Sick Healthcare Workers Worsen Shortage, May Spike Healthcare-Associated Infections
CDC cuts isolation time
By Gary Evans, Medical Writer
The COVID-19 Omicron variant, known to cause breakthrough infections in those fully vaccinated and boosted, is infecting and furloughing healthcare workers even as hospitals face a towering wave of incoming patients.
“We have patients, unfortunately, in hallways and other spaces that we are creating to be able to safely care for them,” said Timothy Dellit, MD, infectious disease physician and chief medical officer at the University of Washington (UW) hospitals in Seattle.
“We have just over 600 employees [who] are out within our clinical environment, either because of infection; about 450, and 150 on quarantine because of exposure,” he said at a briefing to UW faculty and students.1 “We never saw that before with the previous waves.”
In response, on Dec. 23, 2021, the Centers for Disease Control and Prevention (CDC) revamped its isolation guidelines for infected and exposed healthcare workers, reducing the days they may miss work based on symptoms, testing, and other factors as defined in categories of Traditional, Contingency, and Crisis.2 (See table below.)
|
Recommended Work Restrictions for HCP Based on Vaccination Status and Type of Exposure | |||
|
Exposure |
Personal Protective |
Work Restriction for HCP who have received all COVID-19 vaccine and booster doses as recommended by CDC |
Work Restriction for HCP who have not received all COVID-19 vaccine and booster doses as recommended by CDC |
|
Higher-risk: HCP who had prolonged close contact with a patient, visitor, or HCP with confirmed SARS-CoV-2 |
|
|
Option 1:
|
|
Lower-risk: HCP with exposure risk other than those described as higher-risk above |
N/A |
|
|
|
Source: Centers for Disease Control and Prevention. COVID-19. Interim guidance for managing healthcare personnel with SARS-CoV-2 infection or exposure to SARS-CoV-2. Updated Dec. 21, 2021. https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html | |||
The previous recommendation for 10 days has been changed to seven, and shorter than that under certain conditions.
“With the growing number of COVID-19 cases from the Omicron variant, and consistent with current understanding of the disease trajectory, CDC [recommends that] healthcare workers with COVID-19 who are asymptomatic can return to work after seven days with a negative test, and that isolation time can be cut further if there are staffing shortages,” the agency said in a statement.3 “Healthcare workers who have received all recommended COVID-19 vaccine doses, including a booster, do not need to quarantine at home following high-risk exposures.”
The Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) supported the updated CDC guidance, saying “these approaches are crucial to ensure we have the necessary healthcare workforce to respond to the growing Omicron surge. Leaders of infection prevention and control efforts at healthcare institutions should be empowered to implement this guidance to best meet the needs of their individual settings, including adopting extra precautions for healthcare personnel who predominantly work with immunocompromised patients.”4
These updates provide healthcare facilities “with the strategies to limit the effects of staff shortages caused by COVID-19,” the CDC noted, indicating the decisions on isolation and quarantine of medical workers can be made based on the local situation.
“What we’re doing within UW Medicine is, if someone never had symptoms, we’re testing them with an antigen on day 5. If they’re negative, they can come back,” Dellit said. “If they ever had symptoms, they are improving, and if they’re negative on day 7, then they can come back. If they’re positive, then they wait for the full 10 days.”
Joshua Barocas, MD, an infectious disease physician at the University of Colorado Anschutz Medical Campus, said his facility has planned and implemented multiple layers of staff backup.
“People on every service right now have been infected,” he said at recent briefing held by IDSA.5 “I can tell you that this is not just a matter of healthcare workers, but it’s a matter of environmental services workers [and] food services workers within the hospital and health care system as well.”
The Continuing HAI Problem
This does not bode well for controlling healthcare-associated infections (HAIs), which increased dramatically in 2020 while hospitals fought the chaos of the pandemic. Data from the CDC’s National Healthcare Safety Network revealed that four important HAIs, including central line-associated bloodstream infections (CLABSIs), were much higher in 2020 than in 2019.6 The rate of CLABSIs, which have a mortality rate in the 20% range, were about 47% higher than 2019 in the third and fourth quarters of 2020. Likewise, catheter-associated urinary tract infections, ventilator-associated events, and antibiotic-resistant staph infections also prospered during the turmoil of the pandemic.
To put it mildly, that hit infection preventionists (IPs) where it hurts, since preventing HAIs is the central mission of their profession and leadership group, the Association for Professionals in Infection Control and Epidemiology.
Saying she would like to “infuse some hope” into the profession and attract new members, Linda Dickey, RN, MPH, CIC, the new 2022 APIC president, says IP s have been hit hard but still are standing.
“Our members are tired,” she says. “There are a lot of individuals within our profession who are resilient, but it’s been a long marathon.”
All are committed to preventing HAIs despite the obvious obstacles of high census and a very infectious omicron variant, as well as a host of other challenges, says Dickey, senior director for Quality, Patient Safety, and Infection Prevention at the University of California, Irvine Health in Orange County, CA.
“We — not only infection prevention teams — but all healthcare providers across the country are still aimed at providing the best care possible, even in the midst of this pandemic,” she says. “Having said that, we have had supply chain challenges, staffing challenges — challenges to ‘attention-focus.’ We recognize that HAIs have gone up and we want to stay on top of that by calling attention to best practices. IPs are still keeping an eye on that, while realizing we have to be aware of COVID as well.”
The number of HAIs that occurred in actual COVID-19 patients or transmission of SARS-CoV-2 was not reported in the U.S. data, but a study in Italy looked at 59 intensive care unit healthcare infections and found 39 occurred in pandemic patients.
