The Disproportionate Impact of Coronavirus Disease 2019 (COVID-19) Pandemic on Healthcare-Associated Infections in Community Hospitals: Need for Expanding the Infectious Disease Workforce.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic had a considerable impact on US healthcare systems, straining hospital resources, staff, and operations. However, a comprehensive assessment of the impact on healthcare-associated infections (HAIs) across different hospitals with varying level of infectious disease (ID) physician expertise, resources, and infrastructure is lacking. METHODS: This retrospective longitudinal multicenter cohort study included central-line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), Clostridioides difficile infections (CDIs), and ventilator-associated events (VAEs) from 53 hospitals (academic and community) in Southeastern United States from 1 January 2018 to 31 March 2021. Segmented negative binomial regression generalized estimating equations models estimated changes in monthly incidence rates in the baseline (01/2018-02/2020) compared to the pandemic period (03/2020-03/2021, further divided into three pandemic phases). RESULTS: CLABSIs and VAEs increased by 24% and 34%, respectively, during the pandemic period. VAEs increased in all phases of the pandemic, while CLABSIs increased in later phases of the pandemic. CDI trend increased by 4.2% per month in the pandemic period. On stratifying the analysis by hospital characteristics, the impact of the pandemic on healthcare-associated infections was more significant in smaller sized and community hospitals. CAUTIs did not change significantly during the pandemic across all hospital types. CONCLUSIONS: CLABSIs, VAEs, and CDIs increased significantly during the pandemic, especially in smaller community hospitals, most of which lack ID physician expertise. Future efforts should focus on better understanding challenges faced by community hospitals, strengthening the infection prevention infrastructure, and expanding the ID workforce, particularly to community hospitals.

Sensitivity and specificity of the Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised to detect dysarthria in individuals with amyotrophic lateral sclerosis.

INTRODUCTION/AIMS: Given the widespread use of the Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised (ALSFRS-R) to measure disease progression in ALS and recent reports demonstrating its poor sensitivity, we aimed to determine the sensitivity and specificity of the ALSFRS-R bulbar subscale and speech item to detect validated clinical ratings of dysarthria in individuals with ALS. METHODS: Paired ALSFRS-R and validated Speech Intelligibility Test (SIT) data from individuals with ALS were analyzed. Trained raters completed duplicate, independent, and blinded ratings of audio recordings to obtain speech intelligibility (%) and speaking rate (words per minute, WPM). Binary dysarthria profiles were derived (dysarthria ≤96% intelligible and/or <150 WPM). Data were obtained using the Kruskal-Wallis test, receiver-operating characteristic (ROC) curve, area under the curve (AUC), sensitivity and specificity percentages, and positive/negative predictive values (PPV/NPV). RESULTS: A total of 250 paired SIT and ALSFRS-R data points were analyzed. Dysarthria was confirmed in 72.4% (n = 181). Dysarthric speakers demonstrated lower ALSFRS-R bulbar subscale (8.9 vs. 11.2) and speech item (2.7 vs. 3.7) scores (P < .0001). The ALSFRS-R bulbar subscale score had an AUC of 0.81 (95% confidence interval [CI] 0.75 to 0.86). A subscale score of ≤11 yielded a sensitivity of 86%, specificity of 57%, PPV of 84%, and NPV of 60% to correctly identify dysarthria status. The ALSFRS-R speech item score demonstrated an AUC of 0.81 to detect dysarthria (95% CI 0.76 to 0.85), with sensitivity of 79%, specificity of 75%, PPV of 89%, and NPV of 58% for a speech item cutpoint of ≤3. DISCUSSION: The ALSFRS-R bulbar and speech item subscale scores may be useful, inexpensive, and quick tools for monitoring dysarthria status in ALS.

Functional Lingual Pressure Thresholds for Swallowing Safety and Efficiency Impairments in Amyotrophic Lateral Sclerosis.

