The purpose of this document is to highlight practical recommendations to assist acute-care hospitals in prioritization and implementation of strategies to prevent healthcare-associated infections through hand hygiene. This document updates the Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals through Hand Hygiene, published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America, the Association for Professionals in Infection Control and Epidemiology, the American Hospital Association, and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.

We compared the effectiveness of 4 sampling methods to recover Staphylococcus aureus, Klebsiella pneumoniae and Clostridioides difficile from contaminated environmental surfaces: cotton swabs, RODAC culture plates, sponge sticks with manual agitation, and sponge sticks with a stomacher. Organism type was the most important factor in bacterial recovery.

After implementing a coronavirus disease 2019 (COVID-19) infection prevention bundle, the incidence rate ratio (IRR) of non–severe acute respiratory coronavirus virus 2 (non–SARS-CoV-2) hospital-acquired respiratory viral infection (HA-RVI) was significantly lower than the IRR from the pre–COVID-19 period (IRR, 0.322; 95% CI, 0.266–0.393; P < .01). However, HA-RVIs incidence rates mirrored community RVI trends, suggesting that hospital interventions alone did not significantly affect HA-RVI incidence.

Background: SARS-CoV-2 N95 mask contamination in healthcare providers (HCPs) treating patients with COVID-19 is poorly understood. Method: We performed a prospective observational study of HCP N95 respirator SARS-CoV-2 contamination during aerosol-generating procedures (AGPs) on SARS-CoV-2–positive patients housed in a COVID-19–specific unit at an academic medical center. Medical masks were used as surrogates for N95 respirators to avoid waste and were worn on top of HCP N95 respirators during study AGPs. Study masks were provided to HCPs while donning PPE and were retrieved during doffing. Additionally, during doffing, face shields were swabbed with Floq swabs premoistened with viral transport media (VTM) prior to disinfection. Medical masks were cut into 9 position-based pieces, placed in VTM, vortexed, and centrifuged (Fig. 1). RNA extraction and RT-PCR were completed on all samples. RT-PCR–positive samples underwent cell culture infection to detect cytopathic effects (CPE). Contamination was characterized by mask location and front and back of face shields. Patient COVID-19 symptoms were collected from routine clinical documentation. Study HCPs completed HCP-role–specific routine care (eg, assessing, administering medications, and maintaining oxygen supplementation) while in patient rooms and were observed by study team members. Results: We enrolled 31 HCPs between September and December 2021. HCP and patient characteristics are presented in Table 1. In total, 330 individual samples were obtained from 31 masks and 26 face shields among 12 patient rooms. Of the 330 samples, 0 samples were positive for SARS-CoV-2 via RT-PCR. Positive controls were successfully performed in the laboratory setting to confirm that the virus was recoverable using these methods. Notably, all samples were collected from HCPs caring for COVID-19 patients on high-flow, high-humidity Optiflow (AGP), with an average of 960 seconds (IQR, 525–1,680) spent in each room. In addition to Optiflow and routine care, study speech pathologists completed an additional AGP of fiberoptic endoscopic evaluation of swallowing. Notably, 29 (94%) of 31 study HCP had physical contact with their patient. Conclusions: Overall, mask contamination in HCPs treating patients with COVID-19 undergoing AGPs was not detectable while wearing face shields, despite patient contact and performing AGP.

