COVID-19 Outbreak in an Acute-Care Hospital: Lessons Learned

Background: We describe the infection prevention investigation of a cluster of 15 healthcare workers (HCWs) and 7 patients in a single non–COVID-19 unit of an acute-care hospital in September 2020. Methods: The infection prevention team was notified of 13 SARS-CoV-2–positive, symptomatic HCWs in an acute-care non–COVID-19 unit in 1 week (August 30, 2020, to September 3, 2020). In the same week, 2 patients who had been on the unit were diagnosed with nosocomial COVID-19. An epidemiologic investigation identified the exposure period to be between August 19, 2020, and September 3, 2020. The following immediate containment measures were implemented: closing the unit to new admissions, restricting float staff, moving existing patients to private rooms, mandatory masking of patients, and mandatory respirator and eye protection on unit entry for all HCWs. Exposed unit staff were tested immediately and then every 4 days until September 18, 2020. Likewise, exposed patients, including those discharged, were notified and offered testing. Hospital-wide HCW surveillance testing was conducted. Enhanced environmental control measures were conducted, including terminal cleaning and ultraviolet C (UV-C) disinfection of common areas and patient rooms and a thorough investigation of airflow. Detailed staff interviews were performed to identify causes of transmission. Multiple town hall meetings were held for staff education and updates. Results: In total, 108 total patients were deemed exposed: 33 were inpatients and 75 had been discharged. Testing identified 5 additional patient cases among 57 patients who received testing; 51 chose to self-monitor for symptoms. Staff testing identified 2 additional cases. Thus, 15 HCWs and 7 patients were linked in this cluster. The containment measures successfully ended staff transmission as of September 5, 2020. The last patient case was detected on September 10, 2020. Secondary cases were noted in 6 HCW families. We identified staff presenteeism, complacency, and socialization in break rooms and outside work as major causes of transmission. Suboptimal compliance with universal eye protection and hand hygiene (67%) were contributing factors. We determined by contact tracing and temporality that the outbreak could have stemmed from nursing home patient(s) through floating HCWs to staff on the affected unit. Directionality of transmission was from staff to patients in this cluster. Conclusions: Many facets of pandemic fatigue were apparent in this outbreak, namely, inability of HCWs to adhere to changing PPE guidance, presenteeism pressures due to workforce needs, and socialization with peers due to a false sense of security conferred by biweekly surveillance testing. Ongoing PPE education, repeated reinforcement, as well as engagement in staff wellness are crucial to combatting pandemic fatigue, conserving our workforce, and preventing future outbreaks.Funding: NoDisclosures: None

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An Outbreak of Scabies in a Teaching Hospital Lessons Learned

Infection Control and Hospital Epidemiology ◽

10.1086/501818 ◽

2001 ◽

Vol 22 (1) ◽

pp. 13-18 ◽

Cited By ~ 50

Author(s):

Olugbenga O. Obasanjo ◽

Peggy Wu ◽

Martha Conlon ◽

Lynne V. Karanfil ◽

Patty Pryor ◽

...

Keyword(s):

