Background: As the world prepared for and responded to the COVID-19 pandemic in early 2020, a rapid increase in demand for personal protective equipment (PPE) led to severe shortages worldwide. Acquisition of PPE in the general market was an integral part of pandemic response, along with the safeguarding of hospital supplies. We seek to quantify the difference in cost per unit (CPU) of PPE during the first wave of COVID-19 compared to prepandemic prices. Methods: We performed a retrospective review of market prices for PPE during the first surge of the pandemic in Chicago. Cost of PPE was tabulated and compared with prepandemic prices. The maximum cost per unit (CPU) of PPE was tabulated for each week, and the average cost throughout the pandemic was calculated. Disposable gowns, washable gowns, N95 respirators, face masks, and gloves were included in our analysis. Results: PPE prices were significantly higher during the pandemic compared to prepandemic prices (Figure 1). Disposable gown CPU peaked at $12 during the first week of March, 13.7 times higher than prepandemic prices, and the average gown CPU was 7.5 times higher than prepandemic prices. N95 respirators had a peak CPU of $12, and average CPU was 8 times higher than prepandemic prices. Face-mask CPU peaked at $0.55, 11 times higher, and averaged 9 times higher the regular price. Gloves averaged 2.5 times higher than the prepandemic CPU. Conclusions: Market prices for PPE were significantly elevated during the first weeks of the pandemic and remained high throughout the first wave of COVID-19. Multiple factors likely contributed to high prices, including demand shock, disrupted supply chains, and a rush to acquisition by healthcare systems and the general population alike. The impact of COVID-19 on prices highlights the importance of supply chains and national stockpiles for pandemic preparedness.

Funding: No

Disclosures: None

Figure 1.

Background: The novel coronavirus (COVID-19) pandemic has caused significant morbidity and mortality in California: 2,218,000 cases and 24,598 deaths had occurred by December 31, 2020. Deaths at skilled nursing facilities (SNFs) and assisted living facilities (ALFs) comprise 26.2% of deaths in California; the fatality rate (299 per 10,000 SNF and ALF residents) in such facilities is nearly 50 times the statewide COVID-19 mortality rate (6.4 per 10,000 California residents). For healthcare facility (SNF, ALF, acute-care hospitals) and correctional facility outbreak management, the California Department of Public Health (CDPH) Healthcare-Associated Infections (HAI) Program deployed trained infection preventionists (IPs) to perform on-site infection prevention and control (IPC) assessments and to provide recommendations to staff and local health departments (LHDs). We describe the number and distribution of visits across the state and common IPC challenges identified. Methods: From February 1, 2020, to December 31, 2020, CDPH IP visits were requested directly by facilities, coordinated through LHDs and other state agencies, or prompted by a facility’s increasing case count on twice weekly review of the daily California healthcare facility data survey (Survey 123). Deployed IPs evaluated facility COVID-19 IPC protocols, assessed facility staff adherence using a standardized assessment tool, and provided verbal feedback followed by written summary reports and recommendations. We categorized visits geographically into 5 California Health Officer Association regions and by month, and we reviewed visit reports for common findings. Results: In total, 623 visits were performed for 489 outbreaks at 465 distinct facilities across 46 LHDs; 71 facilities received ≥2 visits. Southern California facilities received 292 visits (46.9%), San Joaquin region facilities received 138 visits (22.2%), Bay Area facilities received 131 visits (21%), Greater Sacramento facilities received 54 visits (8.7%), and Rural North facilities received 8 visits (1.3%) (Figure 1). The highest number of visits per month occurred in December (n = 143, 22.9%), followed by July (n = 87, 13.9%), and April (n = 83, 13.3%). Common IPC challenges included inappropriate resident cohorting practices, improper use of personal protective equipment, and lapses in physical distancing, and source control in breakrooms. Conclusions: On-site visits by CDPH IPs during the COVID-19 pandemic in California, though resource-intensive, provided substantial technical support for healthcare facilities during outbreaks and identified key areas for IPC improvement. Ongoing CDPH HAI guidance and training materials for facility-based IP staff are now being informed by these IPC challenges.

Funding: No

Disclosures: None

Figure 1.

Figure 2.

Background: Up to half of all new SARS-CoV-2 infections are acquired from presymptomatic or asymptomatic individuals. Hemodialysis patients and healthcare providers (HCPs) may be at increased risk for COVID-19 due to the need for extended close contact. Universal masking and eye protection are strategies used to reduce SARS-CoV-2 exposure, particularly from presymptomatic or asymptomatic individuals. We describe an outbreak of COVID-19 in an outpatient hemodialysis center despite universal masking and universal HCP eye protection. Methods: An COVID-19 outbreak investigation was performed in a hemodialysis center where universal masking was in use by all HCPs and patients and universal eye protection (goggles, safety glasses) was in use by all HCPs when directly encountering patients. After a cluster of cases was identified in early November 2020, all patients and HCPs were tested for SARS-CoV-2 by real-time reverse transcription polymerase chain reaction (RT-PCR) when symptomatic and weekly until the conclusion of the outbreak. Results: From November 12, 2020, through December 7, 2020, 14 (23.3%) of 60 patients and 9 (28.1%) of 32 HCPs tested positive for SARS-CoV-2 by RT-PCR (Figure 1). The median ages of the patients and HCPs were 64 years (range, 42–87) and 42 years (range, 29–68), respectively. Also, 5 (5.4%) individuals (3 patients and 2 HCPs) were asymptomatic at the time of testing. Furthermore, 7 (7.6%) individuals (5 patients and 2 HPCs) were hospitalized; 2 patients and no HCPs died. No lapses in universal masking or, for HCPs, eye protection prior to or during the outbreak were identified during the investigation. All HCPs and patients wore medical-grade face masks that were discarded at the end of the day; HCPs wore safety glasses or goggles during patient interactions. Although audits of face mask and eye protection compliance were not performed, independent interviews supported high HCP and patient adherence prior to the outbreak. Neither the staff nor patients shared meals at or outside the hemodialysis center. Most patients and HCPs shared the same hemodialysis shift, suggesting the presence of an index case; however, a source case could not be identified despite an extensive investigation. Conclusions: Universal masking and eye protection have been shown to reduce transmission of SARS-CoV-2 from presymptomatic or asymptomatic individuals in the healthcare setting. This report suggests that such measures cannot prevent all outbreaks. We speculate that certain factors associated with hemodialysis care, such as prolonged close patient–HCP contact, may have facilitated this outbreak. Whether nonadherence to universal masking and eye protection or failure of empiric droplet precautions contributed to this outbreak remains unknown.

