Transmission-based Precautions Research Articles

Investigation and management of an outbreak of COVID-19 infection in an acute admission unit in a District General Hospital: lessons learnt

SummaryBackgroundSARS-CoV-2 outbreaks are difficult to recognise and control due to its high infectivity and the wide range of clinical manifestations of the infection. An outbreak at Watford general hospital provided an opportunity to recognise the complexity involved in a COVID-19 outbreak investigation.MethodsAn outbreak control team (OCT) was convened. The terms outbreak, a case and a significant exposure were defined as per Public Health England (PHE) Guidance and in the context of the local outbreak. Root cause analyses (RCAs) were carried out on cases to identify possible causes, possible route of transmission and any learning points. All contact patients and staff were screened with RT PCR and genomic sequencing was performed on a set of positive specimens.In addition to active contact tracing, screening and cohorting of patients and staff, standard and transmission-based precautions were reinforced to control the outbreak.FindingsFifteen patients and four staff members were identified in this outbreak investigation. With contact tracing, screening and through strict infection control measures the outbreak was brought under control.ConclusionWe could successfully contain the spread of this outbreak following PHE outbreak control guidelines and our local guidelines. We recognised several challenges in investigating a COVID-19 outbreak in a hospital setting. Problems arising from variable sensitivity of the tests, difficulty in differentiating COVID-19 related symptoms from underlying diseases, problems related to establishing the route of transmission, issues with contact tracing are discussed. Additionally, the importance and limitations of genomic studies in COVID-19 are discussed.

Validation and implementation of group electronic hand hygiene monitoring across twenty-four critical care units.

An accurate estimate of the average number of hand hygiene opportunities per patient hour (HHO rate) is required to implement group electronic hand hygiene monitoring systems (GEHHMSs). We sought to identify predictors of HHOs to validate and implement a GEHHMS across a network of critical care units. Multicenter, observational study (10 hospitals)followed by quality improvement intervention involving 24 critical care units across 12 hospitals in Ontario, Canada. Critical care patient beds were randomized to receive 1 hour of continuous direct observation to determine the HHO rate. A Poisson regression model determined unit-level predictors of HHOs. Estimates of average HHO rates across different types of critical care units were derived and used to implement and evaluate use of GEHHMS. During 2,812 hours of observation, we identified 25,417 HHOs. There was significant variability in HHO rate across critical care units. Time of day, day of the week, unit acuity, patient acuity, patient population and use of transmission-based precautions were significantly associated with HHO rate. Using unit-specific estimates of average HHO rate, aggregate HH adherence was 30.0% (1,084,329 of 3,614,908) at baseline with GEHHMS and improved to 38.5% (740,660 of 1,921,656) within 2 months of continuous feedback to units (P < .0001). Unit-specific estimates based on known predictors of HHO rate enabled broad implementation of GEHHMS. Further longitudinal quality improvement efforts using this system are required to assess the impact of GEHHMS on both HH adherence and clinical outcomes within critically ill patient populations.

Association between SARS-CoV-2 exposure and antibody status among healthcare workers in two London hospitals: a cross-sectional study

SummaryBackgroundPatient-facing (frontline) health-care workers (HCWs) are at high risk of repeated exposure to SARS-CoV-2.AimWe sought to determine the association between levels of frontline exposure and likelihood of SARS-CoV-2 seropositivity amongst HCW.MethodsA cross-sectional study was undertaken using purposefully collected data from HCWs at two hospitals in London, United Kingdom (UK) over eight weeks in May–June 2020. Information on sociodemographic, clinical and occupational characteristics was collected using an anonymised questionnaire. Serology was performed using split SARS-CoV-2 IgM/IgG lateral flow immunoassays. Exposure risk was categorised into five pre-defined ordered grades. Multivariable logistic regression was used to examine the association between being frontline and SARS-CoV-2 seropositivity after controlling for other risks of infection.Findings615 HCWs participated in the study. 250/615 (40.7%) were SARS-CoV-2 IgM and/or IgG positive. After controlling for other exposures, there was non-significant evidence of a modest association between being a frontline HCW (any level) and SARS-CoV-2 seropositivity compared to non-frontline status (OR 1.39, 95% CI 0.84–2.30, P=0.200). There was 15% increase in the odds of SARS-CoV-2 seropositivity for each step along the frontline exposure gradient (OR 1.15, 95% CI 1.00–1.32, P=0.043).ConclusionWe found a high SARS-CoV-2 IgM/IgG seropositivity with modest evidence for a dose-response association between increasing levels of frontline exposure risk and seropositivity. Even in well-resourced hospital settings, appropriate use of personal protective equipment, in addition to other transmission-based precautions for inpatient care of SARS-CoV-2 patients could reduce the risk of hospital-acquired SARS-CoV-2 infection among frontline HCW.

