Practical Strategies for Physicians to Avoid COVID-19 Infection at Work

The physician workforce is one of the most valuable resources of any hospital, and in the midst of the COVID-19 outbreak we need to do everything possible to ensure that physicians stay healthy. Like other hospital epidemiologists, I spend a lot of time thinking about practical ways to reduce the risk of infection. So to that end, I want to offer some suggestions for reducing your risk of acquiring COVID-19 at work.

• Personal infection prevention: I strongly recommend that everyone in clinical areas follow bare below the elbows. This means that there should be nothing on your forearms, including wrist jewelry and wrist watches. This prevents contamination of sleeves and allows you to perform good hand hygiene. Hospital-laundered scrubs, doffed before going home, is optimal. We want to minimize clothing contamination, so I recommend not wearing white coats, cover jackets, or fleece jackets. Neckties are problematic because they frequently touch the patient/patient surroundings and are rarely cleaned. If you feel the need to wear a necktie, tuck it into your shirt. If you wear a long sleeve shirt, roll up the sleeves. Perform hand hygiene like never before (at least before and after every patient contact), and remember to wipe down your stethoscope after each use. Lastly, avoid touching your face.

• Work rooms: Physician work rooms are often small, so we need to think about how to achieve social distancing in these small spaces. One way to do this is to bring your laptop to work and do your documentation in another site to reduce the number of people in the work room. Also, it’s important to declutter these rooms so that housekeeping can come in to clean all the surfaces. It’s very difficult for them to do this when there is clutter everywhere. You should also wipe down your workspace before you use it. Avoid shared foods in work spaces.


• Conservation of personal protective equipment: Supplies of PPE are tight because many of these products are manufactured in China and factories are closed. This means we really need to conserve these items so that we can safely care for COVID patients for what may be an extended duration. At my hospital, we have modified contact precautions for non-COVID patients to not include gowns, since gowns are particularly in short supply. We continue to wear gloves for patients in contact precautions. If you anticipate a splash or spray, wear a gown for any patient. One way to think about this is to ask yourself: would I rather have this gown to care for a C diff patient today, or this gown to care for a COVID patient 6 weeks from now? I think this question puts the issue into perspective. Face masks and face shields marketed for medical use are in short supply, so consider purchasing a face shield from a hardware store. Here is an example of one. This particular model completely covers your face even laterally, and I think provides good protection and is comfortable. If you are a physician in an area such as urgent care or the emergency department, where there are many patients with respiratory symptoms, I would consider wearing the shield the entire shift. Avoid touching the shield, and wipe it down after use. To reduce supplies used, reduce the number of persons entering the patient room to the minimum necessary.


• Workflow: Again, we need to think about social distancing. In teaching hospitals, we tend to travel in packs, and this needs to stop. Consider asynchronous rounding (attending rounds with each intern separately) to avoid congregating in the hallways on rounds. You might also consider batching your duties to the degree that you can and doing more of your documentation at home. Avoid elevators.


• What to do if you become ill: The most important thing is to not come to work if you have fever or new onset respiratory symptoms. If you begin to feel sick at work, remove yourself from patient care as soon as possible. If you don’t have a thermometer (I didn’t have one until a few days ago), please get one, so that you can check your temp at home should you feel febrile. You might also consider purchasing a pulse oximeter to keep at home for self-monitoring in case you become ill.

Please take care of yourself during this difficult time. Patients need us, so let’s do everything we can to stay healthy!

Mike Edmond

COVID-19: Deep Thoughts and a Little Therapy

I’m not really a crier. I mean, sure, there are moments in life that make me a bit misty.  Turn on those first 10 minutes of the movie Up and on go the tears (curse you, Pixar!).  But something happened Friday that made me realize how unusual and stressful these weeks have and will be for those of us in medicine and, in particular, hospital epidemiology. 

I have worked out with a bunch of dudes early mornings, outside (rain or shine) for the past 2 1/2 years. At the end of every workout, there’s a Circle of Trust where the group leader gives thanks to someone or something higher than himself (be he Christian, Muslim, Buddhist, whatever). On Friday, to celebrate my impending 50^th birthday, I led the workout.  At the end, as we gathered, I started to give thanks but had to stop. I could feel this deep ball of tears and emotion well up inside.  Couldn’t speak. Tears flowed. In front of these dudes.  And that’s when I realized, I wasn’t crying because I was turning 50 . . . this was a massive release with people I trust, and it showed me how much the past 2 weeks in particular have affected me (and I imagine many, if not all, of you).