Although reductions in lingual strength are reported in individuals with amyotrophic lateral sclerosis (ALS) that are associated with dysphagia; determination of a functional lingual pressure threshold (FLPT) has not yet been established. The present study therefore sought to identify an FLPT for impaired swallowing safety and efficiency in individuals with ALS.Thirty individuals with ALS completed a standardized videofluoroscopic swallowing examination and maximum anterior isometric lingual pressure testing using the Iowa Oral Performance Instrument. Duplicate, blinded ratings of the validated Penetration-Aspiration Scale (PAS) scores and Analysis of Swallowing Physiology: Events, Kinematics and Timing (ASPEKT) were performed. Binary classifications of safety (unsafe: PAS: ≥ 3) and efficiency (inefficient: ≥ 3% worst total pharyngeal residue) were derived. Descriptives and receiver operating characteristic curve analyses (AUC, sensitivity, specificity) were performed.Unsafe and inefficient swallowing were instrumentally confirmed in 57% and 70% of ALS patients, respectively. Across the entire cohort, the mean maximum lingual physiologic capacity was 32.1 kilopascals ('kPa'; SD: 18.1 kPa). The identified FLPT for radiographically confirmed unsafe swallowing was 43 kPa (sensitivity: 94%, specificity: 62%, AUC 0.82, p = 0.003). FLPT for inefficient swallowing was 46 kPa (sensitivity: 86%, specificity: 56%, AUC = 0.77, p = 0.02).These data provide preliminary FLPT data in a small cohort of individuals with ALS that need to be further investigated in larger cohorts to inform clinical screening practices.

Swallowing Safety and Efficiency Impairment Profiles in Individuals with Amyotrophic Lateral Sclerosis.

Dysphagia is common in individuals with amyotrophic lateral sclerosis (ALS) and associated with reductions in quality of life and health-related outcomes. Despite the high prevalence of dysphagia in ALS, functional impairment profiles of swallowing safety and efficiency have not been comprehensively examined. We therefore aimed to determine the relative prevalence of unsafe and inefficient swallowing in a large cohort of individuals with ALS. We further sought to examine the impact of global and bulbar disease progression (Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised "ALSFRS-R" total and bulbar scores, respectively), disease duration, and onset type on swallowing impairment profiles. One hundred individuals with ALS completed a standardized videofluoroscopic swallowing examination Two independent and blinded raters performed validated ratings of safety (Penetration-Aspiration Scale, PAS) and efficiency (Analysis of Swallowing Physiology: Events, Kinematics, and Timing, ASPEKT % residue). Binary classifications of safety (unsafe: PAS ≥ 3), efficiency (inefficient: total residue ≥ 3% of C2-42) and global swallowing status were derived. The ALSFRS-R was completed to derive ALSFRS-R total and bulbar subscale scores. Demographic data (disease duration and onset type) for each participant was also recorded.  Descriptives, 2 × 2 contingency tables with Fishers exact test, and independent samples t-tests were performed (α = 0.05). Prevalence of unsafe and inefficient swallowing was 48% and 73%, respectively. Global swallowing profiles were, in rank order: unsafe and inefficient (39%), inefficient but safe (34%), safe and efficient (18%), and unsafe but efficient (9%). There were no differences in global disease progression or disease duration across swallowing impairment profiles. ALSFRS-R bulbar subscale scores were significantly lower in unsafe versus safe swallowers, p < 0.05. Spinal onset patients had a greater proportion of safe swallowers as compared to bulbar onset patients (p = 0.000, Fisher's exact test). Both spinal and bulbar onset patients demonstrated a higher prevalence of inefficient swallowers as compared to efficient swallowers (p = 0.04, Fisher's exact test). Dysphagia was prevalent in this group of individuals with ALS. Approximately half demonstrated safety impairments and two-thirds had impairments in swallowing efficiency. Inefficient swallowing was approximately four times more likely to be the initial functional impairment in patients with one pathophysiologic functional impairment. A longitudinal study is needed to examine the temporal evolution of dysphagia in ALS.

Discriminant Ability of the 3-Ounce Water Swallow Test to Detect Aspiration in Acute Postoperative Cardiac Surgical Patients.

Dysphagia is a common complication of cardiac surgery (CS) contributing to morbidity and mortality. Although early dysphagia detection is important, no current screening guidelines or validated tools exist in the cardiac intensive care setting. We therefore aimed to examine the discriminant ability of the 3-ounce water swallow test (3 oz. WST) to detect aspiration in acute postoperative CS patients. 196 postoperative CS patients were enrolled in this prospective single-center study. Participants completed the 3 oz. WST and a standardized Flexible Endoscopic Evaluation of Swallowing. Independent duplicate ratings of the penetration aspiration scale (PAS) were performed in a blinded fashion (100% agreement criteria). Receiver operating characteristic curve and area under the curve (AUC) analyses were performed with sensitivity, specificity, positive, and negative predictive values (PPV, NPV) derived. Fifty-four CS patients (28%) were confirmed aspirators (PAS ≥ 6), of whom 48% (n = 26) were silent aspirators (PAS = 8). Both the sensitivity and specificity of the 3 oz. WST to identify instrumentally confirmed aspiration was 63% (AUC: 0.63, 95% CI: 0.54, 0.72), and PPV was 39% and NPV 82%. The 3 oz. WST demonstrated fair discriminant ability to detect aspiration in acute postoperative CS patients. The high rate of silent aspiration may explain, in part, these findings given that the screening fail criteria include an overt cough response. In isolation, the 3 oz. WST does not represent a sensitive screen of aspiration in postoperative CS patients with a need to identify alternative screening tools for this setting.