SARS-CoV-2 Infection among Medical Institution Faculty and Healthcare Workers in Tokyo, Japan.

Objective To consider effective measures against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in medical institutions, this study estimated the SARS-CoV-2 infection rate among healthcare workers (HCWs) in Tokyo, Japan, and determined the specific findings for mild coronavirus disease 2019 (COVID-19) cases. Methods This study analyzed the results of serologic tests to detect immunoglobulin G antibodies against SARS-CoV-2 and evaluated the demographic and clinical characteristics of the faculty and HCWs at a Tokyo medical institution in August 2020. The demographic and clinical characteristics of participants with antibody-positive results were compared to those of participants with antibody-negative results. Materials This study recruited 2,341 faculty and HCWs at a Tokyo medical institution, 21 of whom had a COVID-19 history. Results Of the 2,320 participants without a COVID-19 history, 20 (0.862%) had positive serologic test results. A fever and dysgeusia or dysosmia occurred with greater frequency among the participants with positive test results than in those with negative results [odds ratio (OR), 5.475; 95% confidence interval (CI), 1.960-15.293 and OR, 24.158; 95% CI, 2.693-216.720, respectively]. No significant difference was observed in the positivity rate between HCWs providing medical care for COVID-19 patients using adequate protection and other HCWs (OR, 2.514; 95% CI, 0.959-6.588). Conclusion To reduce the risk of COVID-19 spread in medical institutions, faculty and HCWs should follow standard and necessary transmission-based precautions, and those with a fever and dysgeusia or dysosmia should excuse themselves from work as soon as possible.

Infection prevention measures in acute care settings based on severe acute respiratory syndrome coronavirus 2 transmission patterns and risk: a review.

During the coronavirus disease 2019 pandemic, when facing extraordinary infection prevention challenges, acute care settings have balanced routine patient safety needs while minimizing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission risk to patients and healthcare personnel (HCP). Mitigation strategies in acute care settings are based on a combination of basic science, environmental, and epidemiologic evidence. Here, we review the literature on SARS-CoV-2 transmission, how it has shaped infection prevention interventions in acute care settings, and the results of such measures to reduce transmission. HCP adherence to transmission-based precautions in acute care settings, such as the use of personal protective equipment (PPE), is essential to mitigating SARS-CoV-2 spread. Although the SARS-CoV-2 virus has been isolated in nonrespiratory body sites, such exposure has not been shown to definitively cause transmission in humans. Epidemiologic evidence has demonstrated that implementation and adherence to infection prevention strategies reduces acute setting transmission. Given SARS-CoV-2 infection occurs primarily through respiratory transmission, preventing HCP acquisition requires fidelity to consistent PPE usage. Infection prevention strategies and implementation of transmission-based precautions have reduced spread and outbreaks. Epidemiologic studies of acute care outbreaks often include reports of PPE nonadherence and community exposure contributing to SARS-CoV-2 transmission within this setting.

Admissions of COVID-positive patients to US nursing homes with personal protective equipment or staffing shortages.

BackgroundUS nursing homes are required to follow Centers for Disease Control guidance for COVID‐19 transmission‐based precautions (TBP) when admitting COVID‐positive patients.ObjectiveTo assess how frequently nursing homes had shortages of personal protective equipment (PPE) or staffing in weeks when they admitted COVID‐positive patients, which likely made it more difficult to follow TBP, and to compare facility characteristics by admissions practices.Design and SettingFacility‐level data from the Nursing Home COVID‐19 Public File for the period between June 7, 2020 and March 7, 2021 was combined with additional data. The percentages of nursing homes that admitted COVID‐positive patients and that had shortages when admitting were calculated for each week. Descriptive statistics and logistic regression models were used to examine the relationship between facility characteristics and the likelihood of admitting COVID‐positive patients.MeasurementsFacilities were categorized as having admitted COVID‐positive patients in a week if one or more admissions requiring TBP were reported for that week. Facilities that reported having less than a 1‐week supply of any type of PPE or being short any type of staff in a week were defined, respectively, as having a PPE shortage or staffing shortage in that week.ResultsOver the 40‐week study period, 39% of US nursing homes admitted COVID‐positive patients in at least 1 week in which they were experiencing PPE or staffing shortages. Facilities that admitted COVID‐positive patients with shortages generally had lower Centers for Medicare and Medicaid Services overall five‐star ratings than other facilities. Only a small percentage of facilities that admitted COVID‐positive patients while facing shortages were located in counties with severe shortages of PPE or staffing. In logistic regression models, shortages were not associated with COVID‐positive admissions.ConclusionThe widespread practice of admitting COVID‐positive patients while facing shortages may have put nursing home residents and staff at heightened risk of COVID‐19 infection.