As Mike (see also his excellent post from yesterday) has noted in an email chain, this is likely the most stressful time many of us (save maybe the HIV epidemic in the early ‘80s) have experienced in our hosp epi careers.  I told a friend that it feels like I’m strapped into a massive roller coaster ride (which I hate), climbing up that hill, sensing what lies ahead from the screams of people ahead of us (China, South Korea, Italy, Seattle, San Fran, etc.), and wanting desperately to get off the ride, realizing we cannot. 

This week, as Vanderbilt started testing, the variety of emotions hit hard. Patient #1 is a close friend, a physician, whom I didn’t know had been tested.  He attended a school fundraiser, and by the middle of the week, 10 people from that event were positive.  But I also saw resilience.  Two weeks ago, Nashville and middle Tennessee had the added hit of a massive tornado, affecting many in the area. One of which, my colleague who is the hosp epi at an affiliated community hospital, had to leave his apartment and move to a hotel, most of his and his wife’s belongings locked in a damaged building.  The next day, his hospital diagnosed the first COVID-19 case in TN.  New to the job, he handled this with grace and professionalism, even when he had to borrow a tie for the press conference because his were all locked in the damaged apartment.

This will be a marathon, and I offer some simple advice as this gears up (and I am sure others have more to offer):

• Delegate:  At first, I was hit with every question about this outbreak, from patient education, to clinical management, to employee furlough questions.  As the weeks progressed, more people joined in the fray who could help. I quickly learned what is under my expertise (IP) and what others can handle.  No need to micromanage. You simply can’t.  While there’s a core group working tirelessly on COVID prep, there are also many in our medical center wanting to help.  We’ve used our quality abstractors to assess if clinicians are correctly ordering COVID testing per our guidance.  Our stewardship team to work on treatment options.  And even though many of us are ID physicians, delegate the clinical management of these patients to your ID peers.  Focus on the IP stuff.
• Be decisive:  ID docs are known for their ability to opine, think, review data, which is great.  But right now, the questions and decisions are coming so quickly, we have to make quick decisions.  Some may be wrong; some may change as you learn more. We’re building an assembly line as the cars have already started rolling down the track. Some might fall off, some might not run well, but we have to keep building quickly. Don’t overthink things.  Use the science but avoid the margins.  We won’t find solutions that fit every scenario, as overthinking things can be paralyzing. 
• Develop a bench:  If you’re the only hosp epi around, figure out who you can train up quickly.  Another ID faculty member.  Ideally one who is even keeled, can know when they don’t know the answer and ask for help. 
• Take time out: It’s imperative that we all take breaks from this work, to refresh mentally, spiritually, and physically. Spend some time with your loved ones, even if just for an hour.  Step away from Twitter/Facebook/etc. Go for a run. 
• Deal with your emotions:  Cry in front of people you trust.  Meditate. Write. This is why I’m back on this blog – this is my therapy. 

I’m glad people pushed us to reignite this blog, as the collective insights can help the whole.  As always, we’re open for guest bloggers.  Stay healthy, stay grounded, and, of course, wash your damn hands.

Conserving PPE in the COVID-19 Era

Photo by Ashkan Forouzani on Unsplash

In my 25 years as a hospital epidemiologist, this week was the hardest yet. Last Sunday, we learned of 3 COVID-19 cases in the Iowa City area. As of today, there are 14--that we know of. Because testing is still quite limited, these 14 patients likely represent just the tip of the iceberg. As all of this unfolds, it is like watching a train wreck in slow motion. And looking at the situations in Northern Italy and Seattle, we see that what lies ahead for us is quite scary.

One of the things I have focused on this week is personal protective equipment (PPE). It seems clear that, sooner or later, most hospitals will be in trouble. The PPE supply chain is deeply rooted in China and those factories have closed. That coupled with the just-in-time inventory concept has put all of us in a tough spot. For those of you not yet in the thick of this, I will offer some thoughts that may be of use to you.