Acute Care ◽

Teaching Hospital ◽

Prophylactic Treatment ◽

Physical Therapist ◽

Acute Care Hospital ◽

Lessons Learned ◽

Control Measures ◽

Physical Contact ◽

Effective Control ◽

Care Hospital

AbstractObjective:To investigate an outbreak of scabies in an inner-city teaching hospital, identify pathways of transmission, institute effective control measures to end the outbreak, and prevent future occurrences.Design:Outbreak investigation, case-control study, and chart review.Setting:Large tertiary acute-care hospital.Results:A patient with unrecognized Norwegian (crusted) scabies was admitted to the acquired immunodeficiency syndrome (AIDS) service of a 940-bed acute-care hospital. Over 4 months, 773 healthcare workers (HCWs) and 204 patients were exposed to scabies. Of the exposed HCWs, 147 (19%) worked on the AIDS service. Risk factors for being infested with scabies among HCWs included working on the AIDS service (odds ratio [OR], 5.3; 95% confidence interval [CI95], 2.17-13.15) and being a nurse, physical therapist, or HCW with extensive physical contact with infected patients (OR, 4.5; CI95, 1.26-17.45). Aggressive infection control precautions beyond Centers for Disease Control and Prevention barrier and isolation recommendations were instituted, including the following: (1) early identification of infected patients; (2) prophylactic treatment with topical applications for all exposed HCWs; (3) use of two treatments 1 week apart for all cases of Norwegian scabies; (4) maintaining isolation for 8 days and barrier precautions for 24 hours after completing second treatment for a diagnosis of Norwegian scabies; and (5) oral ivermectin for treatment of patients who failed conventional therapy.Conclusions:HCWs with the most patient contact are at highest risk of acquiring scabies. Because HCWs who used traditionally accepted barriers while caring for patients with Norwegian scabies continued to develop scabies, we found additional measures were required in the acute-care hospital. HCWs with skin exposure to patients with scabies should receive prophylactic treatment. We recommend (1) using heightened barrier precautions for care of patients with scabies and (2) extending the isolation period for 8 days or 24 hours after the second treatment with a scabicide for those patients with Norwegian scabies. Oral ivermectin was well tolerated for treating patients and HCWs who failed conventional treatment. Finally, we developed a surveillance system that provides a “barometric measure” of the infection rate in the community. If scabies increases in the community, a tiered triage system is activated to protect against transmission among HCWs or hospital patients.

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161. Prevalence and Risk Factors for Candida auris Colonization Among Patients in a Long-term Acute Care Hospital—New Jersey, 2017

Open Forum Infectious Diseases ◽

10.1093/ofid/ofy209.031 ◽

2018 ◽

Vol 5 (suppl_1) ◽

pp. S14-S14

Author(s):

Faye Rozwadowski ◽

Jarred McAteer ◽

Nancy A Chow ◽

Kimberly Skrobarcek ◽

Kaitlin Forsberg ◽

...

Keyword(s):

Risk Factors ◽

Acute Care ◽

Acute Care Hospital ◽

Clinical Information ◽

Control Measures ◽

Resistant Organism ◽

Invasive Infection ◽

Care Hospital ◽

Candida Auris

Abstract Background Candida auris can be transmitted in healthcare settings, and patients can become asymptomatically colonized, increasing risk for invasive infection and transmission. We investigated an ongoing C. auris outbreak at a 30-bed long-term acute care hospital to identify colonization for C. auris prevalence and risk factors. Methods During February–June 2017, we conducted point prevalence surveys every 2 weeks among admitted patients. We abstracted clinical information from medical records and collected axillary and groin swabs. Swabs were tested for C. auris. Data were analyzed to identify risk factors for colonization with C. auris by evaluating differences between colonized and noncolonized patients. Results All 101 hospitalized patients were surveyed, and 33 (33%) were colonized with C. auris. Prevalence of colonization ranged from 8% to 38%; incidence ranged from 5% to 20% (figure). Among colonized patients with available data, 19/27 (70%) had a tracheostomy, 20/31 (65%) had gastrostomy tubes, 24/33 (73%) ventilator use, and 12/27 (44%) had hemodialysis. Also, 31/33 (94%) had antibiotics and 13/33 (34%) antifungals during hospitalization. BMI for colonized patients (mean = 30.3, standard deviation (SD) = 10) was higher than for noncolonized patients (mean = 26.5, SD = 7.9); t = −2.1; P = 0.04). Odds of colonization were higher among Black patients (33%) vs. White patients (16%) (odds ratio [OR] 3.5; 95% confidence interval [CI] 1.3–9.8), and those colonized with other multidrug-resistant organism (MDRO) (72%) vs. noncolonized (44%) (OR 3.2; CI 1.3–8.0). Odds of death were higher among colonized patients (OR 4.6; CI 1.6—13.6). Conclusion Patients in long-term acute care facilities and having high prevalences of MDROs might be at risk for C. auris. Such patients with these risk factors could be targeted for enhanced surveillance to facilitate early detection of C. auris. Infection control measures to reduce MDROs’ spread, including hand hygiene, contact precautions, and judicious use of antimicrobials, could prevent further C. auris transmission. Acknowledgements The authors thank Janet Glowicz and Kathleen Ross. Disclosures All authors: No reported disclosures.