Assessing Patient Ability to Exercise COVID-19 Transmission Based Precautions: A Proposed Clinical Tool

Clinical decision-making during the present pandemic has challenged healthcare providers to the limits of their endurance. Inpatient facilities are discharging patients who are positive for the COVID-19 infection, based on testing, and who may still be positive but have symptoms that have remitted. Even medically stable patients may not be able to exercise basic transmission-based precautions such as handwashing or wearing a face mask, and may increase the risk of infection spread to others upon discharge. This can present challenging decisions about when, how, and where to discharge COVID inpatients. This article addresses the behavioral health aspects of this problem, offering background information and proposing creation of a Transmission Based Precautions Inventory. This clinical tool will use chart information and a clinical interview to assess the capability of patients upon discharge to exercise the appropriate behavior-based precautions to prevent the spread of any contagious infection. The discussion includes an exemplar that illustrates the dilemma, followed by other metrics for scoring and development of the tool. Administration time of the tool would be approximately 15-20 minutes and responses would score immediately to inform discharge decisions. The need for such a tool is current; however, the usefulness of an efficacious inventory would persist beyond the present pandemic. In the conclusion, the author invites reader feedback to inform the development and implementation process.

Positive Correlation Between Candida auris Skin-Colonization Burden and Environmental Contamination at a Ventilator-Capable Skilled Nursing Facility in Chicago.

BackgroundCandida auris is an emerging multidrug-resistant yeast that contaminates healthcare environments causing healthcare-associated outbreaks. The mechanisms facilitating contamination are not established.MethodsC. auris was quantified in residents’ bilateral axillary/inguinal composite skin swabs and environmental samples during a point-prevalence survey at a ventilator-capable skilled-nursing facility (vSNF A) with documented high colonization prevalence. Environmental samples were collected from all doorknobs, windowsills and handrails of each bed in 12 rooms. C. auris concentrations were measured using culture and C. auris-specific quantitative polymerase chain reaction (qPCR) The relationship between C. auris concentrations in residents’ swabs and associated environmental samples were evaluated using Kendall’s tau-b (τ b) correlation coefficient.ResultsC. auris was detected in 70/100 tested environmental samples and 31/57 tested resident skin swabs. The mean C. auris concentration in skin swabs was 1.22 × 105 cells/mL by culture and 1.08 × 106 cells/mL by qPCR. C. auris was detected on all handrails of beds occupied by colonized residents, as well as 10/24 doorknobs and 9/12 windowsills. A positive correlation was identified between the concentrations of C. auris in skin swabs and associated handrail samples based on culture (τ b = 0.54, P = .0004) and qPCR (τ b = 0.66, P = 3.83e−6). Two uncolonized residents resided in beds contaminated with C. auris.ConclusionsColonized residents can have high C. auris burdens on their skin, which was positively related with contamination of their surrounding healthcare environment. These findings underscore the importance of hand hygiene, transmission-based precautions, and particularly environmental disinfection in preventing spread in healthcare facilities.

Cycle Thresholds Among Solid Organ Transplant Recipients Testing Positive for SARS-CoV-2.

The optimal duration of transmission-based precautions among immunocompromised patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is unknown. Retrospective review of patients with solid organ transplant with positive SARS-CoV-2 polymerase chain reaction result from nasopharyngeal specimens admitted to the hospital between March 13, 2020 and May 15, 2020. Twenty-one percent of solid organ transplant recipients with positive SARS-CoV-2 polymerase chain reaction detected ≥20 d after symptom onset (or after first positive test among asymptomatic individuals) had a low cycle threshold (ie, high viral load). The majority of these patients were asymptomatic or symptomatically improved. Solid organ transplant recipients may have prolonged high viral burden of SARS-CoV-2. Further data are needed to understand whether cycle threshold data can help inform strategies for prevention of healthcare-associated transmission of SARS-CoV-2 and for appropriate discontinuation of transmission-based precautions.

