Poverty, Comorbidity, and Ethnicity: COVID-19 Outcomes in a Safety Net Health System.

Objective: To determine if race-ethnicity is correlated with case-fatality rates among low-income patients hospitalized for COVID-19. Research Design: Observational cohort study using electronic health record data. Patients: All patients assessed for COVID-19 from March 2020 to January 2021 at one safety net health system. Measures: Patient demographic and clinical characteristics, and hospital care processes and outcomes. Results: Among 25,253 patients assessed for COVID-19, 6,357 (25.2%) were COVID-19 positive: 1,480 (23.3%) hospitalized; 334 (22.6%) required intensive care; and 106 (7.3%) died. More Hispanic patients tested positive (51.8%) than non-Hispanic Black (31.4%) and White patients (16.7%, P<.001]. Hospitalized Hispanic patients were younger, more often uninsured, and less likely to have comorbid conditions. Non-Hispanic Black patients had significantly more diabetes, hypertension, obesity, chronic kidney disease, and asthma (P<.05). Non-Hispanic White patients were older and had more cigarette smoking history, COPD, and cancer. Non-Hispanic White patients were more likely to receive intensive care (29.6% vs 21.1% vs 20.8%, P=.007) and more likely to die (12% vs 7.3% vs 3.5%, P<.001) compared with non-Hispanic Black and Hispanic patients, respectively. Length of stay was similar for all groups. In logistic regression models, Medicaid insurance status independently correlated with hospitalization (OR 3.67, P<.001) while only age (OR 1.076, P<.001) and cerebrovascular disease independently correlated with in-hospital mortality (OR 2.887, P=.002). Conclusions: Observed COVID-19 in-hospital mortality rate was lower than most published rates. Age, but not race-ethnicity, was independently correlated with in-hospital mortality. Safety net health systems are foundational in the care of vulnerable patients suffering from COVID-19, including patients from under-represented and low-income groups.

Methicillin-resistant Staphylococcus aureus (MRSA) nasal real-time PCR: a predictive tool for contamination of the hospital environment.

OBJECTIVE We sought to determine whether the bacterial burden in the nares, as determined by the cycle threshold (CT) value from real-time MRSA PCR, is predictive of environmental contamination with MRSA. METHODS Patients identified as MRSA nasal carriers per hospital protocol were enrolled within 72 hours of room admission. Patients were excluded if (1) nasal mupirocin or chlorhexidine body wash was used within the past month or (2) an active MRSA infection was suspected. Four environmental sites, 6 body sites and a wound, if present, were cultured with premoistened swabs. All nasal swabs were submitted for both a quantitative culture and real-time PCR (Roche Lightcycler, Indianapolis, IN). RESULTS At study enrollment, 82 patients had a positive MRSA-PCR. A negative correlation of moderate strength was observed between the CT value and the number of MRSA colonies in the nares (r=-0.61; P<0.01). Current antibiotic use was associated with lower levels of MRSA nasal colonization (CT value, 30.2 vs 27.7; P<0.01). Patients with concomitant environmental contamination had a higher median log MRSA nares count (3.9 vs 2.5, P=0.01) and lower CT values (28.0 vs 30.2; P<0.01). However, a ROC curve was unable to identify a threshold MRSA nares count that reliably excluded environmental contamination. CONCLUSIONS Patients with a higher burden of MRSA in their nares, based on the CT value, were more likely to contaminate their environment with MRSA. However, contamination of the environment cannot be predicted solely by the degree of MRSA nasal colonization.

Hospitals learn their collective power: an isolation gown success story.

BACKGROUND: We describe an investigation and improvement project designed to provide comfortable, affordable, fluid-resistant isolation gowns in response to inadequate compliance with gown use. METHODS: Infection control and purchasing departments determined number of gowns used, cost/gown, and contract information for our laundry service. We investigated disposable gown options. During a conference call for a multihospital project, we learned that 4 local hospitals all used the same laundry service and that all were dissatisfied with the quality of the reusable gowns. The 4 hospitals resolved to meet with the hospital laundry service to negotiate as a group. In preparation, we both investigated laundry services in neighboring cities and reviewed Centers for Disease Control and Prevention and Occupational Safety and Health Administration isolation gown requirements. RESULTS: Confronted with its major customers acting collectively, the laundry service agreed to identify gowns by age, bring gowns to Occupational Safety and Health Administration compliance, mark grids so gowns could be removed after 75 washes, add 6,000 new gowns, and remove 6,000 old gowns. The cost increase was 3.75¢/gown. After the changeover was complete, reports of fluid leaking through gowns stopped. We saved $187,000 by keeping reusable gowns. CONCLUSION: When we tried to provide comfortable, affordable, fluid-resistant isolation gowns, we encountered 2 barriers: our city had only 1 hospital laundry service, and disposable gowns were costly. We solved the problem through unusual collaboration: internal (Infection Control and Purchasing) and external (with otherwise competing hospitals). Collaboration and knowledge sharing led to accountability: the hospital to its staff and budget and the laundry service to the hospitals.

