Infection Preventionists, Hospital Administrators Will Be on Frontlines of Coming COVID-19 Epidemic

Preparation for the impending epidemic of the COVID-19 coronavirus is of utmost importance. The first rule of infection prevention is that the infection preventionist (IP) does not become infected. One needs to make sure your facility has both appropriate protocols and personal protective equipment (PPE) including eye protection, face makes and abundant N-95 masks.¹ The CDC has performed an outstanding job of implementing surveillance and isolation strategies to identify those infected with, and possible carriers, of the COVID-19 virus. Strategies which we feel need to be expanded for the control of other dangerous contagions. These strategies will in all likelihood not prevent the impending epidemic the United States is facing, but they serve to delay its occurrence and slow the spread of the disease. This is of paramount importance, since it will allow for the gathering of important information regarding the spread of the disease, added time for our frontline facilities to prepare, and decrease the number of patients needing healthcare at any given time.

Many questions are still unanswered, such as: How long is someone infectious after no longer showing symptoms? How long does the virus live in the environment? Are there super or asymptomatic spreaders? What is the fatality rate? How best to screen for the disease and what are the false positive and negative rates of the tests? All of these questions need to be answered ASAP.

Prevention includes both community education and facility preparation. Front line facilities will play a major role in the reduction of mortality from the COVID-19 and in the prevention of spread. Involving IPs and hospital administrators in the initial planning process is important. Not only will new protocols need to be implemented, but the hiring of additional staff, ordering of new supplies and even changes to the physical plant may be required.

Administrators will have to adjust operating budgets for the hiring of healthcare staff needed to implement new protocols. For example: Additional staff will be needed to triage patients suspected of COVID-19 infection, both at the time appointments are made and at the entrances of facilities. Identified patients need to be placed into separate waiting areas. Other patients waiting to be seen should be provided with masks, ideally N-95 (but those may rapidly become in short supply). Surgical masks are not recommended to prevent the spread of airborne pathogens but will prevent one from touching your nose and mouth, which are common ports of viral entry.

In addition, there needs to be a reassessment of overall patient flow in the facility along with separation and isolation strategies of infected and suspected patients. Changes to the physical plant may be needed to construct separate waiting areas and private patient rooms, preferably with negative pressure airflows. Finally, an assessment of the facility’s overall airflow and air quality needs to take place, which may require expensive modifications to the physical plant.

Public education regarding ways to minimize exposure to the virus is crucial. IPs can play a key role in this initiative. Not touching one’s nose, mouth and eyes in public places needs to be stressed. Hand hygiene is also of utmost importance. Hand hygiene should follow CDC guidelines. Wash your hands with soap and water for at least 20 seconds or use an alcohol based hand sanitizer.² If there is visible grime on the hands, then soap and water should be used.

Early data indicates that just under 20% of COVID-19 cases may become severely ill.³ The provision of supportive care is important. Basic supportive care would include nutrition, fluids and if pneumonia develops, oxygen may be required. A facility needs to have a plan to prevent the spread of COVID-19 while patients, possibly many, are being treated. IPs will become key to developing improved strategies to prevent the spread of dangerous pathogens and to present these to hospital administration. This includes how to safety care for and transport patients along with proper donning and doffing of PPE.

And IPs need to develop plans for COVID-19 patients not to acquire additional bacterial pathogens. Unlike, MERS and SARS, the current coronavirus infection is less lethal and, thus, there is concern that similar to the flu, bacterial coinfections may become a significant factor in patient mortality. Many of the associated deaths with the flu virus are from pneumonia which also have an associated bacterial coinfection. In the 1918 Spanish flu epidemic, bacterial coinfections in fatal cases occurred in 95% of cases. There was even confusion regarding the causative agent, which gave rise to the bacterial name of H. Influenza.⁴ In the recent 2009 N1H1 Swine flu epidemic, between 29–55% of the viral pneumonia deaths had a bacterial coinfection⁴. The main bacterial organisms associated with deaths from viral pneumonia are H. Influenza, S. pneumonia and Staph aureus⁴.

IPs need to also focus on the prevention of antibiotic resistant bacteria and hospital administrators need to assure that there are both ample trained staff, appropriate strategies and PPE in place. This is of utmost importance in mitigating COVID-19 deaths. This includes both an increase in surveillance and isolation/decolonization strategies of both patients and healthcare staff, who can become carriers of resistant bacteria; along with making sure all are up to date on immunizations, including those for S. pneumonia (a common coinfection in fatal cases of the flu).

All of the above will place a tremendous strain on our healthcare system that will require coordination between the IPs, administrators and the hospital’s board. This impending epidemic underscores the importance of the work that the CDC is undertaking by using surveillance and quarantine strategies to delay entry and slow the spread of this pathogen.  

References:

(1) Interim Infection Prevention and Control Recommendations for Patients with Confirmed Coronavirus Disease 2019 (COVID-19) or Persons Under Investigation for COVID-19 in Healthcare Settings  https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html
 
(2) Coronavirus Disease 2019 (COVID-19): Prevention & Treatment https://www.cdc.gov/coronavirus/2019-ncov/about/prevention-treatment.html
    
(3) Zimmer K.  Why Some COVID-19 Cases Are Worse than Others.  The Scientist.  https://www.the-scientist.com/news-opinion/why-some-covid-19-cases-are-worse-than-others-67160
   
(4) Morris DE, Cleary DW and Clarke SC.  Secondary Bacterial Infections Associated with Influenza Pandemics.  Frontiers in Microbiology, 8, 1041,  Jun 23 2017, eCollection 2017.   https://www.frontiersin.org/articles/10.3389/fmicb.2017.01041/full