Coronavirus Disease 2019 (COVID-19) Diagnostic Clinical Decision Support: A Pre-Post Implementation Study of CORAL (COvid Risk cALculator).

BackgroundIsolation of hospitalized persons under investigation (PUIs) for coronavirus disease 2019 (COVID-19) reduces nosocomial transmission risk. Efficient evaluation of PUIs is needed to preserve scarce healthcare resources. We describe the development, implementation, and outcomes of an inpatient diagnostic algorithm and clinical decision support system (CDSS) to evaluate PUIs.MethodsWe conducted a pre-post study of CORAL (COvid Risk cALculator), a CDSS that guides frontline clinicians through a risk-stratified COVID-19 diagnostic workup, removes transmission-based precautions when workup is complete and negative, and triages complex cases to infectious diseases (ID) physician review. Before CORAL, ID physicians reviewed all PUI records to guide workup and precautions. After CORAL, frontline clinicians evaluated PUIs directly using CORAL. We compared pre- and post-CORAL frequency of repeated severe acute respiratory syndrome coronavirus 2 nucleic acid amplification tests (NAATs), time from NAAT result to PUI status discontinuation, total duration of PUI status, and ID physician work hours, using linear and logistic regression, adjusted for COVID-19 incidence.ResultsFewer PUIs underwent repeated testing after an initial negative NAAT after CORAL than before CORAL (54% vs 67%, respectively; adjusted odd ratio, 0.53 [95% confidence interval, .44–.63]; P < .01). CORAL significantly reduced average time to PUI status discontinuation (adjusted difference [standard error], −7.4 [0.8] hours per patient), total duration of PUI status (−19.5 [1.9] hours per patient), and average ID physician work-hours (−57.4 [2.0] hours per day) (all P < .01). No patients had a positive NAAT result within 7 days after discontinuation of precautions via CORAL.ConclusionsCORAL is an efficient and effective CDSS to guide frontline clinicians through the diagnostic evaluation of PUIs and safe discontinuation of precautions.

Factors Associated With Racial Differences in Deaths Among Nursing Home Residents With COVID-19 Infection in the US

It is important to understand differences in coronavirus disease 2019 (COVID-19) deaths by nursing home racial composition and the potential reasons for these differences so that limited resources can be distributed equitably. To describe differences in the number of COVID-19 deaths by nursing home racial composition and examine the factors associated with these differences. This cross-sectional study of 13 312 nursing homes in the US used the Nursing Home COVID-19 Public File from the Centers for Medicare and Medicaid Services, which contains COVID-19 cases and deaths among nursing home residents as self-reported by nursing homes beginning between January 1, 2020, and May 24, 2020, and ending on September 13, 2020. Data were analyzed from July 28 to December 18, 2020. Confirmed or suspected COVID-19 infection. Confirmed cases were defined as COVID-19 infection confirmed by a diagnostic laboratory test. Suspected cases were defined as signs and/or symptoms of COVID-19 infection or patient-specific transmission-based precautions for COVID-19 infection. Deaths associated with COVID-19 among nursing home residents. Death counts were compared by nursing home racial composition, which was measured as the proportion of White residents. Among 13 312 nursing homes included in the study, the overall mean (SD) age of residents was 79.5 (6.7) years. A total of 51 606 COVID-19-associated deaths among residents were reported, with a mean (SD) of 3.9 (8.0) deaths per facility. The mean (SD) number of deaths in nursing homes with the lowest proportion of White residents (quintile 1) vs nursing homes with the highest proportions of White residents (quintile 5) were 5.6 (9.2) and 1.7 (4.8), respectively. Facilities in quintile 1 experienced a mean (SE) of 3.9 (0.2) more deaths than those in quintile 5, representing a 3.3-fold higher number of deaths in quintile 1 compared with quintile 5. Adjustment for the number of certified beds reduced the mean (SE) difference between these 2 nursing home groups to 2.2 (0.2) deaths. Controlling for case mix measures and other nursing home characteristics did not modify this association. Adjustment for county-level COVID-19 prevalence further reduced the mean (SE) difference to 1.0 (0.2) death. In this study, nursing homes with the highest proportions of non-White residents experienced COVID-19 death counts that were 3.3-fold higher than those of facilities with the highest proportions of White residents. These differences were associated with factors such as larger nursing home size and higher infection burden in counties in which nursing homes with high proportions of non-White residents were located. Focusing limited available resources on facilities with high proportions of non-White residents is needed to support nursing homes during potential future outbreaks.