Funding: No

Disclosures: None

Background:Acinetobacter baumannii, one of the major causes of nosocomial infections in modern healthcare systems, is characterized by its great persistence in the environment and by its ability to rapidly develop resistance to many antimicrobials. Most A. baumannii infections occur in intubated critically ill patients, causing ventilator-associated pneumonia which is a leading cause of mortality. During the coronavirus disease 19 (COVID-19) pandemic an increase in hospital-acquired carbapenem-resistant A. baumannii (CRAB) infection and colonization in acute-care hospitals has been described. CRAB healthcare-associated infections are often linked to breaches of infection prevention and control (IPC). Beginning in April 2020, our hospital’s IPC unit ordered mandatory universal masking for all healthcare workers (HCWs). Shortages of personal protective equipment during the COVID-19 pandemic led to extended use of surgical face masks by HCWs in our hospital. We investigated whether the extended use of surgical face masks was linked to an increase of CRAB colonization in our intubated critically ill patients. Methods: Surgical masks were collected from doctors, nurses, and housekeeping staff working in 2 internal medicine departments, each including a 4-bed unit for intubated critically ill patients. All surgical masks were worn continuously for 4–5 hours before removal. “Cases“ were defined as HCWs who treated CRAB colonized critically ill patients. “Controls“ were defined as HCWs who did not enter the critically ill patient unit. Surgical masks were incubated with BHI enrichment broth (HyLabs Rehovot, Israel) for 48 hours at 35°C. BHI was seeded on multidrug-resistant (MDR)–selective CHROMagar plates (HyLabs) and incubated overnight at 35°C. Identification was performed using MALDI-ToF mass spectrophotometry (bioMérieux, France). Susceptibility was tested using Vitek 2 (bioMérieux). Results: In total, 55 HCWs participated in the study: 25 cases and 30 controls. Masks from 10 cases (40%) were colonized with Acinetobacter spp versus only 3 masks (10%) from controls (OR, 5.98; 95% CI, 1.42–25; P = .012). Of 13 masks contaminated with Acinetobacter spp, 8 of 10 contaminated masks among cases were colonized with CRAB, whereas only 1 of 3 masks of controls was colonized with CRAB. Conclusions: During the COVID-19 pandemic, extended surgical mask use while treating patients colonized with CRAB increased mask contamination with this bacterium. Surgical masks should be changed after treating a patient colonized with CRAB the same way gown and glove removal and hand hygiene are performed.

Funding: No

Disclosures: None

Background: Accurately tracing nosocomial transmission of coronavirus disease 2019 (COVID-19) is critical to developing effective infection prevention policies. Given the high prevalence and variable incubation period of SARS-CoV-2 infection, the utility of traditional contact tracing is limited. We describe a nosocomial outbreak in which whole-genome sequencing (WGS) was pivotal to identifying the primary case. Methods: This study was conducted at a New York City academic hospital. The index case was identified on August 13, 2020, and the last case on September 9, 2020. Hospital policy required all inpatients to be screened for COVID-19 on admission by SARS-CoV-2 molecular amplification testing. All healthcare workers (HCWs) were required to wear masks and eye protection for patient care. After a patient (patient 1), who tested SARS-CoV-2 negative on admission, was positive on preprocedure screening on hospital day 9, contact tracing was initiated. Two patients (patients 2 and 3) and 13 HCWs with high-risk exposures (HREs) to patient 1 were quarantined and referred for testing. Additional surveillance testing was performed on 18 inpatients and 84 HCWs on the affected unit. Patients 2 and 3 and 3 HCWs (HCW-1, -2, and -3), only 1 of whom had a high-risk exposure to patient 1, tested positive. WGS was performed to further investigate this outbreak. Results: The outbreak variant (clade 20A) was found in samples from 6 patients and 2 HCWs. Patients 2 and 3 were roommates of patient 1 in the 2 days before patient 1’s positive test, and they did not consistently wear masks in the room. HCW-1 placed a peripheral IV in patient 1 the day before patient 1’s positive test without wearing eye protection. Four additional cases in this cluster (patients 4–6 and HCW-4) were identified by surveillance WGS of positive tests. A review indicated that patient 1 was located ~3 m (~10 feet) away from patient 4 in the emergency department (ED) for 6 hours on hospital day 1, when the admission SARS-CoV-2 test from patient 4 was not positive. No epidemiologic link was found to patient 5 or 6 or HCW-4. The specimen from HCW-2 was inadequate for WGS. The specimen from HCW-3 was not linked to this cluster. Conclusions: This complex nosocomial outbreak highlights the importance of WGS in understanding transmission events. Patient 4 was not identified by traditional contact tracing but was linked to patient 1 and was recognized as the primary case through WGS, having likely infected patient 1 in the ED. Based on these findings, we focused our corrective actions on more promptly isolating suspected COVID-19 cases in the ED, increasing inpatient masking, and improving HCW adherence to universal eye protection.

