Pandemic response gaps: Infection prevention and control lessons learned during coronavirus disease 2019 (COVID-19) outbreaks in skilled nursing facilities in Detroit, Michigan.

BACKGROUND: Hospitalizations among skilled nursing facility (SNF) residents in Detroit increased in mid-March 2020 due to the coronavirus disease 2019 (COVID-19) pandemic. Outbreak response teams were deployed from local healthcare systems, the Centers for Disease Control and Prevention (CDC), and the Detroit Health Department (DHD) to understand the infection prevention and control (IPC) gaps in SNFs that may have accelerated the outbreak. METHODS: We conducted 2 point-prevalence surveys (PPS-1 and PPS-2) at 13 Detroit SNFs from April 8 to May 8, 2020. The DHD and partners conducted facility-wide severe acute respiratory coronavirus virus 2 (SARS-CoV-2) testing of all residents and staff and collected information regarding resident cohorting, staff cohorting, and personnel protective equipment (PPE) utilized during that time. RESULTS: Resident cohorting had been implemented in 7 of 13 (58.3%) SNFs prior to point-prevalence survey 1 (PPS-1), and other facilities initiated cohorting after obtaining PPS-1 results. Cohorting protocols of healthcare practitioners and environmental service staff were not established in 4 (31%) of 13 facilities, and in 3 facilities (23.1%) the ancillary staff were not assigned to cohorts. Also, 2 SNFs (15%) had an observation unit prior to PPS-1, 2 (15%) had an observation unit after PPS-1, 4 (31%) could not establish an observation unit due to inadequate space, and 5 (38.4%) created an observation unit after PPS-2. CONCLUSION: On-site consultations identified gaps in IPC knowledge and cohorting that may have contributed to ongoing transmission of SARS-CoV-2 among SNF residents despite aggressive testing measures. Infection preventionists (IPs) are critical in guiding ongoing IPC practices in SNFs to reduce spread of COVID-19 through response and prevention.

The argument for rapid influenza polymerase chain reaction (PCR) during the COVID-19 pandemic: Quicker turnaround times correlated with decreased antimicrobial use, reduced admission rates, and shorter length of stay.

The innovation of rapid influenza polymerase chain reaction (XT-PCR) has allowed quick, highly sensitive test results. Consequently, physicians can differentiate influenza from other respiratory illnesses and rapidly initiate treatment. We examined the effect of implementing XT-PCR on antimicrobial use, admission rates, and length of stay at a tertiary healthcare system.

Elevated COVID19 mortality risk in detroit area hospitals among patients from census tracts with extreme socioeconomic vulnerability.

BACKGROUND: the incidence of novel coronavirus disease (COVID19) is elevated in areas with heightened socioeconomic vulnerability. Early reports from US hospitals also implicated social disadvantage and chronic disease history as COVID19 mortality risk factors. However, the relationship between race and COVID19 mortality remains unclear. METHODS: we examined in-hospital COVID19 mortality risk factors in a multi-hospital tertiary health care system that serves greater Detroit, Michigan, a predominantly African American city with high rates of poverty and chronic disease. Consecutive adult patients who presented to emergency departments and tested positive for COVID19 from 3/11/2020 through 4/18/2020 were included. Using log-binomial regression, we assessed the relationship between in-hospital mortality and residence in census tracts that were flagged for extreme socioeconomic vulnerability, patient-level demographics, and clinical comorbidities. FINDINGS: a total of 1,015 adults tested positive for COVID19 during the study period; 80% identified as Black people, 52% were male and 53% were ≥ 65 years of age. The median body mass index was 30•4 and the median Charlson Comorbidity Index score was 4. Patients from census tracts that were flagged for vulnerability related to socioeconomic status had a higher mortality rate than their peers who resided in less vulnerable census tracts (ß 0.26, standard error (SE) 0.11, degrees of freedom (df) 378, t-value (t) 2.27, exp(ß) 1.29, p-value 0.02). Adjustment for age category, Black race, sex and/or the Charlson Comorbidity Index score category reduced the magnitude of association by less than 10% [exp(ß) 1.29 vs. 1.21]. Black race [p = 0.38] and sex [p = 0.62] were not associated with mortality in this sample. INTERPRETATION: people who lived in areas flagged for extreme socioeconomic vulnerability had elevated mortality risk in our predominantly African-American cohort of COVID19 patients who were able to seek hospital care during the so-called 'first wave' of the pandemic. By contrast, Black race was not associated with mortality in our sample.

The impact of coronavirus disease 2019 (COVID-19) response on central-line-associated bloodstream infections and blood culture contamination rates at a tertiary-care center in the Greater Detroit area.

We conducted a comparative retrospective study to quantify the impact of coronavirus disease 2019 (COVID-19) on patient safety. We found a statistically significant increase in central-line-associated bloodstream infections and blood culture contamination rates during the pandemic. Increased length of stay and mortality were also observed during the COVID-19 pandemic.

Initial and Repeated Point Prevalence Surveys to Inform SARS-CoV-2 Infection Prevention in 26 Skilled Nursing Facilities - Detroit, Michigan, March-May 2020.

Skilled nursing facilities (SNFs) are focal points of the coronavirus disease 2019 (COVID-19) pandemic, and asymptomatic infections with SARS-CoV-2, the virus that causes COVID-19, among SNF residents and health care personnel have been described (1-3). Repeated point prevalence surveys (serial testing of all residents and health care personnel at a health care facility irrespective of symptoms) have been used to identify asymptomatic infections and have reduced SARS-CoV-2 transmission during SNF outbreaks (1,3). During March 2020, the Detroit Health Department and area hospitals detected a sharp increase in COVID-19 diagnoses, hospitalizations, and associated deaths among SNF residents. The Detroit Health Department collaborated with local government, academic, and health care system partners and a CDC field team to rapidly expand SARS-CoV-2 testing and implement infection prevention and control (IPC) activities in all Detroit-area SNFs. During March 7-May 8, among 2,773 residents of 26 Detroit SNFs, 1,207 laboratory-confirmed cases of COVID-19 were identified during three periods: before (March 7-April 7) and after two point prevalence surveys (April 8-25 and April 30-May 8): the overall attack rate was 44%. Within 21 days of receiving their first positive test results, 446 (37%) of 1,207 COVID-19 patients were hospitalized, and 287 (24%) died. Among facilities participating in both surveys (n = 12), the percentage of positive test results declined from 35% to 18%. Repeated point prevalence surveys in SNFs identified asymptomatic COVID-19 cases, informed cohorting and IPC practices aimed at reducing transmission, and guided prioritization of health department resources for facilities experiencing high levels of SARS-CoV-2 transmission. With the increased availability of SARS-CoV-2 testing, repeated point prevalence surveys and enhanced and expanded IPC support should be standard tools for interrupting and preventing COVID-19 outbreaks in SNFs.

Clostridioides difficile in COVID-19 Patients, Detroit, Michigan, USA, March-April 2020.

We describe 9 patients at a medical center in Detroit, Michigan, USA, with severe acute respiratory syndrome coronavirus 2 and Clostridioides difficile. Both infections can manifest as digestive symptoms and merit screening when assessing patients with diarrhea during the coronavirus disease pandemic. These co-infections also highlight the continued importance of antimicrobial stewardship.