Funding: None

Disclosures: None

Background: Working while ill, or presenteeism, has been documented at substantial levels among healthcare personnel (HCP) along with its consequences for both patient and HCP safety. Limited literature has been published on HCP presenteeism during the COVID-19 pandemic, and specific motivations for this behavior are not well described. Understanding both individual and systemic factors that contribute to presenteeism is key to reducing respiratory illness transmission in the healthcare setting. We characterized the frequency of and motivations for presenteeism in the workforce of a large academic medical center during the COVID-19 pandemic. Method: We deployed a voluntary, anonymous electronic survey to HCP at University of North Carolina (UNC) Medical Center in December 2021, which was approved by the UNC Institutional Review Board. We received 591 responses recruited through employee newsletters. Respondents recounted their frequency of presenteeism since March 2020, defined as coming to work feeling feverish plus cough and/or sore throat. In total, 24.6% reported presenteeism at least once, with 8.1% reporting twice and 5.3% 3 or more times. Asking more generally about any symptoms while working, the following were most common: headache (26%), sinus congestion (20%), sore throat (13%), cough (13%), and muscle aches (9.3%). Results: Motivations for presenteeism fell broadly into 4 categories: (1) perception of low risk for COVID-19 infection, (2) concerns about workplace culture and operations, (3) issues with sick leave, and (4) concerns about employment record and status. Among HCP reporting at least 1 instance, the most common motivations for presenteeism included feeling low risk for COVID-19 infection due to mild symptoms (59.9%), being vaccinated (50.6%), avoiding increasing colleagues’ workload (48.3%), avoiding employment record impact (39.6%), and saving sick days for other purposes (37.9%). Asked to identify a primary motivation, 40.3% reported feeling low risk for COVID-19 infection due to mild symptoms or vaccination, 21.2% reported a workplace culture issue (ie, increasing colleague workload, perception of weakness, responsibility for patients), 20.6% reported sick leave availability and use (including difficulty finding coverage) and 17.8% reported employment record ramifications including termination. Conclusions: This survey coincided with 2the onset of the SARS-CoV-2 ο (omicron) variant locally, and as such, risk perceptions and motivations for presenteeism may have changed. Responses were self-reported and generalizability is limited. Still, these results highlight the importance of risk messaging and demonstrate the many factors to be considered as potential presenteeism motivators. Mitigating these drivers is particularly critical during high-risk times such as pandemics or seasonal peaks of respiratory illness.

Funding: None

Disclosures: None

Background: Although vaccine hesitancy has been an issue for many years, it has become a major point of contention in the effort to mitigate the COVID-19 pandemic. In August 2021, a large academic medical facility began capturing the vaccination status of admitted COVID-19–positive patients, as well as their interest in the COVID-19 vaccine. We performed a descriptive analysis on the characteristics of unvaccinated patients who contracted COVID-19 and their interest in receiving the COVID-19 vaccine. Methods: Patient history and physical (H&P) notes and demographic data were collected using the internal data warehouse sourced from the electronic medical record for all SARS-COV-2–positive inpatient admissions to UNC Medical Center and UNC Chatham from August 1, 2021, to January 11, 2022. Manual chart reviews of progress notes were completed for patients whose history was not recorded in the initial H&P. Demographic data were summarized by vaccine status overall and by interest in COVID-19 vaccine among unvaccinated patients. We performed χ2 to determine demographic differences between the interested and uninterested unvaccinated groups. Results: In total, 536 patients were admitted with COVID-19 from August 1, 2021, to January 11, 2022. Of these, 15% were fully vaccinated (2 doses mRNA plus 1 dose J&J); 5.4% were partially vaccinated; 75.7% were unvaccinated; and 2.9% had an unknown vaccination status. Demographic characteristics are presented in Table 1. The most common demographics were consistent among the fully vaccinated and unvaccinated groups, with the exception of sex and age group (Table 1). For those whose interest data were available (n = 164), 34% were uninterested in receiving the COVID-19 vaccine. Importantly, race and age were statistically significantly different (P < .05) between the unvaccinated interested and unvaccinated uninterested groups. Conclusions: Even after experiencing COVID-19 firsthand and being hospitalized, some people who remain uninterested in receiving the COVID-19 vaccine. This population had a statistically higher proportion of white and older individuals than the unvaccinated interested group. Recommendations from healthcare providers might not be effective in persuading this population to be vaccinated. Instead, grassroots alternatives might be more successful. Additional analysis should be considered on whether patients who expressed interest in COVID-19 vaccine received immunization.

Funding: None

Disclosures: None

Overall, engagement and compliance from the crowd-sourced hand hygiene observation program, Clean-In-Clean-Out (CICO), were similar between 2019 (96.6%) and 2020 (96.7%) despite fluctuations within 2020 that reflected our hospital’s coronavirus disease 2019 (COVID-19) experience. Shared responsibility and just-in-time reminders can allow manual hand hygiene observation models to be sustainable.

Initial assessments of coronavirus disease 2019 (COVID-19) preparedness revealed resource shortages and variations in infection prevention policies across US hospitals. Our follow-up survey revealed improvement in resource availability, increase in testing capacity, and uniformity in infection prevention policies. Most importantly, the survey highlighted an increase in staffing shortages and use of travel nursing.

Hospital-associated fungal infections from construction and renovation activities can be mitigated using an infection control risk assessment (ICRA) and implementation of infection prevention measures. The effectiveness of these measures depends on proper installation and maintenance. Consistent infection prevention construction rounding with feedback is key to ongoing compliance.