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1263. Managing an Influenza Outbreak Which Spilled Over to an Acute Care Hospital from a Behavioral Health Unit

Open Forum Infectious Diseases ◽

10.1093/ofid/ofy210.1096 ◽

2018 ◽

Vol 5 (suppl_1) ◽

pp. S385-S385

Author(s):

Colleen M Clay ◽

Leonardo Girio-Herrera ◽

Faheem Younus

Keyword(s):

Behavioral Health ◽

Acute Care ◽

Influenza A ◽

Average Length ◽

Acute Care Hospital ◽

Control Measures ◽

Care Hospital ◽

Prevention Measures ◽

Influenza Outbreak ◽

Hospital Acquired

Abstract Background Behavioral health units (BHU) have been implicated in influenza outbreaks due to group activities, low availability of alcohol-based hand gels and unique host factors. We describe the management of an unusual influenza outbreak, which started in the BHU and then spilled over to the acute care hospital (ACH). Methods University of Maryland Harford Memorial Hospital is a 95-bed ACH with a 14-bed closed-door adult BHU located on the fifth floor. Two cases each of hospital-acquired influenza were identified in our BHU during 2016 and 2017. In January 2018, however, hospital-acquired influenza cases in the BHU spilled over to the adjacent ACH to cause an outbreak. A case was defined as a patient with fever of >100.4°F, presence of influenza-like illness, and a positive influenza test >72 hours after admission. Outbreak control measures included twice daily fever screening, enhanced droplet precautions, visitor restrictions, discontinuing community activities, enforcing hand hygiene at all hospital entrances, and hospital-wide chemoprophylaxis with oseltamivir. Results On January 15, 2018, the index patient developed influenza in the BHU followed by a second case in BHU 4-days later. Over the next 10 days, five more patients on the third and fourth floors of ACH tested positive. Attack rate was 3% and average length of stay was 8.9 days. Chemoprophylaxis with oseltamivir 75 mg orally once a day was given to 71% of all eligible hospitalized patients for a week (at a cost of $17,000). All seven patients yielded influenza A, subtype H3N2 and were successfully treated with oseltamivir 75 mg orally twice a day for 7 days. The outbreak lasted 11 days. Figure 1 shows the epidemiologic curve. Conclusion Special attention should be paid to influenza prevention in the BHUs due to the risk of spillover effect to sicker patients in the adjacent ACH. A short, 7-day course of hospital-wide oseltamivir chemoprophylaxis, in addition to promptly implementing the infection prevention measures was effective in controlling the outbreak. Disclosures All authors: No reported disclosures.

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Patient Outcomes and Lessons-Learned from Treating Patients with Severe COVID-19 at a Long-Term Acute Care Hospital

10.1101/2021.06.10.21255008 ◽

2021 ◽

Author(s):

Peter Grevelding ◽

Henry C Hrdlicka ◽

Stephen Holland ◽

Lorraine Cullen ◽

Amanda Meyer ◽

...

Keyword(s):

Length Of Stay ◽

Acute Care ◽

Patient Outcomes ◽

Acute Care Hospital ◽

Lessons Learned ◽

Care Hospital ◽

Patient Age ◽

Holistic Treatment ◽

Patient Âgé

The goal of this study was to describe the characteristics, clinical management, and patient outcomes during, and after, acute COVID-19 phase at Gaylord Specialty Healthcare, a long-term acute care hospital in Wallingford, CT, USA. In this study, we conducted a single-center retrospective analysis of electronic medical records of patients treated for COVID-19-related impairments, from March 19, 2020 through August 14, 2020, to evaluate patient outcomes in response to holistic treatment approach used at our facility. Of the 127 total COVID-19 related patient admissions during this time, 118 were discharged by the data cut-off. Mean patient age was 63 years, 64.1% were male, and 29.9% of patients tested-positive for SARS-CoV-2 infection at admission. The mean (SD) length-of-stay at was 25.5 (13.0) days and there was a positive correlation between patient age and length-of-stay. Of the 51 patients non-ambulatory at admission, 83.3% were ambulatory at discharge. Gait increased 217.4 feet from admission to discharge, a greater increase than the reference cohort of 146.3 feet. 93.8% (15/16) of patients mechanically ventilated at admission were weaned before discharge (mean 11.3 days). 74.7% (56/75) of patients admitted with a restricted diet were discharged on a regular diet. In conclusion, the majority of patients treated at our long-term acute care hospital for severe COVID-19 and related complications improved significantly through coordinated care and rehabilitation.