Here is my practical strategy:

1. Know your inventory. Have your supply chain folks produce a tabular report of all PPE products used in your institution. In this table, ask them to also include the numbers of each item used in an average week so that you know your baseline utilization.
2. Develop an inventory target that includes projected usage and duration. We decided to set our critical target at 300% of normal usage for 12 weeks duration. This can be calculated from your baseline utilization for each item. On the table, any item's total inventory that is less than 300% normal usage over 12 weeks is coded red. Yellow is set at 12-16 weeks at 300% normal usage, and green is set at >16 weeks at 300% normal usage. We review the PPE inventory table daily at our Hospital Incident Command System meeting. The color coding of the table allows quick interpretation of inventory levels.
3. Critically evaluate your current usage and limit usage of PPE. Remember that we are not in normal times. Once you see how far away your current inventory is from your target inventory, you will rapidly begin to think of things that can conserve PPE. Here are several:
• If you use contact precautions for patients colonized with VRE or MRSA, PLEASE STOP! At best, the utility of this practice is questionable. Ask yourself this question: would you rather have PPE to care for a VRE colonized patient today, or that PPE for a COVID patient 6 weeks from now. 
• If you use contact precautions to isolate patients infected with VRE or MRSA, consider stopping. Numerous hospitals have done that with no ill effect. Ask yourself the same question as in the previous bullet.
• We made the decision this week that for non-COVID contact precautions we would stop the use of gowns, but continue gloves, and stress hand hygiene and bare below the elbows (to minimize clothing contamination).
• Begin re-using items such as face shields (after disinfection) and N95 masks.
• Stop annual N95 fit-testing to avoid the use of masks in the fit testing process.
• Limit the number of visitors.
• For patients in isolation precautions, avoid taking the entire rounding team into the patient room. 
• Limit care of the COVID patient to one nurse and one physician.
4. Send your supply chain staff on a scavenger hunt throughout the hospital to identify PPE that can be reclaimed. There are hoarders out there! In addition, secure your inventory to avoid theft.
5. Dispense PPE to individual hospital/clinic units in smaller increments.
6. Investigate alternative products. For example, we have a supply of old cloth surgical gowns that could be used as isolation gowns if needed. 

I'm sure others have ideas that we have not thought of. If so, please place them in the comment section. 

To my colleagues in the infection prevention community: This is hard. We are tired. And it's only the beginning. But our work is more important than ever. Stay strong! 

Namaste.

What scares you?

I’m on a quick weekend trip for a wedding—a trip made possible only because we have a high concentration of hospital epidemiologists in Iowa City, and we haven’t yet diagnosed* a case of COVID-19 (*like much of the country, we’re behind in testing).

It’s disorienting to go from non-stop response planning questions to connecting with old friends. But of course the questions still came, the most common being: “are you scared by this?” My response was “yes”. Here are the three reasons I gave for my concern (before trying to turn the conversation to other things!), in no particular order:

Our healthcare system lacks surge capacity, and is already overstretched. Large tertiary care centers commonly run at capacity with overflowing emergency departments and patients “orbiting” (awaiting transfer from smaller hospitals for a higher level of care). The proportion of COVID-19 patients requiring admission and ICU-level care will quickly overwhelm US hospitals if spread continues at plausible estimated rates. This will cripple our ability to care not only for COVID-19 patients for all others requiring hospital care.

Residents of long term care facilities (LTCF, including long term acute care, rehabilitation centers, etc.) are extraordinarily vulnerable. We know from experience that once a transmissible pathogen enters a LTCF it spreads quickly, and the experience at the Life Care Center in Washington is terrifying.

The social and economic disruption caused by COVID-19 may kill more than the virus does directly—particularly in countries that have frayed or nonexistent social safety nets (I include the US in the “frayed” category). Job loss, loss of health coverage, homelessness, all carry with them additional morbidity and mortality that will continue long after the COVID-19 pandemic is over.

What do my fears imply for response planning?

Lack of surge capacity requires aggressive approaches to keep all but the sickest patients out of the hospital (telehealth, home health), and developing plans for conversion of some general hospital units to ICU-level care if needed. No surge capacity also strengthens the argument for aggressive social distancing approaches in an attempt to “flatten the curve” of the epidemic (amazingly helpful graphic below, and great Twitter thread here), while admittedly worsening the social/economic disruption problems.

The vulnerability of LTCF residents requires drastic measures to protect these facilities—limiting facility access, screening employees for URI/ILI daily, and reducing social contact in ways that could still allow interaction (computer/tablet visits, etc.). Some may even wish to investigate temporary relocation of some residents (e.g. to family with visiting nurse assistance). LTCFs look more and more like the highest risk environments for COVID-19 (combining transmissibility with case fatality rate).

