Integration of hospital with congregate care homes in response to the COVID-19 pandemic.

Background: The coronavirus disease 2019 (COVID-19) pandemic has highlighted the need to improve the safety of the environments where we care for older adults in Canada. After providing assistance during the first wave, many Ontario hospitals formally partnered with local congregate care homes in a "hub and spoke" model during second pandemic wave onward. The objective of this article is to describe the implementation and longitudinal outcomes of residents in one hub and spoke model composed of a hospital partnered with 18 congregate care homes including four long-term care and 14 retirement or other congregate care homes. Intervention: Homes were provided continuous seven-day per week access to hospital support, including infection prevention and control (IPAC), testing, vaccine delivery and clinical support as needed. Any COVID-19 exposure or transmission triggered a same-day meeting to implement initial control measures. A minimum of weekly on-site visits occurred for long-term care homes and biweekly for other congregate care homes, with up to daily on-site presence during outbreaks. Outcomes: Case detection among residents increased following implementation in context of increased testing, then decreased post-immunization until the Omicron wave when it peaked. After adjusting for the correlation within homes, COVID-related mortality decreased following implementation (OR=0.51, 95% CI, 0.30-0.88; p=0.01). In secondary analysis, homes without pre-existing IPAC programs had higher baseline COVID-related mortality rate (OR=19.19, 95% CI, 4.66-79.02; p<0.001) and saw a larger overall decrease during implementation (3.76% to 0.37%-0.98%) as compared to homes with pre-existing IPAC programs (0.21% to 0.57%-0.90%). Conclusion: The outcomes for older adults residing in congregate care homes improved steadily throughout the COVID-19 pandemic. While this finding is multifactorial, integration with a local hospital partner supported key interventions known to protect residents.

Outbreak of Carbapenemase-Producing Enterobacteriaceae in a Regional Burn Center.

Antimicrobial resistance is an increasing problem in hospitals worldwide; however, the prevalence of carbapenemase-producing Enterobacteriaceae (CPE) in our region is low. Burn patients are vulnerable to infection because of the loss of the protective skin barrier, thus burn centers prioritize infection prevention and control (IP&C). This report describes a CPE outbreak in a regional burn center. In a period of 2.5 months, four nosocomial cases of CPE were identified, three containing the Klebsiella pneumoniae carbapenemase (KPC) gene and one Verona integrin-encoded metallo-ß-lactamase (VIM) gene. The first two cases were identified while there was no CPE patient source on the unit. CPE KPC gene was then isolated in sink drains of three rooms. In addition to rigorous IP&C practices already in place, we implemented additional outbreak measures including restricting admissions to patients with complex burns or burns ≥10% TBSA, admitting patients to other in-patient units, and not permitting elective admissions. We began cohorting patients using nursing team separation for CPE-positive and -negative patients and geographical separation on the unit. Despite aggressive IP&C measures already in place, hospital-acquired CPE colonization/infection occurred. Given that CPE contaminated sinks of the same enzyme were identified, we believe hospital sink drains may the source. This highlights the importance of sink design and engineering solutions to prevent the formation of biofilm and reduce splashing. CPE infections are associated with poor outcomes in patients and significant health system costs due to a longer length of stay and additional institutional resources.

Risk of SARS-CoV-2 transmission from universally masked healthcare workers to patients or residents: A prospective cohort study.

In a multifacility prospective cohort study, we identified 116 acute care, 26 long-term care, and 67 rehabilitation patients who received direct care from a universally masked healthcare worker while communicable with COVID-19. Among 133(64%) patients with at least 14-day follow-up, 3 (2.3%, 95% CI, 0.77-6.4) became positive for SARS-CoV-2. Universal masking, embedded with other infection control practices, is associated with low risk of transmission of SARS-CoV-2 from healthcare workers to patients and residents.

Introduction of Group Electronic Monitoring of Hand Hygiene on Inpatient Units: A Multicenter Cluster Randomized Quality Improvement Study.

BACKGROUND: The current approach to measuring hand hygiene (HH) relies on human auditors who capture <1% of HH opportunities and rapidly become recognized by staff, resulting in inflation in performance. Group electronic monitoring is a validated method of measuring HH adherence, but data demonstrating the clinical impact of this technology are lacking. METHODS: A stepped-wedge cluster randomized quality improvement study was performed on 26 inpatient medical and surgical units across 5 acute care hospitals in Ontario, Canada. The intervention involved daily HH reporting as measured by group electronic monitoring to guide unit-led improvement strategies. The primary outcome was monthly HH adherence (percentage) between baseline and intervention. Secondary outcomes included transmission of antibiotic-resistant organisms such as methicillin-resistant Staphylococcus aureus (MRSA) and other healthcare-associated infections. RESULTS: After adjusting for the correlation within inpatient units and hospitals, there was a significant overall improvement in HH adherence associated with the intervention (incidence rate ratio [IRR], 1.73 [95% confidence interval {CI}, 1.47-1.99]; P < .0001). Monthly HH adherence relative to the intervention increased from 29% (1 395 450/4 544 144) to 37% (598 035/1 536 643) within 1 month, followed by consecutive incremental increases up to 53% (804 108/1 515 537) by 10 months (P < .0001). There was a trend toward reduced healthcare-associated transmission of MRSA (IRR, 0.74 [95% CI, .53-1.04]; P = .08). CONCLUSIONS: The introduction of a system for group electronic monitoring led to rapid, significant improvements in HH performance within a 2-year period. This method offers significant advantages over direct observation for measurement and improvement of HH.