Funding: No

Disclosures: None

Background: Asymptomatic SARS-CoV-2 infections play a crucial role in viral transmission. However, they are often difficult to identify given that widespread surveillance has not been the norm. We sought to determine whether COVID-19 rates reported at the county level could predict the positivity rates for SARS-CoV-2 among asymptomatic patients tested in a large academic health system. Methods: This observational study was conducted from April 23, 2020, to December 10, 2020, at Froedtert Health (FH) system, the largest academic health system in Wisconsin. On April 23, 2020, FH implemented SARS-CoV-2 surveillance among all consecutive admissions not suspected of COVID-19, all patients scheduled for elective procedures and deliveries, and all asymptomatic patients with known exposures. Samples were processed by the FH laboratory using molecular methods (RT-PCR). To obtain the daily number of newly confirmed COVID-19 cases in Milwaukee County, we accessed the Wisconsin Department of Health Services publicly available COVID-19 database. For the purpose of this study, COVID-19 rates were defined as the percentage of positive tests among all daily tests performed at the county level, while SARS-CoV-2 positivity rates were the percentage of positive tests among all daily surveillance tests performed at FH among asymptomatic patients. The association between COVID-19 rates in Milwaukee County and asymptomatic rates at FH were assessed using an autoregressive moving average time series analysis. To examine the association between these rates, we fitted a seventh-order autoregression for the residuals based on autocorrelation function and partial autocorrelation function plots of the residuals from linear regression. Results: From April 23, 2020, to December 10, 2020, there were 2,347 new asymptomatic infections detected at FH and 75,196 new COVID-19 cases reported in Milwaukee County. Figure 1 shows the time-series plot of asymptomatic SARS-CoV-2 positivity rates at FH and Figure 2 shows COVID-19 rates in Milwaukee County. As the COVID-19 rate in Milwaukee County increased by 1 unit, the asymptomatic infection rate in FH decreased by 0.024 unit (95% CI, −0.053 to 0.004; P = .095) after accounting for autocorrelation over time. Thus, there was no association between these rates. Conclusions: The positivity rates among asymptomatic patients at a large medical center were not predicted by the positivity rate at the county level. This finding suggests that the epidemiology at a county level may be determined by pockets in the population who may not interact, and thus not affect, the positivity rates among asymptomatic patients served by a hospital system within the county.

Funding: No

Disclosures: None

Figure 1.

Figure 2.

Background: We investigated the contact status of medical staff with confirmed or suspected patients with COVID-19 in Sichuan Province, China, as well as the use of personal protective equipment at the time of contact, and we explored the factors affecting the effective use of personal protective equipment. Methods: We performed a cross-sectional study by distributing a questionnaire on occupational protection and exposure of medical staff in the diagnosis and treatment of COVID-19 using a convenience sampling method for online surveys from February 23 to February 29, 2020. Results: In total, 13,829 valid questionnaires from 644 hospitals in Sichuan Province were retrieved, and 802 people were exposed to confirmed or suspected patients with COVID-19, accounting for 5.80%. 688 (85.79%) of 802 people who reported that they had taken effective personal protection measures for each exposure. Sex, work department, and length of service were the independent factors influencing the effective use of personal protective equipment in multivariate analysis (P < .05). Conclusions: Medical institutions need to continue to strengthen the training regarding standard precautions and personal protection, especially for general departments other than fever clinics and isolation wards, as well as medical staff with few working years, to ensure the occupational safety of medical staff.

Funding: No

Disclosures: None

Background: The County of San Diego Health and Human Services (SDHHSA) established a goal to vaccinate 1.9 million residents as quickly as possible to attain vaccine induced herd immunity. This strategy would minimize the emergence of more transmissible variants, to which some vaccines may be less effective. With this strategy in mind, UC San Diego Health (UCSDH) collaborated with the local health authorities and the San Diego Padres to build a superstation in downtown San Diego in the parking lot of a baseball stadium. Methods: Building on the experience of rapidly vaccinating the UCSDH workforce in mid-December 2020, UCSDH and SDHHSA partnered to more efficiently distribute SARS-CoV-2 vaccine in San Diego County by building a vaccine superstation. The San Diego Padres offered their parking lot as the site; it was centrally located, easily accessible, quick to set up, and semipermanent. They also provided infrastructure support, event coordination, and internet capability. Occupying a space of ~6.5 acres, the superstation included 12 lanes serving 12 cars each, with ~3 cycles every hour, as well as a pedestrian walk-up station. Altogether, the site had the capacity for >5,000 vaccinations daily. This effort required coordination among administration, healthcare providers, IT specialists, and support staff—a daily workforce of >300 persons. The workforce needs were met using a multipronged approach, including flexible staffing, coordination of volunteers, and recruitment of previously retired providers. The private–public partnership enabled the superstation to be up and running in 5 days. Results: The operation was quickly ramped up to provide >6,000 vaccines daily. Initially only open to healthcare workers, on January 17 the superstation was expanded to persons aged >75 years, with further expansion to those aged ≥65 years on January 23. From January 11 to February 5, >100,000 individuals received their first dose of vaccine at the superstation, corresponding to ~31% of all San Diego county vaccinations. Conclusions: Vaccination of as many people as quickly as possible is essential to controlling the pandemic. Unchecked replication of SARS-CoV-2 allows increases the chance that the virus may develop mutations that render vaccines and therapeutics less effective. Our model vaccine superstation was replicated at 3 more sites around the county, the limited allocation of vaccine has been the only barrier to further expansion. A force of 10 superstations could administer a first dose to the remaining 1.6 million county residents within 32 days.

