A Situational Review of Comprehensive Infection Prevention and Control Guidelines Aimed at Preventing the Nosocomial Spread of COVID-19

Introduction

Hospital-Acquired Infections or Nosocomial Infections or Healthcare-Associated Infections have been aptly defined by WHO as: “An infection acquired in the hospital by a patient who was admitted for a purpose other than that infection. An infection occurring in a patient in a hospital or other health care facility in whom the infection was not present or incubating at the time of admission. This includes infections acquired in the hospital but appearing after discharge, and occupational infections among the staff of the facility”.¹

Nosocomial infections continue to persist in both the developed (7%) and the developing (10%) nations.¹ Hospital-Acquired Infections (HAI) are a serious public health problem with the consequent adverse morbidity, mortality, quality of life concerns and commuting to other major public health challenges. These infections substantially lead to catastrophic expenditure needs related to HAI surveillance and monitoring. Even during SARS and Middle East Respiratory Syndrome outbreaks, it was found that nosocomial transmission was associated with numerous frontline healthcare workers (FLHCWs) and accompanying persons being infected. Healthcare settings with relatively closed environments, poor ventilation and defective infection prevention and control strategies are more likely to become transmission sites.² COVID-19 primarily spreads through air droplets and direct contact although there are reports of virus transmission through the excretory route as well.³ Though patients of all diseases are susceptible to COVID-19, the elderly and those with underlying diseases such as hypertension, diabetes and cardiovascular disease are more prone to severe disease.⁴

The National Centre for Disease Control (NCDC) in collaboration with the WHO, India has formulated the National Guidelines for IPC in Healthcare Facilities, which aims to improve and prevent Hospital Acquired Infections (HAI’s) and to enhance the skills and capacity of health workers in prevention and control of infections through standard protocols. It is well known that breaking the epidemiological triad is the most effective way of prevention of nosocomial infection in healthcare facilities.

Lack of self-protective equipment and containment measures can lead to a cluster of cases in a hospital setting. During each stage of the COVID-19 outbreak, the shortage of PPE and lack of awareness of personal protection measures were major contributors to the spread of the disease.⁵ A high-stress environment is also known to weaken the immunity of healthcare workers. It might also be the reality that many of the healthcare workers might not be trained enough for infectious disease control and prevention at their workplaces.⁶

We discuss below a series of notable recommendations and guidelines that are aimed at improving infection prevention and control (IPC) and are relevant in most situations – COVID-19 and beyond. It is recommended that incorporating public health approaches, which are relatively easy to implement and affordable help in the reduction of the HAI:⁷  

•  Proper hand hygiene 
•  Proper use of personal protective equipment (PPE) 
•  Ensuring that stringent aseptic techniques are followed 
•  Paying attention to established practices for cleaning and decontamination of soiled instruments, followed by either sterilization or high-level disinfection 
•  Following appropriate methods of biomedical waste management (BMW) 
•  Appropriate cleaning and disinfection of the environment 
•  Ensuring the incorporation of safety measures in operation rooms and other high-risk areas where vulnerable patients are accommodated and could be exposed to the infective agents (COVID-19) 
•  Upholding a safe working environment and safe work practice

Pre-requisites for an effective IPC program 

•  Developing the policies and guidelines based on the best practices and standard operating procedures (SOPs) to be followed by the healthcare facilities 
•  Capacity building of healthcare staff in handling emergencies and tackling the spread of infections 
•  Continuous supply of requisite quantity of personal protective equipment (PPE) 
•  Instituting an antimicrobial use policy and linking it with the antimicrobial stewardship program (AMSP) 
•  The amalgamation of quality and safety-related activities of healthcare facilities 
•  HAI surveillance and outbreak investigation 
•  Microbiology laboratory support 
•  Environmental protection 
•  Linking with other patient safety programs in the healthcare facility (HCF) 
•  Evaluation of the program activities: monitoring, evaluation, and feedback 
•  Budget allocation 
•  Implementation through a multimodal approach

