Prevention and Control Strategies of Nosocomial Infection and Effectiveness Evaluation in a Tertiary Teaching Hospital during the Epidemic of COVID-19 ()
1. Introduction
Although our hospital is not designated for the admission of COVID-19 patients, suspected cases could be admitted. Therefore, achieving the “four early” policy—early detection, early isolation, early diagnosis, and early treatment—is necessary to promptly prevent nosocomial cross-transmission and ensure the safety of healthcare and medical personnel. In response to the epidemic situation and to prepare for the potential influx of a large number of cases in a short period, our hospital has launched an emergency plan. This plan includes a series of measures aimed at promptly identifying COVID-19 cases, avoiding missed diagnoses and misdiagnoses, and preventing nosocomial infections, especially among medical staff.
2. Methods
2.1. Setting
The First Affiliated Hospital of Zhejiang Traditional Chinese Medical University, a tertiary teaching hospital situated in Hangzhou, Zhejiang Province, boasts 2060 beds, serves 2.7 million outpatients annually, and discharges 60,000 patients every year. It records approximately 30,000 fever-related outpatient visits annually.
2.2. Establishment of Special Working Groups
The following groups were established: Leadership, Diagnosis and Treatment, Infection Prevention and Control, Material Security, Logistics Support, Public Opinion and Information, Student Management, and Supervision. Emergency response was implemented throughout the hospital. The Spring Festival vacation was canceled, and multi-departmental cooperation for prevention and control was implemented.
2.3. Strengthening Pre-Examination and Triage Procedures
A temperature monitoring station is established at the hospital entrance to assess the temperatures of all entering patients, companions, and staff. Individuals exhibiting a temperature of ≥37.3˚C must visit the fever clinic for further consultation. At the entrances of both outpatient and inpatient buildings, patients are questioned about their epidemiological history and any presence of respiratory symptoms. Regardless of fever presence, individuals displaying respiratory symptoms or with a COVID-19 epidemiological background are directed to the fever clinic.
2.4. Reconstruction of the Isolation and Observation Ward
Two medical wards, comprising 65 beds each, were transformed into an isolation and observation ward in just three days. This newly configured space included separate passages for staff, patients, cleaning item delivery, and sewage. The ward was divided into three key zones: cleaning areas, potentially contaminated areas, and contaminated areas. The cleaning zones housed changing rooms, doctors’ offices, and restrooms. Meanwhile, the potentially contaminated zones featured chemical storage rooms, nurses’ offices, and rooms for preparing various articles. The contaminated zones were made up of observation and isolation rooms, alongside rooms designated for the disposal of contaminated materials. Furthermore, one of the additional medical wards, also consisting of 65 beds, was repurposed; half of it became a staff medical observation ward, and the other half served as an employee dormitory.
2.5. Restrictions on General Outpatient and Inpatient Services
From January 24 to February 29, the Stomatology Department, Otolaryngology Department, Ophthalmology Department, and Pulmonary Function Room were closed. Expert Clinics, Special Needs Clinics, and Specialist Clinics were suspended, while General Clinics remained open. Additionally, elective surgery was suspended during this period.
2.6. Strengthening of Nosocomial Infection Prevention and Control
2.6.1. Formulation of Systems and Programs
Six main systems and programs were developed, continuously updated, and optimized in accordance with the latest national and provincial documents to make them scientific, reasonable, and effective. These include: 1) Graded protection scheme and different posts protection standards (See Supplementary appendix Table 1); 2) The process for putting on and taking off personal protective equipment (Refer to Supplementary appendix Figure 1); 3) Instructions for the use of personal protective equipment in short supply; 4) Standard operating procedures (SOP) for cleaning and disinfecting environments affected by COVID-19; 5) Procedures for the disposal of medical waste stemming from COVID-19; 6) Key points of prevention and control of COVID-19.
2.6.2. Risk Classification Management
1) Key departments, including fever clinics (for both pediatrics and adults), respiratory clinics, isolation and observation wards, medical imaging departments, and polymerase chain reaction (PCR) laboratories, were identified as critical control points in the management of COVID-19. These departments underwent strict partition management, further categorized into clean areas, potentially contaminated areas, and contaminated areas. The activities and protective measures within these three zones were rigorously defined to ensure compliance with infection control standards.
2) Risk Department: A protective scheme was established for the stomatology department, endoscopic center, ophthalmology, pulmonary function room, otolaryngology department, hemodialysis room, obstetrics and gynecology department, emergency department, and emergency operation.
3) General outpatient clinic: The outpatient consultation process was formulated and optimized. The protection requirements for personnel in different positions were categorized and can be found in Supplementary Appendix Table A1.
4) General Ward: The department’s infection control group comprises a department director, head nurse, infection control doctor, and infection control nurse. This group is tasked with the training, assessment, supervision, and improvement initiatives within the undergraduate department.
