He was another victim of covid-19, the disease caused by the novel coronavirus. But this was something called nosocomial covid-19, that is, his infection was acquired in the hospital, not in the community.
As an infectious-disease doctor, I know nosocomial infections well. MRSA (methicillin-resistant Staphylococcus aureus), VRE (vancomycin-resistant Enterococcus) and C. diff (Clostridium difficile) are the “bread-and-butter” of my practice, afflicting too many patients getting treated in my hospital. The Centers for Disease Control and Prevention estimates that there are 1.7 million hospital-acquired infections, leading to 100,000 deaths. If doctors and nurses washed their hands diligently, research estimates that 40 percent of these infections could be prevented.
But in the case of my heart failure patient, it was not lack of hand washing that probably caused the infection. So, I explored. Could his infection have been from the hospital staff, such as doctors, nurses, care attendants, or physical and respiratory therapists who frequented the room to provide care? Or, was the infection from surfaces improperly cleaned in the rooms or the CT scanners, or was the infection from family members, like his wife of 40 years who had visited him often?
Initially, I thought it must have come from his family. As the epidemic rages in our community, nearly 1 in 10 people with minor or no symptoms has tested positive for the coronavirus. His family members sat a few feet away from his bed for hours every day. Had they unknowingly passed the virus on to him? Given my patient’s fragile heart and lung condition, he rapidly succumbed to the infection.
If covid-19 from family members was causing infection in our hospitalized patients, then the solution would be simple. Close all visitations or require visitors to test negative at regular weekly or biweekly intervals as a pass to enter the hospital. I spoke to the family and they all had indeed tested negative.
If the coronavirus was coming from surfaces, then the solution would be to double down on hospital cleaning. A study from Wuhan, China, published in the journal Emerging Infectious Diseases from a covid-19 ICU unit, found that 70 percent of floors, half of the swabs from soles of clinicians’s shoes, 75 percent of computer mice, 40 percent of bed handrails and 10 percent of doorknobs tested positive for the coronavirus. But my infection control team said the hospital’s environmental services staff had been diligent and that infection from surfaces had been unlikely.
Could the infection have come from an unsuspecting covid-positive staff member, who had come in to listen to my patient’s heart, change the IV pump or drop off a food tray? The simple act of breathing within a few feet is sufficient to transmit the coronavirus, especially with an estimated 40 percent of infected people being asymptomatic and going to work.
If covid-19 from staff was causing infection, then the solution would be different: rapid, frequent and regular testing.
A children’s cancer hospital has done that, since the facility has no margin of error. Twice a week, nearly every clinical caretaker is tested with a nasal swab. The hospital’s results over the past seven months have been both expected and remarkable. The number of total covid-19 cases among their employees rises and falls as the epidemic comes in waves in the community, as we would expect. But it was remarkable to learn that regular asymptomatic testing picked up 50 percent of all of the cases among the health workers.
If they had not been tested, these covid-positive hospital workers would not have been placed in isolation, and their close contacts would not have been quarantined. Over time, they could have passed on the infection to their immunocompromised patients.
Regrettably, covid-19 among hospital staff is common even after all the precautions with masks, shields and other personal protective equipment. Studies show that front-line health-care workers in the United States have a covid-positive rate that is four times greater than the general population.
Before I enter a room of a covid-positive patient, I am armored: an N95 mask covered with a surgical mask and then a face shield, along with a plastic gown and gloves. A hospital colleague who sees 20 to 25 covid-19 patients each day takes the same precautions. But in November, he texted me: “I have a temp of 100.6 just now . . . I was a little tired the whole day but nothing major.” The next day, he texted me: “I have tested positive.”
Where did he get it? His family tested negative and he has made a beeline from hospital to home each day for months, with no social activity, no shopping or gym visits. “So it must be a patient,” I said, or “maybe other staff members.” In our doctor’s lounge food is served, cable news runs 24/7 with election updates, and doctors, nurse practitioners and medical students frequently gather for coffee and respite, often taking off their masks to share covid-19 war stories. This can be a breeding ground for covid, too.
In our regional Memphis and Shelby County Covid-19 Joint Task Force meeting where hospital executives and mayors strategize, I have said that we need to do regular testing of hospital staff through the affordable technique of pooling up to 20 test samples. The costs for such PCR “gold standard” testing come to about $5 to $15 per pooled test, or that of a cup of coffee and a few doughnuts. If a pool test comes back positive, then individual testing of everyone in that pool can be done. Such once or twice a week covid-19 assurance testing could be done.
One afternoon, before my heart patient had died, I had a conversation with a hospital executive who told me: “I can’t afford to test my entire staff. No, it’s not the expense of the test, but the staff I would lose through furlough if the test came back positive.” The executive was talking about not only those who tested positive being in isolation and furloughed but also all their close contacts being in quarantine. While I was sympathetic, it makes no sense to stick our head in the sand. Without testing, we are flying blind.
Early in the pandemic, studies at academic centers did not find many cases of hospital-acquired covid-19 infections. Perhaps there was no widespread infection in the community, or the academic centers had stringent protocols.
In the case of my patient, as I stood in the hall, peering at the body bag, the ICU nurse told me, “You know a couple of nurses on the floor tested positive, too.” I suspect the infection was transmitted by a staff member, much like other nosocomial infections.
Since that first patient, I have seen five other cases of nosocomial covid in the past four weeks. The Mayo Clinic reported 900 employees who became covid-19 positive in just two weeks in November. Mayo officials said more than 93 percent of those cases were picked up outside the hospital, either at home or in the community. A small percentage of the 900 were exposed at work or through travel.
The Centers for Medicare and Medicaid Services needs to act now. The same regulations which nursing homes adhere to can be applied to hospitals: Until all health-care workers across the country are vaccinated, testing of hospital staff needs to be mandatory based on the community spread of infection in their county, and Medicare payments should be withheld if hospitals do not comply.
My experience tells me that nosocomial covid-19 is rampant, and hospitals are not sounding the alarm. Much like other hospital-acquired infections, covid in the hospital can be prevented, and many vulnerable patients protected. Hospitals should be places where patients come to get better, not sicker; where diseases are treated, not acquired; and where testing and tracing protocols need to be followed.
Manoj Jain is an infectious-disease consultant in Memphis. He also is a clinical associate professor at the University of Tennessee at Memphis and Rollins School of Public Health at Emory University in Atlanta.
Correction: This story has been corrected to say that most of the 900 Mayo Clinic staff members who tested positive for covid did not get it at work.