Nosocomial COVID

Because we need one more fucking thing to worry about–and, yes, that is the worst band name EVAR.

Back in the halcyon days of late 2019, one constant infectious disease problem was nosocomial infection–that is, hospital acquired infections, which can be caught from other patients, medical personnel, or surface contamination. Of course, in those sunshine-filled days of yore, the primary concern was bacterial infection. If you have heard of MRSA, methicillin-resistant Staphylococcus aureus, that was a common hospital-acquired infection (though it’s worth noting that the methicillin-sensitive staphylococci kill lots of people too).

Well, you probably have guessed where this is going (boldface mine):

But in the case of my heart failure patient, it was not lack of hand washing that probably caused the [COVID-19] infection. So, I explored. Could his infection have been from the hospital staff, such as doctors, nurses, care attendants, or physical and respiratory therapists who frequented the room to provide care? Or, was the infection from surfaces improperly cleaned in the rooms or the CT scanners, or was the infection from family members, like his wife of 40 years who had visited him often?

Initially, I thought it must have come from his family. As the epidemic rages in our community, nearly 1 in 10 people with minor or no symptoms has tested positive for the coronavirus. His family members sat a few feet away from his bed for hours every day. Had they unknowingly passed the virus on to him? Given my patient’s fragile heart and lung condition, he rapidly succumbed to the infection.

If covid-19 from family members was causing infection in our hospitalized patients, then the solution would be simple. Close all visitations or require visitors to test negative at regular weekly or biweekly intervals as a pass to enter the hospital. I spoke to the family and they all had indeed tested negative

If covid-19 from staff was causing infection, then the solution would be different: rapid, frequent and regular testing.

A children’s cancer hospital has done that, since the facility has no margin of error. Twice a week, nearly every clinical caretaker is tested with a nasal swab. The hospital’s results over the past seven months have been both expected and remarkable. The number of total covid-19 cases among their employees rises and falls as the epidemic comes in waves in the community, as we would expect. But it was remarkable to learn that regular asymptomatic testing picked up 50 percent of all of the cases among the health workers…

Regrettably, covid-19 among hospital staff is common even after all the precautions with masks, shields and other personal protective equipment. Studies show that front-line health-care workers in the United States have a covid-positive rate that is four times greater than the general population.

So, why don’t many hospitals test workers routinely? It’s more complicated than you might think. Again, returning to our halcyon days of yore, more than one infectious disease specialist raised a serious problem: what if some of your staff test positive for MRSA? While there are therapies to treat MRSA, do you bench part of your neurosurgery team because they test positive for an infection that could persist for weeks? And should you do this if they test positive for other organisms, since many of these organisms live as harmless commensals (i.e., the doctor with MRSA isn’t ill)?

There’s a similar problem at work here:

One afternoon, before my heart patient had died, I had a conversation with a hospital executive who told me: “I can’t afford to test my entire staff. No, it’s not the expense of the test, but the staff I would lose through furlough if the test came back positive.” The executive was talking about not only those who tested positive being in isolation and furloughed but also all their close contacts being in quarantine. While I was sympathetic, it makes no sense to stick our head in the sand. Without testing, we are flying blind.

I agree with the part of the solution:

The Centers for Medicare and Medicaid Services needs to act now. The same regulations which nursing homes adhere to can be applied to hospitals: Until all health-care workers across the country are vaccinated, testing of hospital staff needs to be mandatory based on the community spread of infection in their county, and Medicare payments should be withheld if hospitals do not comply.

I would add that this is where genomic sequencing, when possible, really could help, at least in ruling out cases of hospital transmission (and not mobilizing the U.S.’s considerable resources is one more thing that needs to be fixed and investigated). A fair number of teaching hospitals would have access to this technology.

Routine testing, of course, will mean that some presymptomatic (or asymptomatic) workers will be sent home, but this is a problem we need to understand. Importantly, sick medical workers also put the larger community at risk too, so we would reap benefits there as well. It goes without saying (or should anyway) that medical workers should know, for their own benefit, if they have COVID-19.

This entry was posted in COVID-19. Bookmark the permalink.