COVID-19 Surveillance: Not Everything That Counts Can be Counted, and not Everything That Can be Counted Countsa.

Infectious disease surveillance is one of the most valuable tools in monitoring the COVID-19 pandemic. Here we examine the components of an ideal surveillance system and assess the effectiveness of COVID-19 surveillance in North Carolina and around the world.

Preventable Patient Harm: a Multidisciplinary, Bundled Approach to Reducing Clostridium difficile Infections While Using a Glutamate Dehydrogenase/Toxin Immunochromatographic Assay/Nucleic Acid Amplification Test Diagnostic Algorithm.

Health care facility-onset Clostridium difficile infections (HO-CDI) are an important national problem, causing increased morbidity and mortality. HO-CDI is an important metric for the Center for Medicare and Medicaid Service's (CMS) performance measures. Hospitals that fall into the worst-performing quartile in preventing hospital-acquired infections, including HO-CDI, may lose millions of dollars in reimbursement. Under pressure to reduce CDI and without a clear optimal method for C. difficile detection, health care facilities are questioning how best to use highly sensitive nucleic acid amplification tests (NAATs) to aid in the diagnosis of CDI. Our institution has used a two-step glutamate dehydrogenase (GDH)/toxin immunochromatographic assay/NAAT algorithm since 2009. In 2016, our institution set an organizational goal to reduce our CDI rates by 10% by July 2017. We achieved a statistically significant reduction of 42.7% in our HO-CDI rate by forming a multidisciplinary group to implement and monitor eight key categories of infection prevention interventions over a period of 13 months. Notably, we achieved this reduction without modifying our laboratory algorithm. Significant reductions in CDI rates can be achieved without altering sensitive laboratory testing methods.

Reduction of Healthcare-Associated Infections by Exceeding High Compliance with Hand Hygiene Practices.

Improving hand hygiene from high to very high compliance has not been documented to decrease healthcare-associated infections. We conducted longitudinal analyses during 2013-2015 in an 853-bed hospital and observed a significantly increased hand hygiene compliance rate (p<0.001) and a significantly decreased healthcare-associated infection rate (p = 0.0066).

We can have it all: improved surveillance outcomes and decreased personnel costs associated with electronic reportable disease surveillance, North Carolina, 2010.

OBJECTIVES: We assessed the timeliness, accuracy, and cost of a new electronic disease surveillance system at the local health department level. We describe practices associated with lower cost and better surveillance timeliness and accuracy. METHODS: Interviews conducted May through August 2010 with local health department (LHD) staff at a simple random sample of 30 of 100 North Carolina counties provided information on surveillance practices and costs; we used surveillance system data to calculate timeliness and accuracy. We identified LHDs with best timeliness and accuracy and used these categories to compare surveillance practices and costs. RESULTS: Local health departments in the top tertiles for surveillance timeliness and accuracy had a lower cost per case reported than LHDs with lower timeliness and accuracy ($71 and $124 per case reported, respectively; P = .03). Best surveillance practices fell into 2 domains: efficient use of the electronic surveillance system and use of surveillance data for local evaluation and program management. CONCLUSIONS: Timely and accurate surveillance can be achieved in the setting of restricted funding experienced by many LHDs. Adopting best surveillance practices may improve both efficiency and public health outcomes.

Profiles of Dysarthria and Dysphagia in Individuals With Amyotrophic Lateral Sclerosis.