Background: The use of personal protective equipment (PPE) is a critical intervention in preventing the spread of transmission-based infections in healthcare settings. However, contamination of the skin and clothing of healthcare personnel (HCP) frequently occurs during the doffing of PPE. In fact, nearly 40% of HCP make errors while doffing their PPE, causing them to contaminate themselves. PPE monitors are staff that help to promote their colleagues’ safety by guiding them through the PPE donning and doffing processes. With the advent of the COVID-19 pandemic in early 2020, the UNC Medical Center chose to incorporate PPE monitors as part of its comprehensive COVID-19 prevention strategy, using them in inpatient areas (including COVID-19 containment units and all other units with known or suspected SARS-CoV-2–positive patients), procedural areas, and outpatient clinics. Methods: Infection prevention and nursing developed a PPE monitoring team using redeployed staff from outpatient clinics and inpatient areas temporarily closed because of the pandemic. Employee training took place online and included fundamentals of disease transmission, hand hygiene basics, COVID-19 policies and signage, and videos on proper donning and doffing, including coaching tips. The monitors’ first shifts were supervised by experienced monitors to continue in-place training. Employees had competency sheets signed off by a supervisor. Results: The Medical Center’s nursing house supervisors took over management and deployment of the PPE monitoring team, and infection prevention staff continued to train new members. Eventually, as closed clinics and areas reopened and these PPE monitors returned to their regular positions, areas used their own staff to perform the role of PPE monitor. In the fall of 2020, a facility-wide survey was sent to all inpatient staff to assess their perceptions of the Medical Center’s efforts to protect them from acquiring COVID-19. It included a question asking how much staff agreed or disagreed that PPE monitors “play an important role in keeping our staff who care for COVID-19 patients safe.” Of the 626 staff who answered this question, 67.6% agreed or strongly agreed that PPE monitors played an important role in keeping staff safe. Thus far, there has been no direct transmission or clusters of COVID-19 involving HCP in COVID-19 containment units with PPE monitors. Conclusions: PPE monitors are an important part of a comprehensive COVID-19 prevention strategy. In early 2021, the UNC Medical Center posted and hired paid PPE monitor positions to continue this critical work in a sustainable way.

Funding: No

Disclosures: None

Background: Care bundles comprise evidence-based practices and interventions that are easily and consistently implemented while improving patient outcomes. As patient acuity and task overload continue to increase, infection prevention bundle and process measure compliance and data collection may become a lower priority for registered nurses (RNs). In early 2019, a certified nursing assistant (CNA) began full-time quality liaison work on a 53-bed inpatient adult oncology unit at UNC Medical Center to provide targeted compliance data collection and to correct deficits in real time when possible and within the appropriate scope of practice. Methods: The quality liaison CNA is highly motivated, with a relevant clinical background and effective communication skills. After conducting a gap analysis, the unit developed specific responsibilities for several areas of quality improvement, including infection prevention. In addition to rounding on all patients daily, the quality liaison (1) performs direct patient care tasks like Foley catheter care, (2) conducts patient education on topics such as chlorhexidine gluconate treatments, (3) performs all relevant process measure audits, and (4) easily relays missed or needed care to RNs with a door sign created as part of this initiative. High-risk findings, such as a loose central-line dressing, prompt immediate communication to the RN, with follow-up and escalation when necessary. Results: Patients and staff received the quality liaison well, and the increased attention to care bundle components and auditing ensured consistent, evidence-based care along with accurate and reliable data collection. Compared to the previous calendar year, the number of central-line audits on the unit increased by >1,400 by the end of 2019. Patient outcomes improved, and during 1 fiscal year, the unit achieved rate reductions between 40% and 55% for central-line–associated bloodstream infections, catheter-associated urinary tract infections, and healthcare-associated C. difficile infections. Staffing and logistical challenges imposed by the COVID-19 global pandemic have hampered this work because the quality liaison was redeployed to direct patient care intermittently. Correspondingly, from July to October 2020, the same infection rates increased between 30% and 353%. Conclusions: Having a designated quality liaison is an effective means to achieving quality improvements while remaining an integral member of the patient care team. As staffing has improved on this unit, the quality liaison has refocused efforts, and infection rates are beginning to improve. Given the success of the quality liaison role in improving quality outcomes on this unit, the hospital is exploring expansion of this model to additional units.