Discontinuation of Transmission Precautions for COVID-19 Patients: Polymerase Chain Reaction Diagnostics, Patient Delays, and Cycle Threshold Values.

BackgroundThe decision of when it is safe to discontinue transmission-based precautions for SARS-CoV-2 coronavirus disease 2019 (COVID-19) hospitalized patients has been controversial. The Centers for Disease Control and Prevention offered reverse transcriptase polymerase chain reaction (PCR) diagnostic test- or symptom-based guidelines.MethodsA retrospective chart review of Vidant Health system, Eastern North Carolina, was conducted. Length of stay, days in isolation unit, and date appropriate for discharge or isolation discontinuation based on the symptom-based strategy were recorded.ResultsOf 196 COVID hospitalized patients, 34 had repeated COVID PCR tests 3 or more days from their first positive test result. Half of these patients experienced delays in release from transmission-based precautions because of repeated positive PCR test results and use of the test-based approach. This resulted in an additional 166 days of hospitalization, costing an estimated $415,000. Furthermore, 2 subjects had a combined 16-day delay in necessary medical procedures. Most of the COVID PCR platforms yield quantitative results in the form of cycle threshold (Ct) values, the number of cycles needed to detect the genome. These values have also been used to assess whether patients are likely to remain contagious. None of our patients who met the criteria for symptom-based strategy for transmission-based precaution discontinuation had positive PCR test results with Ct values lower than 25, but 4 had Ct values lower than 30.ConclusionsConcerns surround immunocompromised patients and those treated with steroids who might be delayed or incapable of stopping viral replication and thus remain contagious. Our results suggest that clinicians use all available data including Ct values to evaluate the safety of discontinuation of transmission precautions.

The safety of anaesthetists and intensivists during the first COVID-19 surge supports extension of use of airborne protection PPE to ward staff

A key controversy in the COVID-19 pandemic has been over staff safety in health and social care settings. Anaesthetists and intensivists were anticipated to be at the highest risk of work-related infection due to involvement in airway management and management of critical illness and therefore wear the highest levels of personal protective equipment (PPE) in the hospital. However, the data clearly show that those working in anaesthesia and critical care settings are at lower risk of infection, harm and death from COVID-19 than colleagues working on the wards. The observed safety of anaesthetists and intensivists and increased risk to those in other patient-facing roles has implications for transmission-based infection control precautions. The precautionary principle supports extending training in and use of airborne precaution PPE to all staff working in patient-facing roles who have close contact with coughing patients. This will both reduce their risk of contracting COVID-19, maintain services and reduce nosocomial transmission to vulnerable patients. The emergence of a new variant of the SARS-CoV-2 virus with significantly higher transmissibility creates urgency to addressing this matter.

Use of Failure Mode and Effect Analysis to Reduce Admission of Asymptomatic COVID-19 Patients to the Adult Emergency Department: An Institutional Experience

BackgroundFailure mode and effect analysis is an important tool to identify failures in a system with its possible cause, effect, and set actions to be implemented proactively before the occurrence of problems. This study tries to identify common failure modes with its possible causes and effect to the health service and to plot actions to be implemented to reduce COVID-19 transmission to clients, staff, and subsequent service compromise from asymptomatic COVID-19 patients visiting the adult emergency department of SPHMMC (non-COVID-19 setup).Method and Study DesignA multidisciplinary team, representing different divisions of the adult emergency department at St. Paul’s Hospital Millennium Medical College (SPHMMC), was chosen. This team was trained on failure mode and effect analysis and basics of COVID-19, to identify possible causes of failures and their potential effects, to calculate a risk priority number (RPN) for each failure, and plan changes in practice.ResultsA total of 22 failure modes and 89 associated causes and effects were identified. Many of these failure modes (12 out of 22) were found in all steps of patient flow and were associated with either due to lack of or failure to apply standard and transmission-based precautions. This suggests the presence of common targets for improvement, particularly in enhancing the safety of staff and clients. As a result of this FMEA, 23 general improvement actions were proposed.ConclusionFMEA can be used as a useful tool for anticipating potential failures in the process and proposing improvement actions that could help in reducing secondary transmissions during the pandemic.