PURPOSE: While dysarthria and dysphagia are known bulbar manifestations of amyotrophic lateral sclerosis (ALS), the relative prevalence of speech and swallowing impairments and whether these bulbar symptoms emerge at the same time point or progress at similar rates is not yet clear. We, therefore, sought to determine the relative prevalence of speech and swallowing impairments in a cohort of individuals with ALS and to determine the impact of disease duration, severity, and onset type on bulbar impairments. METHOD: Eighty-eight individuals with a confirmed diagnosis of ALS completed the ALS Functional Rating Scale-Revised (ALSFRS-R), underwent videofluoroscopy (VF), and completed the Sentence Intelligibility Test (SIT) during a single visit. Demographic variables including disease duration and onset type were also obtained from participants. Duplicate, independent, and blinded ratings were completed using the Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) scale and SIT to index dysphagia (DIGEST ≥ 1) and dysarthria (< 96% intelligible and/or < 150 words per minute) status. Descriptive statistics, Pearson chi-squared tests, independent-samples t tests, and odds ratios were performed. RESULTS: Dysphagia and dysarthria were instrumentally confirmed in 68% and 78% of individuals with ALS, respectively. Dysarthria and dysphagia were associated (p = .01), and bulbar impairment profile distributions in rank order included (a) dysphagia - dysarthria (59%, n = 52), (b) no dysphagia - dysarthria (19%, n = 17), (c) no dysphagia - no dysarthria (13%, n = 11), and (d) dysphagia - no dysarthria (9%, n = 8). Participants with dysphagia or dysarthria demonstrated 4.2 higher odds of exhibiting a bulbar impairment in the other domain than participants with normal speech and swallowing (95% CI [1.5, 12.2]). There were no differences in ALSFRS-R total scores or disease duration across bulbar impairment profiles (p > .05). ALSFRS-R bulbar subscale scores were significantly lower in individuals with dysphagia versus no dysphagia (8.4 vs. 10.4, p < .0001) and dysarthria versus no dysarthria (8.5 vs. 10.9, p < .0001). Dysphagia and onset type (p = .003) and dysarthria and onset type were associated (p < .0001). CONCLUSIONS: Over half of the individuals with ALS in this study demonstrated both dysphagia and dysarthria. Of those with only one bulbar impairment, speech was twice as likely to be the first bulbar symptom to degrade. Future studies are needed to confirm these findings and determine the longitudinal progression of bulbar impairments in this patient population.

Maximum lingual pressure impacts both swallowing safety and efficiency in individuals with amyotrophic lateral sclerosis.

BACKGROUND: Although reduced lingual strength is a confirmed early manifestation of amyotrophic lateral sclerosis (ALS), its functional impact on swallowing remains unclear. We therefore sought to examine relationships between maximum anterior isometric lingual pressure (MAIP) with swallowing safety, swallowing efficiency, and swallowing timing metrics in a large cohort of individuals with ALS. METHODS: Ninety-seven participants with ALS completed a standardized videofluoroscopic swallowing examination (VF) and lingual pressure testing (Iowa Oral Performance Instrument). Duplicate and blinded ratings of the Penetration-Aspiration Scale (PAS) and Analysis of Swallowing Physiology: Events, Kinematics and Timing (ASPEKT) percent efficiency (%C2-C42 ) and timing (laryngeal vestibule closure (LVC) duration: amount of time (milliseconds, msec) between LVC onset and laryngeal vestibule opening; time-to-LVC: hyoid burst to onset of LVC (msec); and swallow reaction time: interval between bolus passing ramus of mandible and onset of LVC (msec)) were performed across bolus trials. Swallowing safety (safe PAS: 1, 2, 4; unsafe PAS: 3, 5, 6, 7, and 8) and efficiency (inefficient: ≥3% worst total residue) were derived. Statistical analyses including descriptives, binary logistic regressions, and Spearman's rho correlations were performed (α = 0.05). KEY RESULTS: Mean MAIP was 36.3 kPa (SD: 18.7). Mean MAIP was higher in those with safe swallowing as compared to those who penetrated (mean difference: 12 kPa) or aspirated (mean difference: 18 kPa). Individuals with efficient swallowing demonstrated higher MAIP than those with inefficient swallowing (mean difference: 11 kPa). Binary logistic regression analyses revealed increasing MAIP was significantly associated with a 1.06 (95% CI: 1.03-1.09) and 1.04 (95% CI: 1.01-1.06) greater odds of safe and efficient swallowing, respectively. No relationships were observed between MAIP and swallow reaction time across all bolus trials. Longer time-to-LVC (5 ml thin liquid: rs  = -0.35, p = 0.002; cup sip thin liquid: rs  = -0.26, p = 0.02; moderately thick liquid: rs  = -0.28, p = 0.01) and prolonged LVC duration (cup sip thin liquid, rs  = -0.34, p = 0.003) were associated with lower MAIP. CONCLUSIONS AND INFERENCES: Reduced lingual strength was confirmed in this group of 97 individuals with ALS that was associated with a diminished ability to effectively transport boluses and aide in laryngeal vestibule closure to prevent entry of material into the airway.