Measures to protect healthcare workers

Current National Guidelines for IPC in Healthcare Facilities is in line with the recommendations of the University of California San Francisco which hence adopted a two-tiered approach (standard pre-cautions and transmission-based precautions) as a precautionary measure to control the spread of infections in hospital settings to protect the health care workers, patients, and visitors.^8,9

Standard precautions

The following are the standard recommended precautions for healthcare facilities to prevent the nosocomial spread of COVID-19: hand hygiene, personal protective equipment, respiratory hygiene and cough etiquette, prevention of injuries from sharps, safe handling of patient-care material, adhering to the principles of asepsis and ensuring biomedical infection control (patient placement, environmental cleaning, linen and laundry and waste disposal).

Measures that need to be adopted to support the implementation of the standard precautions

•   Staff education on hand hygiene and standard precautions 
•  Provide ready access to PPE 
•  Visual reminders at the patient bedside in the form of posters, along with verbal reminders from supervising staff 
•  Provision of supplies in designated supply carts or pre-organized packs to provide immediate access to PPE and facilitate their use in resuscitation settings 
•  Monitoring of compliance through “safety” rounds 
•  Possible disciplinary action if there are repeated lapses in compliance

Transmission-based precautions

Transmission-based precautions are based on the route of transmission of the agent/ disease and epidemiology. Here, we find that aseptic techniques and device management for clinical procedures are included along with the standard precautions. These precautions are commonly practised and relevant in special settings such as OTs, ICUs, neonatal wards, haemodialysis units, and central reprocessing units; and, during few high-risk procedures such as aerosol-generating procedures, use of indwelling catheters, and other devices, surgery, and other invasive procedures. The table below represents the following mode of transmission and precautions to be adopted in healthcare facilities:

The global protocols, recommendations, and guidelines for health care facilities during COVID-19

The WHO Strategic and Technical Advisory Group for Infectious Hazards (STAG-IH), based on their continuous reviews and risk assessments, provided recommendations to WHO member states, emphasizing the robust and rapid preparedness, readiness and response to fight against COVID-19, application of a combination of public health response measures (case and contact finding, containment, public awareness, promotion of personal protective hygiene, strengthening the health systems capacity to handle more number of cases. Stronger infection prevention and control in health care facilities, and lockdown measures), active surveillance for timely case finding; isolation, testing, and tracking every contact in containment; practice social distancing; and preparedness of the health-care systems and populations for the spread of infection. Low and Middle Income Countries (LMICs) requesting for technical and financial support are being supported by the WHO, including from the World Bank Pandemic Emergency Financing Facility and other mechanisms and addressing the research gaps about COVID-19.^10,11 CDC Atlanta has also provided practical guidelines that need to be instituted to protect healthcare workers, patients, and communities, with the 10 best ways to operationalize the health care systems effectively during COVID-19 under five broad categories explained below:¹²

A. Workers Safety and Support:

1. Health workers to understand and execute the right method of infection prevention control measures related to COVID-19 with specific training on using personal protective equipment (PPE).

2. Health personnel must implement strategies optimizing PPE, along with the extended use and reuse of N95 respirators, provision of extended use PPE units, exclusively for the patients with COVID-19. Reservation of N95 respirators for aerosol-generating procedures, implementing the walk-up testing booth (Solid transparent panels for the collection of COVID-19 samples), avoiding the unnecessary exposure of the Health care workers to the pathogens.

3. Introduction of the universal source control in health care facilities which includes the staff, patients, and visitors.

4. By using the PPE burn rate calculator consider tracking the availability of the PPE supplies in the health care facilities.

5. Devolving the protocols to healthcare workers for assessing and monitoring the symptoms of COVID-19 manifesting in them. The protocols include work restrictions when sick or post-exposure, and return to work protocols after exposure and/or suspected or confirmed COVID-19 infection.