Funding: No

Disclosures: None

Background: Outcomes among nursing home residents with asymptomatic compared to symptomatic COVID-19 are not well characterized. We assessed all-cause mortality among Veterans’ Affairs (VA) community living center (CLC) residents; we compared those residents with a negative SARS-CoV-2 test to residents with symptomatic, presymptomatic, and asymptomatic SARS-CoV-2 infections. Methods: We conducted a national retrospective cohort study of CLC residents tested for COVID-19 between March 1 and July 31, 2020, based on data compiled through the VA COVID-19 shared data resource. Among those with a positive SARS-CoV-2 test, residents were considered symptomatic if they had experienced COVID-19 symptoms in the 30 days prior to the test. Residents were considered presymptomatic if they did not experience symptoms in the 30 days prior to testing and developed a fever (>38°C) or required supplemental oxygen within 14 and 60 days, respectively, following the test. Residents were considered asymptomatic in the absence of these pre- and posttest symptoms. Results: From March 1 to July 31, 2020, of 9,052 CLC residents screened for COVID-19, 8,325 (92%) tested negative (Table 1). Among 727 residents with positive tests, 467 (64%) were symptomatic, 88 (12%) were presymptomatic, and 172 (24%) remained asymptomatic. We observed significant differences in the racial makeup of these disease groups. Among CLC residents who were symptomatic or presymptomatic, 176 (32%) of 555 were black compared to 39 (23%) of 172 who were asymptomatic and 1,810 (22%) of 8,325 who tested negative for SAR-CoV-2. All-cause 30-day mortality rates for symptomatic and presymptomatic residents were 25% and 34%, respectively, which exceeded the all-cause 30-day mortality of asymptomatic residents (12%) and residents with a negative test (6%) (Figure 1). Conclusions: More than one-third of CLC residents with COVID-19 were asymptomatic at the time of testing. This finding highlights the importance of vigilant infection prevention and control measures. Our finding that mortality among presymptomatic residents exceeded that of symptomatic residents raises consideration for enhancing supportive care measures, such as supplemental oxygen and mitigation of inflammatory reactions, as a means to reduce mortality among nursing home residents with presymptomatic SARS-CoV-2 infections.

Funding: No

Disclosures: None

Table 1.

Figure 1.

Background: The COVID-19 pandemic has affected healthcare systems worldwide, but the impact on infection prevention and control (IPC) programs has not been fully evaluated. We assessed the impact of the COVID-19 pandemic on IPC consultation requests. Methods: The University of Iowa Hospitals & Clinics comprises an 811-bed hospital that admits >36,000 patients yearly and >200 outpatient clinics. Questions about IPC can be addressed to the Program of Hospital Epidemiology via e-mail, in person, or through our phone line. We routinely record date and time, call source, reason for the call, and estimated time to resolve questions for all phone line requests. We defined calls during 2018–2019 as the pre–COVID-19 period and calls from January to December 2020 as the COVID-19 period. Results: In total, 6,564 calls were recorded from 2018 to 2020. In the pre–COVID-19 period (2018–2019), we received a median of 71 calls per month (range, 50–119). The most frequent call sources were inpatient units (n = 902; 50%), department of public health (n = 357; 20%), laboratory (n = 171; 9%), and outpatient clinics (n = 120; 7%) (Figure 1). The most common call topics were isolation and precautions (n = 606; 42%), outside institutions requests (n = 324; 22%), environmental and construction (n = 148; 10%), and infection exposures (n = 149; 10%). The most frequent infection-related calls were about tuberculosis (17%), gram-negative organisms (14%), and influenza (9%). During the COVID-19 period, the median monthly call volume increased 500% to 368 per month (range, 149–829). Most (83%) were COVID-19 related. The median monthly number of COVID-19 calls was 302 (range, 45–674). The median monthly number of non–COVID-19 calls decreased to 56 (range, 36–155). The most frequent call sources were inpatient units (57%), outpatient clinics (16%), and the department of public health (5%). Most calls concerned isolation and precautions (50%) and COVID-19 testing (20%). The mean time required to respond to each question was 10 minutes (range, 2–720). The biggest surges in calls during the COVID-19 period were at the beginning of the pandemic (March 2020) and during the hospital peak COVID-19 census (November 2020). Conclusions: In addition to supporting a proactive COVID-19 response, our IPC program experienced a 500% increase in consultation requests. Planning for future bioemergencies should include creative strategies to provide additional resources to increase response capacity within IPC programs.

Funding: No

Disclosures: None

Figure 1.