Assessing compliance of infection prevention mitigation strategies in hospital construction and renovation.

Hospital-associated fungal infections from construction and renovation activities can be mitigated using an infection control risk assessment (ICRA) and implementation of infection prevention measures. The effectiveness of these measures depends on proper installation and maintenance. Consistent infection prevention construction rounding with feedback is key to ongoing compliance.

Dysphagia after cardiac surgery: Prevalence, risk factors, and associated outcomes.

OBJECTIVES: The study objectives were to determine the prevalence of swallowing impairment in adults after cardiac surgery and examine associated risk factors and health-related outcomes. METHODS: A prospective single-center study was conducted in postoperative adult cardiac surgery patients with no history of dysphagia. A standardized fiberoptic endoscopic evaluation of swallowing was performed within 72 hours of extubation. Blinded raters completed validated outcomes of swallowing safety and efficiency. Demographic, surgical, and postoperative health-related outcomes were collected. Univariate and multivariable regression analyses were performed with odds ratios (OR) and 95% confidence intervals (CIs). RESULTS: In 182 patients examined, imaging confirmed inefficient swallowing (residue) in 52% of patients and unsafe swallowing in 94% (65% penetrators, 29% aspirators). Silent aspiration was observed in 53% of aspirators, and 32% did not clear aspirate material. Independent risk factors for aspiration included New York Heart Association III and IV (OR, 2.9; CI, 1.2-7.0); reoperation (OR, 2.0; CI, 0.7-5.5); transesophageal echocardiogram images greater than 110 (OR, 2.6; CI, 1.1-6.3); intubation greater than 27 hours (OR, 2.1; CI, 0.8-5.3); and endotracheal tube size 8.0 or greater (OR, 3.1; CI, 1.1-8.6). Patients with 3 or 4 identified risk factors had a 16.4 (CI, 3.2-148.4) and 22.4 (CI, 3.7-244.7) increased odds of aspiration, respectively. Compared with nonaspirators, aspirators waited an additional 85 hours to resume oral intake, incurred $49,372 increased costs, and experienced a 43% longer hospital stay (P < .05). Aspiration was associated with pneumonia (OR, 2.6; CI, 1.1-6.5), reintubation (OR, 5.7; CI, 2.1-14.0), and death (OR, 2.8; CI, 1.2-9.0). CONCLUSIONS: Tracheal aspiration was prevalent, covert, and associated with increased morbidity and mortality.

The impact of a comprehensive coronavirus disease 2019 (COVID-19) infection prevention bundle on non-COVID-19 hospital-acquired respiratory viral infection (HA-RVI) rates.

After implementing a coronavirus disease 2019 (COVID-19) infection prevention bundle, the incidence rate ratio (IRR) of non-severe acute respiratory coronavirus virus 2 (non-SARS-CoV-2) hospital-acquired respiratory viral infection (HA-RVI) was significantly lower than the IRR from the pre-COVID-19 period (IRR, 0.322; 95% CI, 0.266-0.393; P < .01). However, HA-RVIs incidence rates mirrored community RVI trends, suggesting that hospital interventions alone did not significantly affect HA-RVI incidence.

A comparison of methods for microbiologic environmental sampling.

We compared the effectiveness of 4 sampling methods to recover Staphylococcus aureus, Klebsiella pneumoniae and Clostridioides difficile from contaminated environmental surfaces: cotton swabs, RODAC culture plates, sponge sticks with manual agitation, and sponge sticks with a stomacher. Organism type was the most important factor in bacterial recovery.

Methodologic challenges and lessons learned through conducting a hospital-based Salmonella Javiana case-control study.

OBJECTIVE: Determine the food(s) most likely contaminated by Salmonella Javiana associated with a salmonellosis outbreak involving 2 hospitals in North Carolina that were within 50 miles of each other in November 2021. METHODS: A 2:1 matched case-control study was conducted. Food histories were obtained from hospital food orders and potential confounder covariates were collected from patient medical records. Attack rates and conditional logistic regression odds ratios (OR) were estimated at the 80% confidence interval (CI) for each food exposure and salmonellosis. RESULTS: There were 21 cases and 42 controls included. Fruit cups had the strongest association with salmonellosis (matched and adjusted OR = 7.9 80% CI: 2.7, 23.6). Hospital-specific ORs varied for several food items, but attack rates analyses provided additional evidence that fruit cups were a likely common source. CONCLUSION: Our analyses implicated fruit cups in an outbreak of salmonellosis in 2 hospitals. Other methodologic challenges included selection of controls among sick patients, heterogeneity of food exposures, reliance on food orders rather than foods consumed, and retention of food history records. Understanding and anticipating these challenges through changes to policies and operational procedures is critical for conducting efficient and effective case-control studies in the hospital setting.

