Infection Prevention and Control in a health care setting
In this article Emilio Hornsey, Senior Infection Prevention and Control Nurse for the UK-Public Health Rapid Support Team, writes about Infection Prevention and Control for COVID-19 in a health care setting.
The aims of Infection Prevention Control (IPC) in the context of an outbreak of a novel Acute Respiratory Infection (ARI) such as SARS-CoV-2 causing COVID-19, are to promptly identify and treat any suspect or confirmed cases in such a way as protects the staff and patients in the rest of the health facility1. If health facilities become compromised during an outbreak this can both fuel the wider outbreak and impact broader health services to the detriment of the population.
Measures should be planned proactively and involve systemic preparation from the facility as a whole, as well as health care workers’ individual actions. Preparation for outbreaks involves a mix of activities in health care facilities, from sensitisation of staff and visitors, to supply of consumables and managing the infrastructure and layout of the facility. A useful first step is to undertake a thorough assessment of preparedness; there are some tools openly available to do this which will help highlight gaps and prioritise actions2, 3, 4.
A key intervention is heightened surveillance within the facility. Early detection and isolation of cases will minimise risk of transmission in the facility. Screening on admission is commonly employed; for this to be effective staff need to be trained to observe for symptoms and there needs to be a controlled entrance for admissions to the hospital. It is also important to maintain heightened surveillance in wards and other departments as patients may only start to show symptoms further into their hospital admission. To do this all clinical staff should have awareness of the case definition for suspect cases and know how to identify and report cases.
Once suspected cases are identified the facility needs a designated area for treatment, which minimises risk of transmission to others. Some health facilities will have isolation rooms, others will have a ward where suspected cases are cohorted together. Individual isolation rooms are gold standard, especially for suspected cases. Cohorting patients together risks transmission of disease between patients where some are, and some are not, infected.
The flow and transfer of patients should be planned, including location of isolation rooms and wards – where do patients have to travel from and to in the hospital to reach them? How is the room linked to other departments, sanitary and ventilation systems? Consider the need for intensive care level treatment, and how and where that will be delivered.
There are many different possible hospital layouts, and they all have different considerations in outbreaks. Even if national guidance documents are available 5 - 10 they will have to be interpreted according to local circumstances. Local Standard Operatine Procedures (SOPs), algorithms or policies should be developed and disseminated where required.
Transmission based precautions
The World Health Organization currently recommends standard droplet and contact precautions are employed for all suspected and confirmed COVID-19 cases8. Patients should be isolated and wear a mask if they have to transit through shared areas. Staff should wear gloves, gown, eye protection and a medical mask within 1m of the patient as a minimum. More extensive environmental cleaning should be conducted using any of the readily available detergents or disinfectants11 and airborne precautions implemented during aerosol generating procedures.
When dealing with a novel pathogen with a mechanism of transmission that is poorly understood it is prudent to apply a precautionary approach if there is the capacity to do so. On that basis some countries are using airborne precautions for all suspected and confirmed cases and regard a 2m distance as close contact. Airborne precautions include isolating the patient in a naturally well ventilated room or with negative pressure ventilation. Health care workers should wear a fit tested respirator such as an N95 (US CDC9 FFP3 (UK12 when treating the patient. Specific Personal Protective Equipment (PPE) guidance for COVID-19 has been published12- 14 each with subtle differences specific to each health system.
Challenges in implementation
Challenges in implementation exist at all levels of the health system. In countries without a comprehensive national programme for infection prevention and control, specialist training programmes and dedicated staff to implement national guidance, it is more challenging to implement IPC as part of outbreak preparedness or response. There are also challenges specific to every health facility, the results of the preparedness self-assessment should highlight the key areas to prioritise. This should be repeated periodically to monitor the effect of interventions.
Surveillance and triage is challenging as the symptoms of COVID-19 are similar to many other acute respiratory viral infections. Case definitions may change as epidemiological links become broader and this will put pressure on health services as the number of suspect cases increases.
While transmission is incompletely understood it is difficult to prioritise which infection control measures to focus on, especially in areas with limited resources. In overcrowded health facilities it is difficult to maintain social distancing in shared waiting areas and find a space to dedicate for isolation of suspect and confirmed cases.
Consumables such as expensive imported and bulky PPE can put a huge additional strain on finance and logistic chains in an outbreak. Guidelines such as the WHO rational use guidelines15 may help minimise wastage.
In such a rapidly evolving outbreak it is important to keep up to date with national and international recommendations.
International and regional guidance can be found at dedicated COVID-19 websites hosted by
- World Health Organization
- European Centre for Disease Prevention and Control
- Africa Centres for Disease Control and Prevention
Many national Public Health agencies are also synthesising the evidence for their own circumstances and have published specific national guidance. Some examples of these are listed below.
- Government of the United Kingdom
- Nigeria Centre for Disease Control
- Centres for Disease Control and Prevention (United States of America)
© London School of Hygiene & Tropical Medicine 2020