Pediatric Endoscopy During the COVID-19 Pandemic: Implications of Universal Preprocedural Testing for PPE Utilization.

Pediatric Endoscopy During the COVID-19 Pandemic: Implications of Universal Preprocedural Testing for PPE Utilization.

Acceptance of a Symptom-Based Approach for COVID-19 rtRT-PCR Testing to Conserve Resources in a Lower Middle-Income Setting.

SARS-CoV-2 initially emerged in Wuhan, China in late 2019. It has since been recognized as a pandemic and has led to great social and economic disruption globally. The Reverse Transcriptase Real-Time Polymerase Chain Reaction (rtRT-PCR) has become the primary method for COVID-19 testing worldwide. The method requires a specialized laboratory set up. Long-term persistence of SARS-CoV-2 RNA in nasopharyngeal secretion after full clinical recovery of the patient is regularly observed nowadays. This forces the patients to spend a longer period in isolation and test repeatedly to obtain evidence of viral clearance. Repeated COVID-19 testing in asymptomatic or mildly symptomatic cases often leads to extra workload for laboratories that are already struggling with a high specimen turnover. Here, we present 5 purposively selected cases with different patterns of clinical presentations in which nasopharyngeal shedding of SARS-CoV-2 RNA was observed in patients for a long time. From these case studies, we emphasized the adoption of a symptom-based approach for discontinuing transmission-based precautions over a test-based strategy to reduce the time spent by asymptomatic and mildly symptomatic COVID-19 patients in isolation. A symptom-based approach will also help reduce laboratory burden for COVID-19 testing as well as conserve valuable resources and supplies utilized for rtRT-PCR testing in an emerging lower-middle-income setting. Most importantly, it will also make room for critically ill COVID-19 patients to visit or avail COVID-19 testing at their convenience.

824. Isolation Rounding - Enforcing Existing Isolation Policies to Conserve Personal Protective Equipment

BackgroundDuring the COVID-19 pandemic, supplies of personal protective equipment (PPE) have been limited and sold at increased cost. Prior to the pandemic, we had initiated a project to improve PPE adherence and decrease cost by removing eligible patients from transmission based precautions (TBPs). At baseline, ordering providers are responsible for TBP utilization with orders through the electronic medical record. We observed that patients were in TBP when not indicated; remained in TBP beyond the appropriate time; and a reluctance on the part of providers to discontinue the orders. We tested the effect on TBP duration and PPE utilization house-wide through frequent review of TBP by a nurse educator with communication to providers of discontinuation opportunities.MethodsFrom November 2019 to February 2020, all TBP orders in the pediatric intensive care unit (PICU) were reviewed intermittently. In March 2020, review was expanded to all inpatients with daily reviews in all units. Changes recommended and completed were tracked for all reviewed patients. We estimated cost of PPE in the PICU over time based on the number of patients in isolation and type of TBP utilized to determine whether our intervention resulted in reduced PPE use.ResultsRegular rounding in the PICU increased the proportion of patients in appropriate TBP and reduced the need to communicate with providers directly (33% vs 3% requiring intervention, Figure 1). Over the same time period, less PPE was used and PPE-related costs lowered (average total PPE cost $306.18 vs $95.15 per day, Figure 2). Less of an effect was seen when analyzing house-wide data.Figure 1 - P-chart of Percent Interventions Among Patients in TBP Figure 2 - X-chart of Total PPE Cost in the ICU ConclusionIsolation rounds is an effective means to ensure proper TBP adherence and manage PPE use appropriately. Additional study is needed to confirm a return on investment, to account for variation among units, and to sustain COVID-19-influenced gains beyond the pandemic.Disclosures All Authors: No reported disclosures

866. Assessment of Infection Control Training among Healthcare Workers in Three Tertiary Care Public Hospitals, Bangladesh, 2015-17