Funding: No

Disclosures: None

Background: Hand hygiene is essential to preventing the spread of disease in hospitals. Renewed emphasis has been placed on hand hygiene during the COVID-19 pandemic. We investigated whether UNC Medical Center’s well-established Clean-In Clean-Out (CICO) program for hand hygiene observations was sustainable throughout a public health and healthcare crisis and whether the COVID-19 pandemic had an effect on hand hygiene compliance. Methods: UNC Medical Center utilizes a crowd-sourced hand-hygiene audit application, CICO, to track hand-hygiene observations, compliance, and feedback. This application encourages participation from all staff and promotes providing real-time feedback in the form of a compliment or reminder when performing hand hygiene observations. During this evaluation, hand hygiene data were queried from the CICO application on the number of observations performed, hand hygiene compliance percentage, and feedback compliance percentage from July 2019 to December 2020. Hand hygiene data were compared to patient volumes in different care settings and the number of hospitalized patients being treated for COVID-19. Results: Initial increases in hand hygiene observations, compliance, and feedback were detected in the months leading up to UNC Medical Center receiving its first SARS-CoV-2–positive patient. Observations were highest when patient volumes were low due to closed clinics and restrictions on elective surgeries (Figure 1). When patient volumes returned to pre–COVID-19 levels coupled with treating more COVID-19 patients, the number of observations and compliance rate metrics declined. Feedback compliance percentage remained relatively stable through the entire period (Figure 2). Conclusions: Despite the additional strain on healthcare staff during COVID-19, the CICO model was a sustainable method to track hand hygiene observations and compliance. Notably, however, engagement was highest when patient census was lower, demonstrating that operating at a high capacity is not beneficial for patient safety. Due to the success and sustainment of the CICO program, UNC Medical Center used this model to create a Mask-On Mask-Up campaign to engage staff to submit observations, track compliance, and encourage feedback to promote the appropriate use of masks during COVID-19.

Funding: No

Disclosures: None

Figure 1.

Figure 2.

Background: Reports of hospitals overwhelmed by COVID-19 patients created severe shortages of personal protective equipment (PPE). In this large academic medical system, we used a systematic team approach to proactively maintain an adequate PPE supply. The team consisted of staff from multiple departments including infection prevention, environmental health and safety, operational efficiency, and supply chain. The healthcare system solicited donations of PPE, and our team was tasked with developing a sustainable method to provide healthcare workers with safe and effective N-95 respirators. Respirators are normally fitted to our 6,000+ healthcare workers through a fit-testing process using 4 models of N-95s. We received >60 models, many in small quantities, posing a new level of complexity that prevented use of our typical fit-testing method. Methods: Donated respirators were manually verified on the CDC/NIOSH website to validate approval or approved alternative. A categorization system was developed, and respirators were sorted based on quality, style, and condition. User seal checks replaced qualitative fit testing due to the uncertain and quickly changing respirator supply. Staff were educated about the importance of performing a seal check to evaluate respirator fit and were provided instructions for what to do if they failed a seal check. We performed limited quantitative fit testing on a small group previously fit tested to 1 of the 4 models of N-95s normally stocked to identify the most effective alternative respirators to serve as substitute N-95s. Results: We were able to provide staff with new N-95s and delay the release of reprocessed N-95s. Overall, 18 models of respirators were tested on staff for filtration effectiveness and fit. We deemed 61% masks to be of last resort, and these were not released. We determined that 39% were acceptable as an alternative for at least 1 of our usual respirator models. However, only 3 models (17%) available in small quantities fit wearers whose size was in shortest supply. This scarcity led to the evaluation and purchase of a new respirator prototype for small N-95 wearers, which was an important success of our team’s work and for staff safety. Conclusions: Collaboration between teams from a variety of backgrounds, using both qualitative and quantitative data, resulted in a sustainable method for receiving, sorting, and evaluating donated N-95 respirators, ensuring the delivery of a steady supply of effective N-95 respirators to our staff. This quality-driven approach was an efficient and effective strategy to maintain our N-95 respirator supply during a pandemic driven global shortage.

Funding: No

Disclosures: None

We evaluated the ability of an ultraviolet-C (UV-C) room decontamination device to kill Candida auris and C. albicans. With an organic challenge (fetal calf serum), the UV-C device demonstrated the following log10 reductions for C. auris of 4.57 and for C. albicans of 5.26 with direct line of sight, and log10 reductions for C. auris of 2.41 and for C. ablicans of 3.96 with indirect line of sight.