6. Establishing the plan for the provision of mental health, parenting, meals, and non-punitive sick policies, as the additional benefit for health care workers.

B. Patient Service Delivery:

7. Encouraging the HCW’s to be well versed in evidence-based care of patients with COVID-19, following the guidelines by CDC, National Institutes of Health, the Infectious Diseases Society of America, the World Health Organization, and the Surviving Sepsis Campaign.

8. Provision of Standard Operating Procedures (SOP’s) for the discharge of patients with suspected or confirmed COVID-19 from hospital to home or a long-term care facility for follow-up care.

9. Utilization of advanced technologies like telehealth strategies to provide high quality, feasible patient care, and reducing the risk of COVID-19 transmission in the health facilities. Planning to implement the phone advice line to clarify the doubts of COVID-19 patients and triage patients.

C. Data Streams for Situational Awareness:

10. Provision of health awareness and health education on COVID-19 status in the health facilities and the community. Access to evidence-based guidelines for COVID-19 patient care.

11. Inclusion of hospital capacity reporting and patient impact data into the COVID-19 module for improvising the National Healthcare Safety Network (NHSN).

D. Facility practices:

12. Strengthening the health care facility’s response mechanisms by getting accustomed to COVID-19 specific, standard care resources:

•   Using the hospital preparedness checklist and the COVID-19 Surge spread-sheet to estimate and respond to the increasing demand for hospitalbased services.
•   Activating the plans for grouping the patients with COVID-19 and assigning dedicated staff. 
•  Creation of plans to reduce staff deficits and evaluate the need for alternative care sites. 
•  Setting up an Emergency Operations Centre (EOC) at the healthcare facilities, if unavailable, and ensuring the operationality with adequate staffing for responding to the emergencies. 
•  Along with the enhancement of telehealth services, resuming and maintaining the essential healthcare services using a risk/benefit analysis for in-person care visits.

E. Communications: 

13. Development and maintenance of a communication plan for healthcare workers, patients, and the community. Utilizing virtual town halls, routine meetings with local community leaders and partners, employing emails and phone conferences for staff, media briefs, and others for communication purposes.

Further, the recommendations for specific health care settings as per CDC Atlanta are enumerated below:¹³

In these difficult times of the COVID-19 pandemic, it is crucial for the health care facilities to balance the health care provision for both COVID-19 and non-COVID-19 cases. Adaptation of the innovative technologies and standardized, evidence-based precautionary measures in the health care setup will minimize the risk, stigma, and fear of COVID-19 among the patients, visitors, and health care workers.

Provision of Non-COVID-19 Clinical Care During the COVID-19 Pandemic

Health care service provision for the Non-COVID-19 patients is to be finalized by the State and local authorities based on the pandemic transmissibility in the community.

1. Optimizing the telehealth services wherever possible based on the availability. Plan for the gradual expansion of in-person clinical care services as the pandemic reduces.

2. Prioritizing the at-risk populations including the patients with complications due to delayed care and for those with the absence of telehealth services. 

Additional Recommendations for Specific Healthcare Settings

Inpatient facilities

•  Visual Alerts: Placing visual alerts such as signs and posters at the entrances and suitable places (hand hygiene, respiratory hygiene, and cough etiquette), which must be visible, legible, clear, and by adopting appropriate languages. 
•  Maintain physical distancing: Physical distancing through video conferences, workstation spacing, reducing the gatherings in the common platforms such as canteens, break rooms and elevators, etc. 
•  Guidelines for visitors: Assessment for the COVID-19 symptoms before entering the hospital and compulsory instruction for wearing the face mask or cloth face covering while in the hospital, following frequent hand hygiene, respiratory hygiene, and cough etiquette, and restricted unnecessary movements within the health facilities.