Construction: a model program for infection control compliance.

ISSUE: In the 21st century, one of the most challenging tasks for the infection control practitioner (ICP) is establishing collegiality and trust with contractors, architects, maintenance and engineering personnel. We describe how an urban teaching hospital's infection control program cooperated with contractors during a large demolition, construction, and renovation project in order to protect its large population of immunosuppressed patients. PROJECT: Most contractors are not accustomed to taking special precautions during demolition. Because of a previous Aspergillus outbreak in our heart transplant population, we already had an established infection control (IC) training program for contractors. We expanded and codified it in response to a major hospital renovation. The IC, in-house Design and Construction, and outside contractors meet before the initiation of all major renovation projects to anticipate IC concerns and proactively plan for infection control interventions. Now, all contractors and maintenance staff are required to receive IC training at the time of their employment. A hospital identification badge with attached sticker that indicates the IC training date is required. Infection Control Risk Assessments (ICRA) are initiated by project managers and completed jointly with IC. The ICPs make rounds on all projects at least weekly and large projects are visited daily. We established a team comprised of ICP, project manager, construction manager, and area nurse manager to monitor and make recommendations for improvement continually during the project. Staff are educated about construction so they can help monitor airflow and cleanliness. RESULTS: Our contractors are more compliant with our IC specifications since they now understand why we insist on them. Through the years of major construction, the workers have jumped on the bandwagon. It is not unusual for construction or maintenance staff to contact IC for advice. There were four years of extensive construction without any hospital acquired Aspergillus infections. In the 5th year, after a neighboring institution started demolition and new construction, we identified two possible nosocomial infections and took immediate steps to make more corrections. There have been no further infections. LESSONS LEARNED: The IC compliance is based on trust, education, and on-going monitoring. Proactive education and collaboration lead to long-term relationships, trust and patient safety. OBJECTIVE: This article describes how a large teaching hospital's infection prevention program achieved compliance from contractors during a large renovation.

Surveillance of infectious disease occurrences in the community: an analysis of symptom presentation in the emergency department.

OBJECTIVES: To determine the effectiveness of a simulated emergency department (ED)-based surveillance system to detect infectious disease (ID) occurrences in the community. METHODS: Medical records of patients presenting to an urban ED between January 1, 1999, and December 31, 2000, were retrospectively reviewed for ICD-9 codes related to ID symptomatology. ICD-9 codes, categorized into viral, gastrointestinal, skin, fever, central nervous system (CNS), or pulmonary symptom clusters, were correlated with reportable infectious diseases identified by the local health department (HD). These reportable infectious diseases are designated class A diseases (CADs) by the Ohio Department of Health. Cross-correlation functions (CCFs) tested the temporal relationship between ED symptom presentation and HD identification of CADs. The 95% confidence interval for lack of trend correlation was 0.0 +/- 0.074; thus CCFs > 0.074 were considered significant for trend correlation. Further cross-correlation analysis was performed after chronic and non-community-acquirable infectious diseases were removed from the HD database as a model for bioterrorism surveillance. RESULTS: Fifteen thousand five hundred sixty-nine ED patients and 6,489 HD patients were identified. Six thousand two hundred eight occurrences of true CADs were identified. Only 87 (1.33%) HD cases were processed on weekends. During the study period, increased ED symptom presentation preceded increased HD identification of respective CADs by 24 hours for all symptom clusters combined (CCF = 0.112), gastrointestinal symptoms (CCF = 0.084), pulmonary symptoms (CCF = 0.110), and CNS symptoms (CCF = 0.125). The bioterrorism surveillance model revealed increased ED symptom presentation continued to precede increased HD identification of the respective CADs by 24 hours for all symptom clusters combined (CCF = 0.080), pulmonary symptoms (CCF = 0.100), and CNS symptoms (CCF = 0.120). CONCLUSIONS: Surveillance of ED symptom presentation has the potential to identify clinically important ID occurrences in the community 24 hours prior to HD identification. Lack of weekend HD data collection suggests that the ED is a more appropriate setting for real-time ID surveillance.

Sexual transmission of typhoid fever: a multistate outbreak among men who have sex with men.

In August 2000, the Ohio Department of Health reported a cluster of men with typhoid fever who denied having traveled abroad. To determine the cause and the extent of the outbreak, an epidemiological investigation was initiated in which 7 persons in Ohio, Kentucky, and Indiana with culture-confirmed Salmonella enterica serotype Typhi infection and 2 persons with probable typhoid fever were evaluated; all were men, and all but one reported having had sex with 1 asymptomatic male S. Typhi carrier. We document sexual transmission of typhoid fever, which may be acquired by means of oral and anal sex, as well as via food and drink.