HIS webinar – Understanding hospital-onset and hospital-acquired COVID-19 infection | Reflections on Infection Prevention and Control

The second in the series of excellent Healthcare Infection Society (HIS) interactive audience-led webinars went out a few weeks ago. The theme for this was hospital-onset and hospital-acquired COVID-19 infections, and here’s the video.

The panel (featuring several colleagues!) was as follows:

Dr Eimear Brannigan, Consultant in Infectious Diseases and Deputy Director of Infection Prevention and Control, Imperial College Healthcare NHS Trust
Professor Alison Holmes, Professor of Infectious Diseases, Imperial College London
Dr Lisa Ritchie, Head of Infection Prevention and Control, NHS England and NHS Improvement
Dr Walter Zingg, Head Consultant in Infection Prevention and Control, University of Geneva Hospitals, Geneva, Switzerland
(Chair) Dr James Price, Consultant in Infection Prevention and Control and Antimicrobial Stewardship, Imperial College Healthcare NHS Trust

If you don’t have time to tune into the webinar, here’s my take on the Q&A:

What is the difference between hospital-onset and hospital-acquired COVID-19 infection? Both terms are used as surveillance definitions for COVID-19 that is first identified in hospitalised patients. Pinning down the point of acquisition of any HCAI is tricky – but it’s even more difficult with COVID-19 due to the incubation period that can be up to 14 days (although median = 5). Most COVID-19 that is identified in the first few days of hospitalisation will probably reflect community acquisition and most COVID-19 identified after 14 days of hospital admission will probably represent hospital-acquisition – and there’s a sliding scale of grey in between! Testing and symptom checking at the time of admission will help to rule out community-onset COVID-19 presenting in patients arriving at hospital.

Should we screen all staff and patients routinely for COVID-19? The panel interpreted this to mean diagnostic testing rather than ‘screening’ for symptoms. Routine testing of patients and staff and segregation of those who are infected (asymptomatic or otherwise) should be seen as a key part of recovery – and this is supported by the new NHS operating framework. The risk of poor positive predictive value and false positives, especially in a setting of falling prevalence, requires that positive results require careful interpretation (more on this here). There’s also a role for point-of-care diagnostics here to change the patient pathway at the point of admission or during cluster-related investigations. Testing symptomatic staff is a no-brainer but routine testing of asymptomatic staff is much more difficult (and no easy answer here).

How can we maintain physical distancing and visitor restrictions in healthcare settings? SARS-CoV-2 spreads primarily by respiratory droplets, which is why physical distancing and the “2m rule” is so important.

Physical distancing for patients has been implemented fairly effectively during the peak of the pandemic (e.g. telemedicine). However, it will become more difficult as hospitals open up elective services. Signage and floor markings will be key tools to help to support this. Bed spacing will need to be modified to a minimum of 2m, perhaps with the use of screens to improve physical distancing between patients.
Physical distancing amongst healthcare staff is much more difficult. But some progress has been made (home working, video meetings, smaller ward rounds, staggered breaks etc).
Physical distancing for visitors has been supported fairly effectively by the use of digital options to connect patients with their visitors – and some aspects of this are here to stay.

What should we do when we detect hospital-onset COVID-19 infections? The response will depend on the circumstances What’s going on with the patient? Is it a single case or a cluster? What is the setting (speciality, ‘colour’ of pathway)? But some key principles include rapid segregation of patients with new hospital-onset COVID-19 infections, and an opportunity to reinforce hand and environmental hygiene. Plus a need to introduce some investigating patient and staff testing, and preventing or reducing admissions in some circumstances.

What could be done nationally to support the investigation of hospital-onset COVID-19 infections locally? National surveillance systems will help, but hospitals need guidance to introduce effective physical distancing (in clinical and non-clinical areas). Some specific guidance on the most effective ways to respond to new hospital-onset COVID-19 infections would be helpful, especially in specialist services. And access to sufficient laboratory capacity for testing.

What are other countries doing to prevent hospital-acquisition of COVID-19? Similar strategies are being put in place in other countries, albeit with different surveillance definitions. A key focus has been on behaviours and managing risks related to healthcare workers as potential sources of COVID-19 for patients.

How do you manage patients who are readmitted more than 4 weeks after their initial COVID-19 episode but are still test positive? These patients would be managed in a COVID-19 risk managed pathway – it would not be possible to admit them to a COVID-19 protected pathway, but the risk of transmission would be considered very low.

Do you think that valved masks (that do not filter outgoing air) could contribute to transmission from asymptomatic staff? These masks should not be used in healthcare settings if this can be avoided. The use of visors would mitigate this risk.

Finally, some notice of two further upcoming HIS COVID-19 webinars (and please note the opportunity to submit questions in advance for these planned webinars and suggest topics for future webinars):