Coronavirus: 41.3% of cases in Wuhan are due to nosocomial infections. How can we protect against COVID-19?

41.3% of COVID-19 (Coronavirus) cases are due to Nosocomial Infections in Wuhan. How can we protect HCWs and patients?

Of the 41.3% HAI (Healthcare Acquired Infections) cases of COVID-19 (Coronavirus) in Wuhan, an alarming 29% of the total cases are healthcare workers (HCWs) themselves. As many of them were working in general wards, they were unlikely to have been adequately protected. A single patient admitted in surgical ward with abdominal symptoms could have been responsible for infecting almost 10% of these affected HCWs.

With this pandemic already affecting our social and business lives in many countries, which is expected to get worse before getting better, we may have to additionally consider the clinical characteristics related to this Coronavirus SARS-CoV-2, while handling the existing 4-decade old chronic issue of HAIs already affecting 10% of all our hospitalized patients. Now the risk for HCW is an added reason to minimize HAIs.

From HAI prevention stand point, what we do know about this Coronavirus SARS-CoV-2:

• A large number of patients are asymptomatic and we may be facing a biggest silent outbreak of a viral disease. By the time we screen people based on fever and CT scans, we may have missed out many who may be further spreading it.
• Although published work shows the incubation period is short (3-4 days), and the 14-day quarantine period is sufficient, there are many cases of undetected original and reinfections, leading to longer “incubation” periods.
• Reinfections are considered to be even more dangerous often leading to heart failures. This is due to Cytokine storm and the unbalancing of ACE2 pathway leading to vasoconstriction, fibrosis, hypertrophy, inflammation.
• At least in the beginning, there seems to be confusing symptoms such as abdominal pain, nausea or vomits. In Wuhan for patients with these symptoms, it took more than 5 days on an average to develop shortness of breath. After this, the delay to hospitalize the patient was of 2 days.
• PPE (Personal Protection Equipment) may not be available for those who are handling unknown cases.

These reasons will make HCWs and our patients especially vulnerable and will make us want to comply with hand hygiene protocols. Hand washing continues to be the most important way for HCWs to protect themselves and their patients. A renewed personal commitment of HCWs to comply with hand hygiene protocol will be needed but not sufficient.

In addition to the commitment of HCWs, there are some systemic issues that healthcare organizations need to fix to facilitate the hand-hygiene protocol compliance:

1. Ensure hand sanitizer is available at all points of use (portable ones often disappear from point of use).
2. Introduce a systematic replenishment control when the sanitizer flasks become empty. Do not wait for the HCW to detect when he or she needs to use it.
3. Ensure the amount of sanitizer used is sufficient for effective hand hygiene depending on hand size.
4. Let supervisors monitor the hand hygiene of their team members. Do not expect a centralized hand hygiene team to do that job.
5. Facilitate real-time hand hygiene protocol compliance monitoring system in all shifts, for all employees and all days of the year. Feed that data back to employees through their own direct managers/supervisors. Govisystem™ has been designed with these characteristics to resolve all these systemic issues.

We have failed in preventing HAIs for four decades because we have been placing the burden on our people through “awareness training and reminders”. That is a bad strategy. It is time for the management to put the burden on the system, if we really want to protect our patients, and now HCWs as well, from this Coronavirus SARS-CoV-2. A good system design has follow-up mechanisms to ensure each and every HCW has developed the right habit.

_____________________

1Wang et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China. JAMA. doi:10.1001/jama.2020.1585 Published online February 7, 2020.

The author of this article is Dr. Rajaram Govindarajan.