” the investigators noted. “Clinicians should make every effort to implement protocols for surveillance and prevention of infectious complications,” they concluded.” (D)

“The majority of patients who contracted COVID-19 while in hospital did so from other patients rather than from healthcare workers, concludes a new study from researchers at the University of Cambridge and Addenbrooke’s Hospital.

The study provides previously unprecedented detail on how infections might spread in a hospital context, showing that a minority of individuals can cause most of the transmission…

Looking back at data from the first wave, researchers identified five wards at Addenbrooke’s Hospital, part of Cambridge University Hospitals (CUH) NHS Foundation Trust, where multiple individuals, including patients and healthcare workers, tested positive for COVID-19 within a short space of time, suggesting that a local outbreak might have occurred.

Using new statistical methods that combine viral genome sequence data with clinical information about the locations of individuals, the researchers identified cases where the data were consistent with transmission occurring between individuals in the hospital. Looking in detail at these transmission events highlighted patterns in the data.

The results of the study, published today in eLife, showed that patients who were infected in the hospital were mostly infected by other patients, rather than by hospital staff. Out of 22 cases where patients were infected in hospital, 20 of these were the result of the virus spreading from patients to other patients

Dr Chris Illingworth, a lead author on the study, who carried out his research while at Cambridge’s MRC Biostatistics Unit, said: “The fact that the vast majority of infections were between patients suggests that measures taken by hospital staff to prevent staff transmitting the virus to patients, such as the wearing of masks, were likely to have been effective.

“But it also highlights why it is important that patients themselves are screened for COVID-19 regularly, even if asymptomatic, and wear face masks where possible.” (E)

“Hospital-acquired COVID-19 represents a serious public health problem and the first articles indicate there was an alarming rate of HAIs. It is a problem that could cause reluctance of patients to seek hospital care for fear of becoming infected. Scientific studies have proven that in-hospital transmission of COVID-19 is not negligible. According to several reports, the hospital-acquired SARS-CoV-2 infection rate is 12–15%. Patients admitted to hospitals must give undivided attention to individual protection measures. Healthcare personnel must do all that is possible to address the problem and prevent further spreading, through rigorous compliance with procedures for containing the infection. The reporting of these events and in-depth hospital investigations are necessary to fully understand the origin of the infection, implement corrective measures, and prevent an increase in cases.” (F)

“Tennessee hospitals may soon be forced to allow visitors for coronavirus patients pending Gov. Bill Lee signing a bill passed by the Tennessee General Assembly in its recent special session.

The bill states “a hospital shall not restrict a patient from having at least one (1) family member present with the patient during the stay in the hospital as long as the family member tests negative for COVID-19 and is not exhibiting symptoms of COVID-19 or another virus or communicable disease.”

But there appears to be a difference of opinion between the offices of Republican House Speaker Cameron Sexton and Republican Lt. Gov. Randy McNally, the Senate speaker, on how to implement the new visitation requirement — which took the Tennessee Hospital Association by surprise when it was added at the tail end of the session.

“We do have some concerns regarding a late addition to the legislation dealing with visitation for COVID patients and how that provision will ultimately be implemented,” Dr. Wendy Long, president and CEO of the Tennessee Hospital Association, said in a statement.

“We have reached out to leadership and members of the General Assembly and they have expressed to us, as well as in committee meetings, that the legislative intent was for end-of-life scenarios. We are already in discussion with the House and Senate to better clarify their intent when they reconvene in regular session in January.”

In an email, Sexton spokesman Doug Kufner said based on discussions with committee members and the bill’s sponsor, “the intent of the legislation was to help families support their loved ones who are nearing or in end-of-life scenarios.”” (G)

• A.Patients Went Into the Hospital for Care. After Testing Positive There for Covid, Some Never Came Out., By Christina Jewett, https://khn.org/news/article/hospital-acquired-covid-nosocomial-cases-data-analysis/  (This story also ran on USA Today. It can be republished for free.)
• B.COVID-19 increased the number of healthcare-acquired infections, by Susan Morse, https://www.healthcarefinancenews.com/news/covid-19-increased-number-healthcare-associated-infections
• C.11% of early COVID-19 was acquired in-hospital, study says, by Lianna Matt McLernon, https://www.cidrap.umn.edu/news-perspective/2021/08/11-early-covid-19-was-acquired-hospital-study-says
• D.Outcomes of Hospital-Acquired Infections in Patients With Severe COVID-19, by Rita Aghjayan, https://www.infectiousdiseaseadvisor.com/home/topics/nosocomial-infections/outcomes-of-hais-in-severe-covid-19/
• E.Hospital-acquired COVID-19 tends to be picked up from other patients, not from healthcare workers, https://www.cam.ac.uk/research/news/hospital-acquired-covid-19-tends-to-be-picked-up-from-other-patients-not-from-healthcare-workers
• F.Hospital-Acquired SARS-Cov-2 Infections in Patients: Inevitable Conditions or Medical Malpractice?, by Rosario Barranco,* Luca Vallega Bernucci Du Tremoul, and Francesco Ventura, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7827479/
• G.Tennessee law would allow COVID-19 patients one visitor, but some hospitals are concerned, Elizabeth Fite, https://www.yahoo.com/now/tennessee-law-allow-covid-19-040100573.html
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