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Impact of a Multidisciplinary Infection Prevention Initiative on Central Line and Urinary Catheter Utilization in a Long-term Acute Care Hospital

Open Forum Infectious Diseases ◽

10.1093/ofid/ofy156 ◽

2018 ◽

Vol 5 (7) ◽

Cited By ~ 4

Author(s):

Suganya Chandramohan ◽

Bhagyashri Navalkele ◽

Ammara Mushtaq ◽

Amar Krishna ◽

John Kacir ◽

...

Keyword(s):

Acute Care ◽

Infection Prevention ◽

Urinary Catheter ◽

Acute Care Hospital ◽

Central Line ◽

Care Hospital ◽

Intervention Period ◽

Infection Rates ◽

Rebound Increase

Abstract Background Prolonged central line (CL) and urinary catheter (UC) use can increase risk of central line–associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI). Methods This interventional study conducted in a 76-bed long-term acute care hospital (LTACH) in Southeast Michigan was divided into 3 periods: pre-intervention (January 2015–June 2015), intervention (July–November 2015), and postintervention (December 2015–March 2017). During the intervention period, a multidisciplinary infection prevention team (MIPT) made weekly recommendations to remove unnecessary CL/UC or switch to alternate urinary/intravenous access. Device utilization ratios (DURs) and infection rates were compared between the study periods. Interrupted time series (ITS) and 0-inflated poisson (ZIP) regression were used to analyze DUR and CLABSI/CAUTI data, respectively. Results UC-DUR was 31% in the pre- and postintervention periods and 21% in the intervention period. CL-DUR decreased from 46% (pre-intervention) to 39% (intervention) to 37% (postintervention). The results of ITS analysis indicated nonsignificant decrease and increase in level/trend in DURs coinciding with our intervention. The CAUTI rate per catheter-days did not decrease during intervention (4.36) compared with pre- (2.49) and postintervention (1.93). The CLABSI rate per catheter-days decreased by 73% during intervention (0.39) compared with pre-intervention (1.45). Rates again quadrupled postintervention (1.58). ZIP analysis indicated a beneficial effect of intervention on infection rates without reaching statistical significance. Conclusions We demonstrated that a workable MIPT initiative focusing on removal of unnecessary CL and UC can be easily implemented in an LTACH requiring minimal time and resources. A rebound increase in UC-DURs to pre-intervention levels after intervention end indicates that continued vigilance is required to maintain performance.

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Outcomes of and Lessons Learned from Patients with Severe COVID-19 in a Long-term Acute Care Hospital

Archives of Physical Medicine and Rehabilitation ◽

10.1016/j.apmr.2021.01.013 ◽

2021 ◽

Vol 102 (4) ◽

pp. e3-e4

Author(s):

Peter Grevelding ◽

Henry Hrdlicka ◽

Stephen Holland ◽

Lorraine Cullen ◽

Amanda Meyer ◽

...

Keyword(s):

Acute Care ◽

Acute Care Hospital ◽

Lessons Learned ◽

Care Hospital

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Patient Outcomes and Lessons-Learned from Treating Patients with Severe COVID-19 at a Long-Term Acute Care Hospital: A Single-Center Retrospective Analysis (Preprint)

JMIR Rehabilitation and Assistive Technologies ◽

10.2196/31502 ◽

2021 ◽

Author(s):

Peter Grevelding ◽

Henry Charles Hrdlicka ◽

Stephen Holland ◽

Lorraine Cullen ◽

Amanda Meyer ◽

...

Keyword(s):

Retrospective Analysis ◽

Acute Care ◽

Patient Outcomes ◽

Acute Care Hospital ◽

Lessons Learned ◽

Care Hospital ◽

Single Center

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Patient Outcomes and Lessons-Learned from Treating Patients with Severe COVID-19 at a Long-Term Acute Care Hospital (Preprint)

10.2196/preprints.31502 ◽

2021 ◽

Author(s):

Peter Grevelding ◽

Henry Charles Hrdlicka ◽

Stephen Holland ◽

Lorraine Cullen ◽

Amanda Meyer ◽

...