Diagnosis and Management of First Case of COVID-19 in Canada: Lessons Applied From SARS-CoV-1.

We report diagnosis and management of the first laboratory-confirmed case of coronavirus disease 2019 (COVID-19) hospitalized in Toronto, Canada. No healthcare-associated transmission occurred. In the face of a potential pandemic of COVID-19, we suggest sustainable and scalable control measures developed based on lessons learned from severe acute respiratory syndrome.

Prevention of respiratory outbreaks in the rehabilitation setting.

BACKGROUND: Respiratory viral (RV) outbreaks in rehabilitation facilities can jeopardise patient safety, interfere with patient rehabilitation goals and cause unit closures that impede patient flow in referring facilities. PROBLEM: Despite education about infection prevention practices, frequent RV outbreaks were declared each year at our rehabilitation facility. METHODS: Before and after study design. The primary outcome was the number of bed closure days due to outbreak per overall bed days. Process measures included delays in initiation of transmission-based precautions, RV testing and reporting of staff to occupational health and safety (OHS). Balancing measures included the number of isolation days and staff missed work hours. INTERVENTIONS: Based on comprehensive analysis of prior outbreaks, the following changes were implemented: (1) clear criteria for initiation of transmission-based precautions, (2) communication to visitors to avoid visitation if infectious symptoms were present, (3) exemption of staff absences if documented due to infectious illness, (4) development of an electronic programme providing guidance to staff about whether they should be excluded from work due to infectious illness. RESULTS: The number of bed closure days due to outbreak per overall bed days dropped from 2.8% to 0.5% during the intervention season and sustained at 0.6% during the postintervention season (p<0.001). There were fewer delays in initiation of droplet and contact precautions (28.8% to 15.5%, p=0.005) and collection of RV testing (42.9% to 20.3%, p<0.001), better reporting to OHS (9 vs 28.8 reports per 100 employees; p<0.001) and fewer isolation days (7.8% vs 7.3%; p=0.02) without a significant increase in missed work hours per 100 hours worked (4.0 vs 3.9; p=0.12). CONCLUSION: This Quality Improvement study highlights the process changes that can prevent respiratory outbreaks in the rehabilitation setting.

Nosocomial transmission of New Delhi metallo-ß-lactamase-1-producing Klebsiella pneumoniae in Toronto, Canada.

DESIGN: An analysis of a cluster of New Delhi metallo-ß-lactamase-1-producing Klebsiella pneumoniae (NDM1-Kp) and a retrospective case-cohort analysis of risk factors for acquisition in contacts of NDM1-Kp-positive patients. SETTING: A 1,100-bed Canadian academic tertiary care center. PATIENTS: Two index patients positive for NDM1-Kp as well as 45 contacts (roommates, ward mates, or environmental contacts) were investigated. METHODS: Retrospective chart reviews of all patients colonized or infected with NDM1-Kp as well as contacts of these patients were performed in order to describe the epidemiology and impact of infection prevention and control measures. A case-cohort analysis was conducted investigating 45 contacts of NDM1-Kp-positive patients to determine risk factors for acquisition of NDM1-Kp. Rectal swabs were screened for NDM1-Kp using chromogenic agar. Presence of bla(NDM-1) was confirmed by multiplex polymerase chain reaction. Clonality was assessed with pulsed-field gel electrophoresis (PFGE) using restriction enzyme XbaI. RESULTS: Two index cases carrying NDM1-Kp with different PFGE patterns were identified. Nosocomial transmission to 7 patients (4 roommates, 2 ward mates, and 1 environmental contact) was subsequently identified. Risk factors for acquisition of NDM1-Kp were a history of prior receipt of certain antibiotics (fluoroquinolones [odds ratio (OR), 16.8 (95% confidence interval [CI], 1.30-58.8); [Formula: see text]], trimethoprim-sulfamethoxazole [OR, 11.3 (95% CI, 1.84-70.0); [Formula: see text]], and carbapenems [OR, 16.8 (95% CI, 1.79-157.3); [Formula: see text]]) and duration of exposure to NDM1-Kp-positive roommates (26.5 vs 6.7 days; [Formula: see text]). CONCLUSION: Two distinct clones of NDM1-Kp were transmitted to 7 inpatient contacts over several months. Implementation of contact precautions, screening of contacts for NDM1-Kp carriage, and attention to environmental disinfection contributed to the interruption of subsequent spread of the organism. The appropriate duration and frequency of screening contacts of NDM1-Kp-positive patients require further study.