Coping with the COVlD‑19 pandemic: Strategies for controlling nosocomial infections in the observation area in a general hospital in China

Feng‑Li GAO, Shu DING, Juan CAI

Department of Nursing, Beijing Chao‑Yang Hospital, Capital Medical University, Beijing, China

ABSTRACT

This study shared experiences in implementing infection prevention and control strategies in an observation area to minimize nosocomial infections of COVID‑19 in a 3A‑level general hospital in China, including area division, human resources and teamwork, instructions for infection control, and the establishment of workflow management groups in the operation center. These experiences will be helpful to countries, especially developing countries, who arefighting against COVID‑19 now and other infectious diseases in the future to control nosocomial infections.

Keywords: COVID‑19, infection control, nosocomial infections, pandemic

INTRODUCTION

An outbreak of COVID-19 has spread rapidly worldwide since December 2019. In the early stage of the epidemic, many suspected cases were screened daily in general hospitals for the diagnosis of COVID-19 infection in China. They would stay in the observation area for more than 24 h to wait for the outcomes of various tests to confirm their diagnoses. Since COVID-19 is highly contagious even during the incubation period[1]and transmissions can occur through respiratory droplets, close contact, fecal-oral route, and aerosols under certain conditions,[1,2]strategies to control cross-infections in screening and observation areas are highly important and imperative. Evidence has indicated that proper infection prevention and control measures can remarkably change the course of the outbreak.[3]This study aimed to share experiences in implementing infection prevention and control strategies in an observation area to minimize nosocomial infections in a 3A-level general hospital in China. We made discussions on the following four points: area division, human resources and teamwork,instructions for infection control, and the establishment of workflow management groups in the operation center.

AREA DIVISION

There are structural limitations in preventing and controlling infectious diseases, especially respiratory infectious diseases, in most general hospitals in China.[4]Thus, the existing ward needed to be modified temporarily to meet the requirements of treating infectious diseases and to be replanned and divided based on function and possible levels of contamination. The area was initially divided into a screening area and an observation area. The screening area is similar to a fever clinic, which will not be elaborated here.In the observation area, every suspected case will stay for more than 24 h for his or her diagnosis. Thus, cross-infections may occur in this area due to the crowded space and the mix of infected and noninfected patients with COVID-19. Ideally,each patient should be isolated in a single room. However,with the rapidly increasing number of suspected cases, it is hard to do so. Thus, on top of requesting each patient to wear a surgical mask, three new strategies have been applied to prevent cross-infections. First, the observation area is divided into “three zones and two routes.” The three zones include a clean zone, a semi-contaminated zone, and a contaminated zone, and equipment, suppliers, and working contents are determined based on each zone. Administrative regulations for the cleaning and disinfection of each zone are also issued.The two routes include a route for patients and a route for health-care workers (HCWs) to avoid cross-mixing. To ensure the isolation effect of “three zones and two routes,”the following questions are used by the manager: “Are the various diagnostic and treatment activities smooth?” “Is the workflow among HCWs coherent?” “Do the disinfection and isolation methods meet the requirements?” and “Are the HCWs’ daily activities such as meals and excretion properly arranged?” All these are practiced with simulation. Second,patients will be placed separately based on the severities of their conditions. Patients with mild symptoms are isolated in a room, and they are suggested to rest and not to walk around while wearing a surgical mask. For patients with critical conditions, some treatments and procedures will be carried out, so chances of contamination by blood and body fluids will be high, which will result in a higher infection rate.Thus, HCWs should pay more attention to prevent infections while providing care to these patients. Third, during the outbreak, the hospital activated a lounge (a clean zone)for HCWs for resting and having meals, which can be easily contaminated by contaminated clothes and shoes from the working zone (contaminated zone). Thus, one experienced staff is assigned at the clean zone during each shift to monitor the status of all HCWs to make sure that each staff takes off all potentially contaminated items at the semi-contaminated zone and takes a shower before he or she enters in the clean zone. The staff also monitors every HCW’s symptoms to check whether he or she has an infection. HCWs are also advised not to stay together.