“Patients admitted in 2020 were found to be positively associated with both HAI and device-related HAI,” the authors noted.7 “A greater proportion of device-related HAIs seemed to occur in COVID-19 patients, especially ventilator-associated pneumonia, and catheter-related urinary tract infections.”
These results would appear to confirm the effect of the organizational challenges experienced during the COVID-19 pandemic, disrupting and undermining HAI prevention efforts.
“Indeed, although several initiatives aimed at reducing SARS-CoV-2 spread may have increased awareness on infection prevention measures, many healthcare facilities had to contend with physical space limitations, constrained availability of personnel, shortages in personal protective equipment, and a large number of patients,” they concluded.
A well-documented result of staff shortages — which can directly contribute to HAIs as lines go unchecked and wounds unseen — is the phenomenon of “missed nursing care.”
Missed nursing care generally is defined as delaying, omitting, or rationing care by nursing staff, said Linda Enos, RN, BSN, MS, COHN-S, CPE, a consulting nurse in Oregon with more than 25 years of experience.
“What some of the data [are] telling us is that missed nursing care, if we can identify it on a unit, may be an early warning indicator before we have increased adverse events and patient deaths,” she said at a recent webinar.8
A paper that tied missed nursing care directly to HAI increases suggested these problems are going to be present as long as the pandemic is front and center.
“There is evidence that missed nursing care is associated with [HAIs],” the authors emphasized.9 “[These] HAIs pose a threat to patient safety, prolong hospital stays and considerably increase healthcare costs. Healthcare facility administrators should make efforts to optimize nursing care and reduce missed care.”
Audacity of Hope
Going back to Dickey’s goal of infusing hope, the two speakers at the IDSA briefing were asked what they were optimistic about. They welcomed the question, agreeing they had contemplated tragic and adverse outcomes far too long as the pandemic enters its third calendar year.
Jeanne Marrazzo, MD, MPH, infectious diseases director at the University of Alabama at Birmingham, said there are oral antiviral medications coming on the market that may work as well against SARS-CoV-2 as similar drugs do against flu.
“I think I’m most optimistic about the Paxlovid, because it’s an oral drug that is for five days,” she said at the IDSA briefing. “I think of it very similar to Tamiflu [for influenza] and [it] can really make a big difference if we start it early. If we could gear that up and get it to people, I think that that would address so much of our staffing problems, because we could keep people out of the hospital, we could prevent severe illness, and it looks like a pretty safe drug.”
Looking back to the bleak early days of the pandemic, Barocas said he is quite optimistic about how the clinical toolkit has expanded against SARS-CoV-2.
“I can’t express in words how big my toolbox actually has become compared to March 2020,” he said. “I felt helpless, I felt that absolutely all I was doing was shuffling deck chairs and trying to keep a boat afloat at the same time. And now we have preventive measures, we have treatments, and we have a public health infrastructure that’s growing. We have grown our genomic surveillance as well, which was something that we didn’t have two years ago at the beginning of all of this. We go to the hospital now, and no matter how overwhelmed and exhausted we all are, it’s a vastly different landscape than what we had in March 2020.”
REFERENCES
- YouTube. Webinar – Winter quarter and the omicron variant. University of Washington School of Public Health. Published Jan. 6, 2022. https://www.youtube.com/watch?v=0NucT9AYDps
- Centers for Disease Control and Prevention. Interim guidance for managing healthcare personnel with SARS-CoV-2 infection or exposure to SARS-CoV-2. Updated Dec. 23, 2021. https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html
- Centers for Disease Control and Prevention. CDC releases emergency guidance for healthcare facilities to prepare for potential omicron surge. Published Dec. 23, 2021. https://www.cdc.gov/media/releases/2021/s1223-emergency-guidance-prepare-for-omicron.html
- The Society for Healthcare Epidemiology of America. IDSA and SHEA statement on CDC updated guidance for health care personnel isolation and quarantine to mitigate staffing shortages. Published Dec. 23, 2021. https://shea-online.org/idsa-and-shea-statement-on-cdc-updated-guidance-for-health-care-personnel-isolation-and-quarantine-to-mitigate-staffing-shortages/
- Infectious Diseases Society of America. IDSA media briefing: COVID-19 & omicron – practical advice. Published Jan. 11, 2022. https://www.idsociety.org/multimedia/videos/idsa-media-briefing-covid-19--omicron---practical-advice/
- Weiner-Lastinger LM, Pattabiraman V, Konnor RY, et al. The impact of coronavirus disease 2019 (COVID-19) on healthcare-associated infections in 2020: A summary of data reported to the National Healthcare Safety Network. Infect Control Hosp Epidemiol 2021; Sep 3:1-14. doi:10.1017/ice.2021.362. [Online ahead of print].
- Grasselli G, Scaravilli V, Mangioni D, et al. Hospital-acquired infections in critically ill patients with COVID-19. Chest 2021;160:454-465.
- Enos L. Enhancing patient safety and outcomes: The safe patient handling connection. Association of Occupational Health Professionals in Healthcare. Aug. 11, 2021. https://www.aohp.org/aohp/EDUCATION/OnlineEducationPrograms/ArchivedWebinars/tabid/247/CategoryID/8/ProductID/64/Default.aspx
- Mynaríková E, Jarošová D, Janíková E, et al. Occurrence of hospital-acquired infections in relation to missed nursing care: A literature review. Cent Eur J Nurs Midw 2020;11:43-49.
The COVID-19 omicron variant, known to cause breakthrough infections in those fully vaccinated and boosted, is infecting and furloughing healthcare workers even as hospitals face a towering wave of incoming patients.
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