Keyword(s):

Length Of Stay ◽

Acute Care ◽

Patient Outcomes ◽

Acute Care Hospital ◽

Lessons Learned ◽

Care Hospital ◽

Patient Age ◽

Holistic Treatment ◽

Patient Âgé

BACKGROUND Patients hospitalized with severe coronavirus disease-2019 (COVID-19) may face long hospital lengths-of-stay, making it unreasonable to expect a discharge to home without long-term consequences.Post-acute care, such as that provided at long-term acute care hospitals (LTACHs) can provide rehabilitation and/or palliative care in the post-COVID phase, as well as provide an alternative to conventional short-term acute care hospitalization (STACH) for active treatment, thereby reducing the burden on the STACH system. OBJECTIVE To describe characteristics, clinical management, and patient outcomes during and after acute COVID-19 phase in a LTACH in the Northeastern United States. METHODS A single-center retrospective analysis of electronic medical records of patients treated for COVID-19-related impairments, from March 19, 2020 through August 14, 2020, was conducted to evaluate patient outcomes in response to the facility’s holistic treatment approach. RESULTS Of the 127 total COVID-19 related patient admissions during this time, 118 admissions were discharged by the data cut-off. Mean patient age was 63 years, 64.1% were male, and 29.9% of patients tested-positive for SARS-CoV-2 infection at admission. The mean (SD) length-of-stay at was 25.5 (13.0) days and there was a positive correlation between patient age and length-of-stay. Of the 51 patients non-ambulatory at admission, 83.3% were ambulatory at discharge. Gait increased 217.4 feet from admission to discharge, a greater increase than the reference cohort of 146.3 feet. 93.8% (15/16) of patients mechanically ventilated at admission were weaned before discharge (mean 11.3 days). 74.7% (56/75) of patients admitted with a restricted diet were discharged on a regular diet. CONCLUSIONS The majority of patients treated at a long-term acute care hospital for severe COVID-19 and related complications improved significantly through coordinated care and rehabilitation.

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1268. Transmissibility of Candida auris by Type of Inpatient Healthcare Facility

Open Forum Infectious Diseases ◽

10.1093/ofid/ofy210.1101 ◽

2018 ◽

Vol 5 (suppl_1) ◽

pp. S386-S387

Author(s):

Prabasaj Paul ◽

Kaitlin Forsberg ◽

Snigdha Vallabhaneni ◽

Shawn R Lockhart ◽

Anastasia P Litvintseva ◽

...

Keyword(s):

Acute Care ◽

Reproduction Number ◽

Acute Care Hospital ◽

Healthcare Facility ◽

Control Measures ◽

Care Hospital ◽

Candida Auris ◽

Healthcare Facilities ◽

Colonization Pressure ◽

Facility Type

Abstract Background Candida auris is a multidrug-resistant yeast causing outbreaks in healthcare settings. Stopping the spread of C. auris requires rapid identification of healthcare facilities at risk of higher transmission to help targeted implementation of infection control measures. We used data collected during public health investigations to quantify transmissibility of C. auris by type of healthcare facility. Methods In two states, 3,159 patient swabs were collected during 96 C. auris point prevalence surveys conducted at 36 inpatient healthcare facilities in November 2016 and April 2018. We estimated facility transmissibility and facility reproduction number (number infected by one index colonized patient per day, and per stay, respectively, at the facility) of C. auris based on estimated colonization pressure, a count of newly colonized patients between successive surveys at the same facility, and mean lengths of stay at facilities (estimated from CMS administrative data). The results were summarized by facility type: acute care hospital (ACH), long-term acute care hospital (LTACH) or ventilator unit at skilled nursing facility (VSNF), and were compared with previous estimates for transmissibility of carbapenem-resistant Enterobacteriaceae (CRE). Results Swabs were collected from 13 ACHs, 12 LTACHs, and 11 VSNFs. The C. auris facility reproduction number may exceed the critical value of 1 in both ACHs and VSNFs, and may exceed that for CRE in ACHs (table). Conclusion Transmissibility of C. auris is comparable to that of CRE. The transmissibility within VSNFs emphasizes their potential role as amplifiers in the outbreak. Understanding transmissibility by facility type helps evaluate the potential impact of interventions in various settings. Disclosures All authors: No reported disclosures.

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