The social and economic disruptions are the most difficult to address. In the near term, it requires recognizing when some of the more disruptive control strategies are no longer providing a benefit that overrides the ongoing damage to society. As one example, I think we’re reaching a point at which travel restrictions will have diminishing returns. This excellent modeling paper demonstrates the likely benefit of travel bans from China before extensive international spread had occurred. The impact of travel restrictions is likely to be much less now that the virus is so widespread globally. In fact, I think the motivation for many current travel restrictions being implemented in the US is out of fear that the traveler will be subject to home quarantine upon return (and unable to work or contribute to response efforts)—once community spread is documented across the US, the use of home quarantine after travel becomes illogical. Moreover, the whole idea of quarantining healthcare personnel after exposures needs to be abandoned if we hope to have any work force for patient care. CDC recognizes this in recent updated guidance.

OK, now that I’ve revived this recently moribund blog, we’ll have to address some more COVID-19 controversies soon. Or you could just search the site for our 10 year old posts about the H1N1 N95 mask fiasco?

The resistance continues...and you can help!

Billions & Billions (Eric Daigh) Each of the 34,800 pills in the picture represents 1 million doses of antibiotics, totalling 34.8 billion doses given each year around the world. 

 

 

As SHEA president this year,  I have not been doing much blogging but I have been traveling and learning and representing SHEA in many different places.  In the last few weeks, I was able to attend the International Conference for Prevention and Infection Control (ICPIC) in Geneva and also attend a ‘side event’ at the United Nations General Assembly focused on antimicrobial resistance. 

In Geneva, I heard about efforts to combat and contain multi-drug resistant infections in many different countries.  (I also realized that many European countries are still struggling to raise their healthcare worker influenza vaccination rates over 40 or 50%!)  In addition, Kristy Weinshel, SHEA executive director, and I met with leaders from WHO to discuss how SHEA can best support WHO efforts to improve infection prevention and antimicrobial usage around the world.  We discussed training courses to develop local expertise in resource limited countries, continued engagement of past participants in SHEA’s International Ambassador program, and adaptation of infection prevention guidance for these challenging settings.

In New York city, at an event sponsored by CDC, ASM, the Gates Foundation and Wellcome Trust, we heard from DHHS Secretary Azar, a young man who survived a multi-drug resistant infection after a train accident in India, “England’s CMO” Dame Sally Davies and others about the risks of continued antimicrobial overuse in agriculture and in medicine.  The night also included multi-media artworks including comic books about a post-antibiotic apocalyptic future, ‘petri dish’ microbial art including a street map of NYC and Van Gogh’s sunflowers, textiles stained with bacterial growth and the picture above  Many countries, individuals, companies and organizations were there to celebrate progress since last year’s commitment in The AMR Challenge and to re-commit to continued progress. 

One of SHEA’s commitments is to expand scholarships in order to continue to grow the community of experts that can improve the appropriate use of antimicrobials in human populations.  These scholarships are used to support education for physicians, pharmacists and other providers who are involved in stewardship research or practice.  Since 2015, SHEA members have raised over $30,000 through our annual Race AgainstResistance, originally conceived by Judy Guzman-Cottrill and carried forward by David Calfee.  Due in part to support from all of you, last year I was the leading fundraiser, without running a step!  This year my speed reading team of 1 (me!) is in 4^th place behind some stiff competition from actual athletes.

Now’s your chance to help!  Donate to the Race Against Resistance (pick any team)! Help fight the spread of antimicrobial resistance!  Help SHEA fund colleagues building skills in antimicrobial stewardship research and clinical practice!  Help prove that you don’t have to be an athlete to raise money (look for the team picture that is a book and a cocktail)!

Hope to see many of you at IDWeek next week! 

Time to Review Your Hospital Tuberculosis Control Plan: Updated CDC Guidance

This is a guest post by Jorge Salinas, MD, Hospital Epidemiologist at University of Iowa Hospitals and Clinics.

The National Tuberculosis Controller Association (NTCA) and the Centers for Disease Control and Prevention (CDC) just published their updated guidance for the prevention of M. tuberculosis (TB) transmission in healthcare settings.

The previous guidelines (2005) called for tuberculosis screening for all healthcare workers upon hire and yearly if working in medium-risk settings. The setting risk was calculated based on the number of TB cases seen in the previous year. While most United States Hospitals were considered low risk, many large academic medical centers and hospitals in states with a higher incidence of TB were considered medium-risk. Fortunately, a number of studies performed in developed settings show that the rate of latent TB infection among healthcare workers is not different than the general population. In the updated guidance, hospitals previously considered medium-risk would continue testing upon hire but discontinue yearly TB screening (tuberculin skin testing or interferon gamma-release essay). This recommendation is welcomed as employee health resources can then be allocated to other emerging concerns (e.g., maximizing immunizations among healthcare workers).