Standing-up COVID-19 monoclonal antibody infusion centers: Infection prevention and control.

This paper describes the creation of outpatient monoclonal antibody (mAb) infusion centers for COVID-19 patients in a large academic medical center. It shows how the early and consistent partnership between infection prevention and the clinical and operational teams to establish and implement policies and procedures led to efficient and safe workflows.

A helping hand: The impact of a central line insertion support team.

As part of a central line-associated bloodstream infections prevention initiative, our academic medical center formed a dedicated nursing team to assist with central line insertions and provide support with caring for difficult lines and dressings. During the program's first 3 years, the proportion of insertion-related central line-associated bloodstream infections occurring in areas within the team's scope declined overall by 47%.

A prospective examination of swallow and cough dysfunction after lung transplantation.

OBJECTIVES: Swallow and cough dysfunction are possible surgical complications of lung transplantation (LT). We examined voluntary cough strength, sensorimotor reflexive cough integrity, and swallow-related respiratory rate (RR) across swallowing safety and aspiration response groups in recovering LT recipients. METHODS: Forty-five LT recipients underwent flexible endoscopic evaluation of swallowing indexed by the validated Penetration Aspiration Scale. RR before and after a 3-ounce water drinking task was measured. Voluntary and reflexive cough screening were performed to index motor and sensory outcomes. T-tests, one-way ANOVAs, and chi-square (odds ratios) were used. RESULTS: 60% of patients exhibited laryngeal penetration (n = 27) and 40% demonstrated tracheal aspiration (n = 18); 72% (n = 13) demonstrated silent aspiration. Baseline RR was higher in aspirators versus non-aspirators (26.5 vs. 22.6, p = 0.04) and in silent aspirators compared to non-silent aspirators (27.9 vs. 20.7, p = 0.01). RR change post-swallowing did not differ between aspiration response groups; however, it was significantly higher in aspirators compared to non-aspirators (3 vs. -2, p = 0.02). Compared to non-silent aspirators, silent aspirators demonstrated reduced voluntary cough peak expiratory flow (PEF; 166 vs. 324 L/min, p = 0.01). PEF, motor and urge to cough reflex cough ratings did not differ between aspirators and non-aspirators. Silent aspirators demonstrated a 7.5 times higher odds of failing reflex cough screening compared to non-silent aspirators (p = 0.07). CONCLUSIONS: During the acute recovery period, all LT participants demonstrated some degree of unsafe swallowing and reduced voluntary cough strength. Silent aspirators exhibited elevated RR, reduced voluntary cough physiologic capacity to defend the airway, and a clinically distinguishable blunted motor response to reflex cough screening.

Creation and impact of containment units with high-risk zones during the coronavirus disease 2019 (COVID-19) pandemic.

BACKGROUND: The rapid spread of coronavirus disease 2019 (COVID-19) required swift preparation to protect healthcare personnel (HCP) and patients, especially considering shortages of personal protective equipment (PPE). Due to the lack of a pre-existing biocontainment unit, we needed to develop a novel approach to placing patients in isolation cohorts while working with the pre-existing physical space. OBJECTIVES: To prevent disease transmission to non-COVID-19 patients and HCP caring for COVID-19 patients, to optimize PPE usage, and to provide a comfortable and safe working environment. METHODS: An interdisciplinary workgroup developed a combination of approaches to convert existing spaces into COVID-19 containment units with high-risk zones (HRZs). We developed standard workflow and visual management in conjunction with updated staff training and workflows. The infection prevention team created PPE standard practices for ease of use, conservation, and staff safety. RESULTS: The interventions resulted in 1 possible case of patient-to-HCP transmission and zero cases of patient-to-patient transmission. PPE usage decreased with the HRZ model while maintaining a safe environment of care. Staff on the COVID-19 units were extremely satisfied with PPE availability (76.7%) and efforts to protect them from COVID-19 (72.7%). Moreover, 54.8% of HCP working in the COVID-19 unit agreed that PPE monitors played an essential role in staff safety. CONCLUSIONS: The HRZ model of containment unit is an effective method to prevent the spread of COVID-19 with several benefits. It is easily implemented and scaled to accommodate census changes. Our experience suggests that other institutions do not need to modify existing physical structures to create similarly protective spaces.