Background: The impact of the coronavirus disease 2019 (COVID-19) pandemic on healthcare-associated infection (HAI) is not yet known. Diversion of resources from traditional HAI surveillance and prevention efforts toward institutional COVID-19 response, along with decrease in patient contact due to fear or required quarantine or isolation, may have increased HAI rates. In contrast, increased compliance with hand hygiene and personal protective equipment may have decreased HAI rates. Methods: We sought to determine the impact of COVID-19 pandemic on healthcare-associated central-line–associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI). CLABSI and CAUTI rates and standardized infection ratios (SIRs) reported to the NHSN from the first quarter of 2015 to the fourth quarter of 2020 were obtained for the entire facility and for the medical intensive care unit (MICU), which was converted during the pandemic to an intensive care unit solely for critically ill patients with COVID-19. Changes in CLABSI and CAUTI rates and SIRs before the pandemic (Q1 2015 to Q4 2019) and during the pandemic (Q1 2020 to Q4 2020) were assessed using an independent-sample t test. Results: The CLABSI rate was unchanged, with a mean (SD) of 0.64 (±0.34) CLABSIs per 1,000 central-line days before the pandemic and 0.72 (±0.22) during the pandemic (P = .62) (Figure 1). The SIR remained stable at 0.54 (±0.29) before and 0.96 (±0.59) during the COVID-19 pandemic (P = .25). However, CLABSI rate in MICU increased significantly from 0.92 (±1.00) to 2.75 (±1.00) (p < 0.01), along with SIR from 0.81 ± 0.89 to 2.53 ± 1.07 (p < 0.01) (Figure 1). CAUTI rate was unchanged with 1.17 ± 0.38 CAUTI per 1000 catheter days per quarter before, and 1.04 ± 0.87 during COVID-19 pandemic (p = 0.64). CAUTI SIR remained stable at 0.82 ± 0.31 before and 0.83 ± 0.86 during COVID-19 pandemic (p = 0.96). CAUTI rate in MICU was 0.78 ± 1.20 before and 2.17 ± 3.24 after COVID-19 pandemic (p = 0.45) (Figure 2). Conclusions: Although our institutional CLABSI and CAUTI rates and SIRs remained unchanged, our medical intensive care unit, which housed our critically ill patients with COVID-19, experienced significant increases in CLABSI rate and SIR. This finding is likely multifactorial in the setting of overextended nursing staff, use of prone position, and challenges of infection prevention efforts under isolation precautions.

Funding: No

Disclosures: None

Figure 1.

Figure 2.

Background: As the world grapples with the pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), it is important to consider the full impact of coronavirus disease 2019 (COVID-19) on healthcare delivery. Evidence from outbreaks of novel H1N1 and Ebola indicates that response to these types of outbreaks requires extraordinary resources, which are diverted from routine infection prevention and control activities. However, little is known about the impact of COVID-19 on adherence to patient safety protocols in hospitals, including infection prevention and control activities. We have described the reports of acute-care registered nurses (RNs) in adhering to patient safety protocols while delivering care to COVID-19 patients. Methods: In October 2020, we conducted a cross-sectional electronic survey of all active RNs in the state of New Jersey who provided direct patient care in a New Jersey hospital in an emergency or adult inpatient unit during the onset of the COVID-19 pandemic. Results: More than 3,027 RNs participated in the survey, for a 15% response rate based on number of eligible RNs. Moreover, 15% of respondents reported that they tested positive for COVID-19 during the initial peak of COVID-19 in New Jersey (March–June 2020). Most RNs reported that the number of patients they were assigned during the first peak of the pandemic affected their ability to adhere to patient safety protocols (eg, deep-vein thrombosis screening, central-line bundles, pressure ulcer prevention). In open-ended responses, they shared that being understaffed, the extra time it took for downing and doffing of PPE, the lack of access to ancillary staff (ie nursing assistants, runners), and the need to cluster care affected the quality of care. A nurse working in the intensive care unit (ICU) lamented, “We were sometimes given 4–5 ICU patients who were very sick and required a lot of care. Shortcuts had to be taken to prioritize the most important needs. Sometimes IVs remained longer than desired. Foleys remained in longer. To avoid PPE shortages, we didn’t go into the rooms nearly as much as we normally would, [and] things got missed.” Feelings of being overwhelmed and helpless permeated the nurses’ comments. Conclusions: When caring for COVID-19 patients, frontline nurses struggled with adherence to necessary patient safety protocols, which ultimately disrupted care delivery. Future research should quantify the extent to which the COVID-19 pandemic affected care delivery, including adherence to patient safety protocols among frontline providers.