The new guidance does not reduce the requirement for fit testing likely because the current TB infection prevention measures (administrative and environmental controls and personal protective equipment use) are likely the reason for such low levels of TB transmission among healthcare workers. As more data is gathered, next research steps could involve studying the necessary frequency of fit testing or the best method used (qualitative or quantitative methods).

These new recommendations will need to be accompanied by adequate contact investigations in healthcare settings. In the past, even if some contacts were not identified, the routine yearly screening would detect those patients within one year of the exposure. Now, an unidentified contact could go unnoticed until TB disease occurs. This increases the importance of training and knowledge of TB contact investigations in healthcare settings. However, TB contact investigations in healthcare settings are not straightforward: healthcare workers may have baseline positive skin testing and it is difficult to quantify the exposure risk (there is no standard recommended threshold for distance from patient or duration of exposure). Even if there was a recommended threshold, it would likely vary depending on other factors such as patient infectiousness (cavities, smear positivity) and healthcare worker immune status. Out of caution, healthcare workers may also tend to overreport exposures potentially overwhelming infection prevention programs. Another unique aspect of TB in healthcare settings involves extrapulmonary TB. Although in public health settings extrapulmonary TB is deemed likely not transmissible, it may lead to exposures in healthcare settings, especially during wound care, or procedures that may generate aerosols or splashes (irrigation, or bone surgery).

Congratulations and thank you to NTCA and CDC for their updated recommendations in light of new evidence. Those on the frontlines (Employee Health and Infection Prevention programs) will be able to reallocate resources and put their TB contact investigations skills to test.

SENTRY at 20: So many bugs!

The SENTRY Antimicrobial Surveillance Program was begun at the University of Iowa in 1997, moving a few years later to JMI Laboratories (also in Iowa!). Since inception, it’s been an industry-funded platform that performs central laboratory testing of clinical isolates of bacteria and fungi from centers around the world. The isolate submission process has been consistent over time, involving submission of organisms from consecutive episodes of infection at specified body sites (more information here and in the many publications that have come from SENTRY). 

So SENTRY has been operating for >20 years, and there are hundreds of thousands of isolates characterized. The major trends are reported in an OFID supplement and in recent publications in JAC and AAC. The supplement articles and the AAC report on trends in 20 years of bloodstream infection (BSI) isolates are open access—take a look if interested! 

I’ll focus briefly just on the AAC report (which I first-authored, so that’s shameless self-promotion right there)—two major points, each of which confirms on a large scale what regional surveillance programs have reported:

• S. aureus and E. coli dominate the BSI landscape—together account for >40% of all episodes reported to SENTRY. Continued focus on prevention, detection and treatment of these two bad actors is critical, and IMO should include vaccine approaches, despite the disappointments to date.
• There’s an interesting divergence in proportion of BSI caused by important resistance phenotypes among Gram-positives (MRSA, VRE, DRE, etc.) versus Gram-negatives (ESBL, CRE) over the second decade of surveillance (2005-2016). The Gram-positive resistance phenotypes are stable-to-declining, whereas Gram-negative phenotypes steadily increase (as proportion of BSI episodes) over the entire surveillance period.

The decline in MRSA as a proportion of all SA BSI is particularly striking, occurring as it does at the same time worldwide (and at all body sites, both healthcare- and community-onset, as more detail in the OFID report of all SENTRY S. aureus confirms). As Eli and I discussed in this JAMA editorial almost 10 years ago*, this is not easily explained by hospital-based infection control interventions. The waxing and waning of epidemic clones of MRSA is more likely to be informative. There is so much we still don’t understand about an organism (S. aureus) that lives in relative harmony with 20-30% of the human population when it isn’t causing horrendous, difficult-to-treat infections.

Finally, the scope and number of isolates collected by SENTRY and similar programs represent an underutilized public health resource. Regulatory requirements for drug development and approval mandate surveillance for AMR. Better partnerships between public health authorities and the industry sponsors of such surveillance programs could enhance surveillance and response, particularly in the genomic era when ready access to large isolate collections can be so powerful. Some of this is already happening, but more could be done.

*still behind a paywall after 10 years?  What gives?