BackgroundHospital-acquired infections (HAI) are a rising global public health concern that disproportionately affects low and middle-income countries. Healthcare workers (HCWs) are the frontline work-stream against HAIs in healthcare settings. As part of a pilot infection prevention and control (IPC) program, we assessed the acceptability of infection control training in practice among HCWs in three public hospitals in Bangladesh to better mitigate HAI risks and occupational exposures.MethodsWe piloted an IPC intervention, as a part of the emergency preparedness, from 2015 to 2017 and IPC training was one of the key components. Trained IPC staff conducted a half-day training session for each three different level HCW groups, doctors, nurses and support staff. The training comprised of instructive method on standard and transmission-based precautions with infection control techniques. A practical demonstration was held followed by hands-on training on hand hygiene steps and mask, gloves use. The participants’ attitudes and practices on infection control measures were obtained through structured observation and qualitative interviews.Training on Infection Control And Prevention with Healthcare workers (Nurses) Training on Infection Control And Prevention with Healthcare workers (Doctors) ResultsA total of 1562 HCW’s participated in the training: 804 doctors, 445 nurses and 313 support staff in 26 training sessions. Majority of the participants (85%) did not receive any formal training earlier on infection control and often provided incorrect responses on basic IPC during interactive session. None of the hospitals had an IPC committee. After the training, we found a significant increase from 0% at baseline to 24% (p< 0.001) in hand hygiene including 43% (p< 0.001) and 45% (p< 0.001) in mask and gloves use respectively. All respondents (n=84) from the qualitative assessment, reported the training as highly effective which reinforce their learning in action in the hospitals. Participants from all three groups urged to arrange refresher training more frequently and in small groups to uphold the practices.ConclusionThis pilot program demonstrated HCWs lack basic IPC principals and tailored IPC training sessions can significantly improve HCWs IPC practice. Formation of active IPC committee could enable arranging periodic refresher and in-service training updates for HCWs with the reallocation of resources to adopt regular IPC practices.Disclosures All Authors: No reported disclosures

474. Using telemedicine to provide virtual care for COVID-19 patients at home

BackgroundIn response to the COVID-19 pandemic in San Diego, California, the Infectious Disease Division at the University of California San Diego established a COVID-19 Clinic dedicated solely to managing patients safely in their homes. This strategy was developed in response to: i) concerns regarding transmission of infection in the healthcare setting, ii) avoiding overwhelming the healthcare system with COVID-19 patients, iii) providing patients with expedited access to specialists, and iv) reducing the burden on the emergency department and urgent care.MethodsThe COVID-19 clinic staff is comprised of a dedicated nurse, administrative assistant, and four infectious diseases (ID) physicians who aim to see patients within 24 hours of referral via virtual clinics 5 days a week. An ID physician initially assesses each patient in a direct telemedicine visit and answers their questions, assesses disease severity, provides both symptom management and emotional support, and education about self-isolation and transmission-based precautions. The patients are then triaged to daily nursing phone calls and follow up visits as needed.ResultsOver a period of 12 weeks (March 27 to June 16, 2020), the clinic has seen 179 patients. To assess the impact of the clinic, patients are asked to complete a 6-point verbal patients satisfaction survey after their visit. Of the 133 patients who have completed the survey to date, the vast majority reported high satisfaction with their encounters with the COVID-19 physician, with a mean score of 4.8 or higher on all six questions (on a scale of 1 to 5). When asked “Did you feel comfortable talking to your COVID-19 ID physician?” on a scale of 1 to 5, the average score was 4.9. When asked “Did the physician do a good job answering your questions?” the average was 4.9. Patients reported feeling safer after talking with their physician (mean score 4.8), and felt better educated on how to self-quarantine at home (mean score 4.85) and when to seek care from an emergency room, urgent care or hospital (mean score 4.83).ConclusionThe UCSD COVID-19 Clinic demonstrates how telemedicine can be utilized in response to a public health crisis by creating a virtual clinic to provide ID care for patients in their homes.Disclosures All Authors: No reported disclosures

Transmission-Based Precautions.

AORN JournalVolume 112, Issue 5 p. 558-566 Column Transmission-Based Precautions Lisa Spruce DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN, Lisa Spruce DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAANSearch for more papers by this author Lisa Spruce DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN, Lisa Spruce DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAANSearch for more papers by this author First published: 28 October 2020 https://doi.org/10.1002/aorn.13237 1.2: www.aornjournal.org/content/cme Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Volume112, Issue5November 2020Pages 558-566 RelatedInformation