HUMAN RESOURCES AND TEAMWORK

Regarding human resources, the following three aspects are considered: workforce, staff emotion and confidence,and collaboration among the team. First, the principle of “three echelons” is used to build teams based on the limited number of workforce.[5]We considered abnormal conditions that may occur among HCWs and that patients’conditions might become worse during the period. Under these circumstances, alternate HCWs will be needed to ensure that there is enough workforce in the observation area. In addition, a reasonable work schedule for HCWs is very important to avoid their fatigue. Thus, the manager needs to review and update work schedules from time to time with the consideration of the staff’s changing needs.Second, keeping a good mood among HCWs during this period is extremely important to reserve their immunities and to ensure the quality of care for patients. Confidence is very important to avoid emotional distress. HCWs will only establish confidence when they believe and recognize that the current workflow is safe for them and good for patients.Thus, it is important to have a reasonable workflow that is designed by a well-recognized competent leader. Care provided to HCWs should include all detailed aspects of their daily work and lives, such as the provision of warm food, drinks, and a conducive and warm environment.Finally, collaboration among the team includes cooperation within the team and cooperation between staff working in the treatment area and those outside this area. This requires multidepartment and multiteam communication and cooperation. For example, HCWs working outside the treatment area should be arranged reasonably to support HCWs working in the treatment area to handle patients’payments, medication deliveries, specimen deliveries, and daily living needs, as well as the dead, including packing,disinfection, storage, and transfer. That is, HCWs who are working in the treatment area should not leave the area to avoid the spread of the infection.

INSTRUCTIONS FOR INFECTION CONTROL

HCWs and patients in the observation area are at risk of COVID-19 infection. Therefore, in order to achieve the target of zero nosocomial infections, simply providing guidelines on disinfection, diagnosis, and treatment is not enough. During the implementation process, it is important to have someone act as an auditor and educator to keep an eye on HCWs'hand hygiene compliance and infection prevention process.For example, regarding a guideline on how to perform the disinfection of goggles and face shields, the implementation should include how to take off goggles and face shields,where to and who should perform the disinfection procedure,where to dry or wipe goggles and face shields, and whether there are any contaminations when HCWs take off or wear goggles and face shield. Thus, all procedures and workflows should be designed reasonably and meet the requirements of the infection control guidelines. HCWs who are responsible for the infection control should monitor the practice and ensure that all workflows and practices are in place.

ESTABLISHMENT OF THE WORKFLOW MANAGEMENT GROUPS IN THE OPERATION CENTER

An infectious control supervision team and three coordination groups were established during the COVID-19 outbreak period. The infectious control supervision team is responsible for designing and monitoring different work areas, workflow,materials and equipment handling, room disinfection, and the handling of the bedsheets and clothes after usage. This team needs to find problems and propose solutions from every work detail. At the early stage, the team member should stay in the treatment area to observe HCWs’ work and provide supervision to them.

Among the three groups in the operation center, the first one is a material coordination group, which is responsible for the efficient and reasonable use of limited protective resources,performs daily checking, replenishment, and distribution to guarantee that HCWs in the treatment area do not need to worry about any materials that they need. The second group is a treatment workflow management group that consists of experienced staff. Although the routine work is the same as before, under the infectious control guidelines during the COVID-19 outbreak, the working area is divided by the clean area and the contaminated area. Thus, all diagnostic,treatment, and nursing workflows related to patient contacts should be reorganized and documented. These planned and standardized workflows allow for safety and quality practices among staff and reduce their fears of infection. The third group is a dedicated training group to train anyone who is going to enter and work in the treatment area, including staff from various departments such as radiology, laboratory,logistics, and other departments. The training provides a hands-on practice specifically related to contents such as key points and specific requirements when working in the treatment area and when handling work inside and outside the treatment area.

To summarize, the COVID-19 has been spread to more than 200 countries with accumulated 1,770,138 confirmed cases as of April 13, 2020.[6]Thus, these experiences will be helpful to countries who are fighting against COVID-19 now and other infectious diseases in the future, especially developing countries, to control nosocomial infections.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.