Outpatient facilities and ambulatory care practices 

• Follow up in case of the patients with COVID-19: COVID-19 patients have the potential of developing further complications and must be followed up on regular basis for ensuring their adherence to the current drug and therapeutic regimens, confirming the access to medication stocks, and to instruct them for notifying the facility in case of emergency. 
•  Patients with COVID-19 symptoms: Prior information, preparation and infection control measures must be adopted by the health staffs receiving the patients with COVID-19 symptoms. 
•  No penalization: No penalty must be levied in case of cancelling or missing the appointments. 
•  Usage of visual alerts: Compulsory usage of visual alerts (signboards or posters) at the entrance and the designated areas using appropriate languages. 
•  Waiting rooms with physical distancing measures: The crowding at the waiting area can be reduced by requesting the patients to stay in their vehicles or a designated outdoor waiting area, until they are called into the facility for their appointment. Another alternative is triage booths to screen patients safely.

Also, interesting to note are the NIH guidelines for Infection control in health Facilities¹⁴ which discuss the risk that healthcare workers are exposed to various aerosol-generating medical procedures during their routine duties. There is an increasing risk of the health workers getting exposed to the virus (SARS COV-2), get infected, and the chance of transmitting them to their co-workers, other patients, and family members, and substantially spreading to the community. Therefore, the NIH recommends the following infection control measures:

1.  Following the specific airborne protection measures, including using appropriate personal protective equipment (gloves, gown, and eye protection such as a face shield or safety goggles), including N-95 or equivalent high-level respirators (WHO). 
2. Health workers with experience in airway management, performing endotracheal intubation, etc., in patients with COVID-19. The use of video laryngoscopy is preferred over the direct, to avoid the close facial proximity and high-level concentration of viral aerosols 
3. Avoid unnecessary staff during the intubation procedure to reduce the spread.

Challenges during the COVID-19 at the health facilities⁵

1. Shortage of personal protective equipment (PPE):

The major apprehension during these tough times is the accessibility and availability of personal protective equipment (PPE) in health facilities for health workers.

2. Poor quality personal protective equipment: 

Health workers are supplied sometimes with PPE of substandard quality.

3. Personal Safety: 

The health workers at the health facility are working without breaks.

4. Psychological challenges:

During these times of adversity, health workers have witnessed the losses of their colleagues, families, and patients, which might affect their mental health status. Studies suggest that various common mental disorders are becoming evident in this group. They are the most vulnerable group; so there is always a fear among them of getting infected and may substantially infect others. Hence, it is important to address the issues as early as possible for the smooth running of the healthcare system.⁶

5. Physical Challenges:

Continuous and long working hours without a break; isolation from their family, makes them demoralised and demotivated to work.

6. Financial Challenges:

Health workers are paid less, expected to work for long, resulting in loss of motivation and job dissatisfaction.

7. Family challenges:

Health workers are working intensely at the health facilities leaving behind their families (younger children, older parents, sick spouses, etc). These social isolation policies have made their life difficult in terms of the availability of food and other essential items to their families.

Recommendations

An enormous amount of effort and planning is required to prevent the nosocomial spread of COVID-19 infection. It is very important to institute adequate infection prevention and control practices that are aimed at preventing transmission of infection in clinical settings. Nosocomial infection control constitutes an important aspect of dealing with an epidemic, especially as we see highly burdened health facilities managing high-risk populations with inadequate adherence to prevention and control measures. The essentials of prevention of nosocomial infections effectively remain - maintaining recommended distance, adequate isolation facilities, provision of personal protective equipment and training on how to use them, provision of adequate material supplies and the extensive use of teleconsultations and telemedicine facilities to limit the spread. As the pandemic waxes and wanes, much of future research will depend on unearthing the association between nosocomial infection spread of COVID-19 and the effect of subtypes of the infection (ordinary, severe or critical), the number of hospital bed days, admittance to ICU or not, relapse cases and other hospital-acquired infections during the hospitalization. Response to COVID-19 has highlighted the need for comprehensive infection prevention and control practices as much ‘necessary’ interventions will actually guide the development of public health preparedness and provide evidence-based learnings to handle any such future epidemics in the future.