Funding: No

Disclosures: None

Background: The coronavirus disease 2019 (COVID-19) vaccine is an important intervention to control the COVID-19 pandemic. As the most trusted profession integral to providing care to patients across all care settings, nurses play a critical role in educating patients regarding the SARS-CoV-2 vaccine. However, little is known about the readiness of registered nurses (RNs) to receive the vaccine. Methods: In October 2020, prior to FDA approval of vaccines, we conducted a cross-sectional electronic survey of all active registered nurses in the state of New Jersey. The eligibility criteria included providing direct patient care in a New Jersey hospital in an emergency or an adult inpatient unit during the emergence of COVID-19 (March 2020). Results: In total, 3,027 RNs completed the survey (15% response rate). When asked whether they plan to get vaccinated, 27% of RNs responded yes, 30% responded no, and 43% were undecided. Among those RNs who reported that they were planning to get vaccinated, their main reasons for their willingness to receive the vaccine included (1) wanting to protect themselves and their families (95%), (2) wanting to protect the community at large (76%), wanting to protect their patients (75%), the belief that life won’t get back to normal until most people are vaccinated (72%), and the belief that getting vaccinated is the best way to avoid getting seriously ill from COVID-19 (67%). The main reasons reported for not planning to or being undecided about getting vaccinated included the belief that the vaccine will likely be developed too quickly to be safe (81%) and concern about the side effects from the vaccine (74%). RNs also reported being in a low-risk group for becoming seriously ill (12%) and having had COVID-19 (8%) as reasons for planning not to get vaccinated. In open-ended responses, participants also discussed several additional issues driving vaccine hesitancy: their lack of trust in the political process, planning to become pregnant or currently pregnant or breastfeeding, questions about effectiveness of the vaccine and long-term side effects, and the need for more information before making a decision. Conclusions: This cross-sectional study of all acute-care RNs in the State of New Jersey was conducted prior to the FDA approval of COVID-19 vaccines. The results outline factors driving vaccine hesitancy among RNs. Although vaccine efficacy data and approval by the FDA may have alleviated some of these fears, immunization programs for healthcare workers and the public should focus on dispelling myths about vaccine development and side effects.

Funding: No

Disclosures: None

Background: Research analyzing COVID-19 symptom screening has primarily focused on adult patients. In efforts to safely reopen schools, symptom screeners are being widely utilized. However, pediatric-specific outpatient data on which symptom combinations best identify children with COVID-19 are lacking. Such data could refine school symptom screening by improving screener sensitivity and specificity. In this study, we assessed the frequency of symptoms and symptom combinations in children tested for SARS-CoV-2 in outpatient settings. We aim to contribute to the optimization of pediatric COVID-19 screening questionnaires, to ultimately minimize both COVID-19 transmission in schools and missed school days. Methods: We conducted a retrospective analysis of outpatient symptoms screens, SARS-CoV-2 test results, and demographics of children (≤18 years) tested for SARS-CoV-2 between March 30 and November 30, 2020, at 3 UCSF-affiliated COVID-19 outpatient screening clinics in northern California. Those with incomplete symptom screens, >7 days between symptom documentation and test, and invalid test results were excluded. Results: Of 473 children tested at 1 site, 21 children had positive SARs-CoV-2 results and 452 children had negative results (4.4% positivity rate). Moreover, 85.7% of SARS-CoV-2–positive children had a known exposure to COVID-19 (Table 1). Of SARS-CoV-2–positive children, 61.9% had >1 symptom. Also, 52.4% of SARS-CoV-2–positive children had at least 1 symptom (fever, cough, or loss of taste or smell) versus 62.8% of SARS-CoV-2–negative children (Table 2). Runny nose or nasal congestion was the most frequently reported symptom in the SARS-CoV-2–positive group (47.6%) as well as the SARS-CoV-2–negative group (58.6%). Also, 14.3% of SARS-CoV-2–positive children had eye redness or discharge versus 3.1% of SARS-CoV-2–negative children. Isolated runny nose presented in 10.8% of SARS-CoV-2–negative versus 9.5% of SARS-CoV-2–positive children. All children with isolated diarrhea (n = 5), isolated headache (n = 3), and isolated rash (n = 2) tested negative. Preliminary symptom data based on 176 children from a second site showed that 9.9% of symptomatic children had a positive test result. Conclusions: Runny nose or nasal congestion was the most frequently reported symptom in all children tested for SARS-CoV-2. However, isolated runny nose or nasal congestion identified 2 cases of COVID-19 in our cohort. Eye redness or discharge may be an important symptom to screen for COVID-19 in children. Further research with a larger number of positive cases is needed to make conclusions about improving efficiency and efficacy of symptom screeners for COVID-19 in children.

Funding: No

Disclosures: None

Table 1.

Table 2.

Background: At our institution, the concern for false-negative nasopharyngeal testing for SARS-CoV-2 at the onset of illness led to a general policy of retesting inpatients at 48 hours. For such patients, 2 negative SARS-CoV-2 PCR test results were required prior to discontinuation of COVID-19 control precautions. To assess the utility of routine repeat testing We analyzed patients presenting to our hospital who initially tested negative for SARS-CoV-2 but were found to be positive on repeated testing. Methods: All inpatients with symptoms concerning for COVID-19 were tested via nasopharyngeal sample for SARS-CoV-2 by PCR on admission. Patients with continued symptoms and no alternative diagnosis were retested 48 hours later. Testing was performed using either the Roche cobas SARS-CoV-2 RT-PCR assay or the Cepheid Xpert Xpress SARS-CoV-2 test. Between March 17, 2020, and May 10, 2020, we retrospectively analyzed data from patients with false-negative SARS-CoV-2 PCR test results who were subsequently confirmed positive 48 hours later. We evaluated demographic information, days since symptom onset, symptomatology, chest imaging, vital sign trends, and the overall clinical course of each patient. Results: During the study period, 14,683 tests were performed, almost half (n = 7,124) were performed through the ED and in the inpatient setting. Of 2,283 patients who tested positive for SARS-CoV-2, only 19 (0.01%) initially tested negative. Patients with initial false-negative test results presented with symptoms that ranged from fever and dyspnea to fatigue and vomiting. Notably, few patients presented “early” in their disease (median, 6 days; range, 0–10 days). However, patients with initial false-negative PCR test results did seem to have consistent imaging findings, specifically bilateral bibasilar ground glass opacities on chest radiograph or computed tomography scan. Conclusions: Among inpatients with COVID-19, we found a very low rate of initial false-negative SARS-CoV-2 PCR test results, which were not consistently related to premature testing. We also identified common radiographic findings among patients with initially false-negative test results, which could be useful in triaging patients who may merit retesting. Based on these data, we revised our existing clearance criteria to allow for single-test removal of COVID-19 precautions. Evaluating subsequent reduction in unnecessary testing is difficult given changing community prevalence, increased census, and increased opening to elective procedures. However, given the significant percentage of ED and inpatient testing, removal of repeated testing has likely resulted in a reduction of several thousand unnecessary COVID-19 tests monthly.

Funding: No

Disclosures: None

Background: We describe the infection prevention investigation of a cluster of 15 healthcare workers (HCWs) and 7 patients in a single non–COVID-19 unit of an acute-care hospital in September 2020. Methods: The infection prevention team was notified of 13 SARS-CoV-2–positive, symptomatic HCWs in an acute-care non–COVID-19 unit in 1 week (August 30, 2020, to September 3, 2020). In the same week, 2 patients who had been on the unit were diagnosed with nosocomial COVID-19. An epidemiologic investigation identified the exposure period to be between August 19, 2020, and September 3, 2020. The following immediate containment measures were implemented: closing the unit to new admissions, restricting float staff, moving existing patients to private rooms, mandatory masking of patients, and mandatory respirator and eye protection on unit entry for all HCWs. Exposed unit staff were tested immediately and then every 4 days until September 18, 2020. Likewise, exposed patients, including those discharged, were notified and offered testing. Hospital-wide HCW surveillance testing was conducted. Enhanced environmental control measures were conducted, including terminal cleaning and ultraviolet C (UV-C) disinfection of common areas and patient rooms and a thorough investigation of airflow. Detailed staff interviews were performed to identify causes of transmission. Multiple town hall meetings were held for staff education and updates. Results: In total, 108 total patients were deemed exposed: 33 were inpatients and 75 had been discharged. Testing identified 5 additional patient cases among 57 patients who received testing; 51 chose to self-monitor for symptoms. Staff testing identified 2 additional cases. Thus, 15 HCWs and 7 patients were linked in this cluster. The containment measures successfully ended staff transmission as of September 5, 2020. The last patient case was detected on September 10, 2020. Secondary cases were noted in 6 HCW families. We identified staff presenteeism, complacency, and socialization in break rooms and outside work as major causes of transmission. Suboptimal compliance with universal eye protection and hand hygiene (67%) were contributing factors. We determined by contact tracing and temporality that the outbreak could have stemmed from nursing home patient(s) through floating HCWs to staff on the affected unit. Directionality of transmission was from staff to patients in this cluster. Conclusions: Many facets of pandemic fatigue were apparent in this outbreak, namely, inability of HCWs to adhere to changing PPE guidance, presenteeism pressures due to workforce needs, and socialization with peers due to a false sense of security conferred by biweekly surveillance testing. Ongoing PPE education, repeated reinforcement, as well as engagement in staff wellness are crucial to combatting pandemic fatigue, conserving our workforce, and preventing future outbreaks.

Funding: No

Disclosures: None

Background: In November 2020, bamlanivimab received emergency use authorization (EUA) to treat patients with early, mild-to-moderate COVID-19 who are at high risk of progression. Montefiore Medical Center serves an economically underserved community of >1.4 million residents in the Bronx, New York. Montefiore’s antimicrobial stewardship team (AST) developed a multidisciplinary treatment pathway for patients meeting EUA criteria: (1) outpatients and hospital associates and (2) acute-care patients (EDs or inpatient). Methods: The Montefiore AST established a centralized process for screening high-risk COVID-19 patients 7 days a week. Referrals were sent by e-mail from occupational health, primary care practices, specialty practices, emergency departments, and urgent care centers. Patients were screened in real time and were treated in the ED or a newly established infusion center within 24 hours. After infusion, all patients received phone calls from nurses and had an infectious diseases televisit. Demographics, clinical symptoms, subsequent ED visit or hospital admission, and timing from infusion to ED or hospitalization were obtained from the electronic health record. Results: In total, 281 high-risk patients (median age, 62 years; 57% female) received bamlanivimab at the infusion center or in the acute-care setting between December 2, 2020, and January 27, 2021 (Table 1). The number of treated patients increased weekly (Figure 1). Also, 62% were Hispanic or black, and 96% met EUA criteria. Furthermore, 51 (18%) were referred from occupational health, 205 (73%) were referred from the community, and 25 (9%) were inpatients (https://www.fda.gov/media/143605/download). All patients were successfully infused without adverse reactions. In addition, 23 patients (8.2%) were hospitalized and 6 (2.1%) visited EDs within 30 days of treatment. The average number of days between symptom onset and infusion was 4.9. The median age of admitted versus nonadmitted patients was 68 years versus 61.5 years (P = .07). Conclusions: An AST-coordinated bamlanivimab treatment program successfully treated multiple high-risk COVID-19 patients and potentially reduced hospitalizations. However, the effort, personnel, and resources required are significant. Dedicated hospital investment is necessary for maximal success.

Funding: No

Disclosures: None

Table 1.

Figure 1.

Background: Current literature suggests that older age, hypertension, and diabetes mellitus confer a significant increased risk of mortality among patients with COVID-19. The purpose of this study is to further characterize the predictors of mortality in patients with COVID-19 in residents of Flint, Michigan, based on variables such as gender, age, smoking status, health insurance plan, and comorbidities. Methods: Hurley Medical Center, is a 443-bed public, nonprofit, teaching medical center located in Flint, Michigan. In total, 289 consecutive adult patients (aged ≥18 years) with confirmed SARS-CoV-2 infection by nasal polymerase chain reaction (PCR), admitted and discharged from our facility from March 2020 through June 2020, were retrospectively analyzed. Results: During the 4-month study period, the overall in-hospital case fatality rate (CFR) was 18% (51 of 289), with highest CFR in the age group aged 60–69 years (36%; P = .06). Nonsurvivors tended to be older with mean age of 67 years (95% CI, 61.6–71.8) versus survivors with mean age of 60 years (95% CI, 57.7–62.4). Highest mortality was seen in patients with Medicare or Medicaid as their sole health plan (39%, P = .59). Men comprised 51% (148 of 289) of the cohort with CFR of 21% versus 14% in females. Females tended to be younger with a higher body mass index (BMI) than their male counterparts (mean age of 58 years, mean BMI of 35 in women vs a mean age of 62 and BMI of 29 in men). A higher proportion of deceased were active smokers (51%; P = .02). CFR was highest in patients with hypertension (92%,; P = .15), followed by diabetes (44%; P = .85), chronic kidney disease (CKD) (31%; P = .10), obstructive sleep apnea (OSA) (28%; P = .25), asthma (22%; P = .64), and coronary artery disease (22%; P = .34). It was lowest in patients with end-stage renal disease (3%; P = .69). Conclusions: Our study suggests trends towards higher mortality with male sex, hypertension and diabetes, along with other comorbidities. Smoking seems to be a strong predictor of mortality in this cohort. Further studies are needed to ascertain the relationship between possible risk factors with COVID-19 mortality in residents of Flint, Michigan. Describing and understanding the potential risk factors is the key to improving outcomes in this population.

Funding: No

Disclosures: None

Background: Fungemia is associated with high rates of morbidity, mortality, and increase in length of hospital stay. Several studies have recognized increased rates of candidemia since the COVID-19 pandemic. Methods: Patients with candidemia during January through May 2020 were identified through Theradoc. Patient demographics, comorbidities, hospital management, and microbiology were extracted by medical chart review. Patients were divided into cohorts based on COVID-19 status. The Fisher exact and Satterthwaite tests were used for analyses of categorical and continuous variables, respectively. Results: Overall, 31 patients developed candidemia and 12 (38.7%) patients tested SARS-CoV-2 positive. Candida glabrata was the most prevalent causative organism in both groups. On average, COVID-19 patients developed fungemia 12.1 days from admission, compared to 17.8 days in the COVID-19 negative or untested cohort (P = .340). Additionally, COVID-19 patients with a fungemia coinfection were significantly more likely to expire; 10 COVID-19 patients (83.3%) died, compared to 7 (36.8%) in the COVID-19–negative or untested cohort (P = .025). The cohorts did not demonstrate statistically significant differences in terms of demographic, comorbidities, hospital management, or coinfections. Conclusions: The prevalence of fungemia in COVID-19 patients is significantly greater than historically reported figures. Known risk factors for candidemia, such as use of corticosteroid, use of central venous catheters, and prolonged ICU length of stay were higher in the SARS-CoV-2–positive cohort in this period, which likely contributed to increased fungemia rates, as these factors are also more pronounced in those with COVID-19. Patients who developed candidemia in the COVID-19 cohort had poorer outcomes than those who were SARS-CoV-2 negative or were untested. Further investigation should be conducted in larger studies.

Funding: No

Disclosures: None

Table 1.

Background: Methicillin-resistant Staphylococcus aureus (MRSA) remains a key pathogen in burn patients and is associated with increased morbidity and mortality. Disruption of skin barrier exposes these individuals to a myriad of infections. Various decolonization approaches, including chlorhexidine baths and intranasal mupirocin, have shown favorable outcomes in preventing MRSA infections in this cohort. Methods: In August 2020, a mupirocin decolonization protocol was implemented in Michigan’s largest trauma-level 1 burn intensive care unit. All patients admitted to the burn unit received daily intranasal mupirocin for the initial 5 days of hospitalization. We compared MRSA bacteremia rates per 1,000 patient days from January–July 2020 to those after August 2020. A hospital-acquired MRSA bacteremia infection was defined as a positive blood culture after hospital day 3. Patient characteristics and hospital course were collected through medical chart review. A 2-tailed t test was used for analysis. Results: We identified 5 cases of hospital-onset MRSA bacteremia and no cases of community-onset MRSA bacteremia. On average, there were 2.6 cases per 1,000 patient days before mupirocin implementation and 1.0 cases per 1,000 patient days after mupirocin implementation (P = .26) (Figure 1). In this patient cohort, the average total body surface area burned was 45.6% (range, 18%–90%), and 60% (n = 3) of patients had sputum culture positive for MRSA prior to developing bacteremia (Table 1). Also, 2 patients (40%) with MRSA bacteremia died. Notably, the patient in the postintervention cohort was admitted in July, prior to implementation. Conclusions: Implementation of a decolonization protocol with intranasal mupirocin in burn-surgery patients markedly decreased the incidence of MRSA bacteremia in this cohort. This is the first study to evaluate the use of mupirocin as a decolonizing agent in burn victims. Continued long-term surveillance is recommended, and this strategy has potential for application to other high-risk cohorts.

Funding: No

Disclosures: None

Figure 1.

Table 1.