5) Logistics Support Department: The Joint Logistics Support Department, along with the Medical Security Department, Information Department, and Security Department, conducted training and assessments on nosocomial infection prevention and control. This training was targeted at personnel who might come into contact with patients or enter high-risk departments. Participants included cleaning staff, engineering service staff, transportation staff, equipment engineers, information engineers, and security staff.
2.6.3. Personal Protection Management
The National and Provincial Health Committee requirements for the protection against COVID-19 were strictly implemented. A protection plan, tailored to the
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Figure 1. Flow chart of putting on and taking off protective equipment.
specific needs of our hospital, was developed. The procurement department ensured that all acquired or donated protective materials were inspected by infection control professionals. This was to confirm compliance with national standards or other relevant benchmarks. Due to the scarcity of certain supplies (such as protective clothing, gowns, medical protective masks, eye masks, and face masks), centralized limited distribution was enforced. This approach aimed at promoting scientific use and preventing overuse of these vital resources. Additionally, an alternative plan was established to ensure emergency preparedness in case the primary strategy proved insufficient.
2.6.4. Intensive Full Staff Training
Various online and offline methods were used to enhance staff training. A learning plan was accessible via the DingDing App on mobile phones. Staff from isolation and observation wards, fever clinics, medical imaging departments, laboratory departments, and logistics support departments underwent face-to-face training. The proficiency in donning and doffing personal protective equipment was evaluated by infection control professionals for each individual.
2.6.5. Strengthening Supervision
Three infection control professionals were appointed to oversee the clinic for at least half a day to implement nosocomial infection prevention and control measures. The fever clinic and isolation and observation ward adopted a 24-hour “two members, two supervision” system. An infection supervisor was stationed in each clinical and logistics service department to report daily results, which were then summarized and analyzed for further improvements. Although issues were resolved on the same day, the implementation of rectified measures was not instantaneous.
2.7. Effect Analysis
2.7.1. Control of the Source of Infection
The management efficiency of febrile patients with the outpatient rate of the fever clinic was evaluated. The outpatient rate of the fever clinic during Chinese Lunar New Year’s Eve 2020 to the lunar January 19 (January 24-February 12, 2020) was compared to that during the lunar time last year (lunar February 4-February 23, 2019). The outpatient rate of fever clinic = (the number of fever outpatients/the total number of outpatients and emergency outpatients during the same period) × 100%. The isolation observation rate, the proportion of suspected patients in isolation, and the proportion of confirmed patients in isolation were used to evaluate the control of the source of infection. The data were collected from January 24 to February 12, 2020. Isolation observation rate = (The number of patients in isolation/(the number of fever outpatients + newly admitted patients in the same period)) × 100%. The proportion of suspected patients in isolation = (total number of suspected patients/isolated patients) × 100%. The proportion of confirmed patients in isolation = (confirmed patients/suspected patients) × 100%. The definition of suspected and confirmed cases is mentioned in “The Diagnosis and Treatment Plan of New Coronavirus Pneumonia (Trial Version 6)” [5] . The data were obtained from the medical record system.
2.7.2. Staff Exposure Assessment and Medical Observation
Under the graded protection scheme, the infection diagnosis and treatment team, alongside the infection prevention and control expert group, assessed the effectiveness of personal protective measures for staff who were in close contact with suspected and confirmed cases. They then determined the need for medical observation [12] . The duration of medical observation was set at 14 days.
2.7.3. Compliance Analysis of Nosocomial Infection Prevention and Control Measures
Hand hygiene compliance was utilized as a metric to assess the implementation rate of prevention and control measures within the hospital. This measure, alongside hand disinfectant consumption, was evaluated from the eve of the Chinese Lunar New Year 2020 to lunar January 19 (January 24-February 12, 2020), and compared to the corresponding period in the previous year (February 4-February 23, 2019). An infection-control nurse monitored hand hygiene compliance across several departments, including the emergency department, fever clinic, infectious disease department, ICU, hematology, oncology, neurology, and gastrointestinal surgery departments. The observation methods adhered to the WHO Observation Tool [13] . The consumption data for hand disinfectants, classified as hazardous chemicals requiring usage records in each department, was obtained through consultation of these records.
2.7.4. Problem Solving
To improve the problems detected between January 20 and February 12, 2020, four lists, problem, rectification, responsibility, and problem-solving, were established, which required coordination among multiple departments. Problem resolution rate = (number of solved problems/number of problems) × 100%.
2.8. Data Analysis
SPSS 22.0 software (IBM, Armonk, NY, USA) was used to perform statistical analysis. A chi-square test was used to compare the rates. P < 0.05 was considered statistically significant.
3. Results
3.1. Source of Infection Control
3.1.1. Outpatient Rate of Fever Clinic
Compared to the lunar period of the previous year, the outpatient rate of the fever clinic increased by 1.85-fold in the current year (4.64% vs. 1.63%, P < 0.001) (See Table 1).
3.1.2. Isolation Observation
103 cases were observed in isolation, of which 15 were suspected of COVID-19, and 1 was diagnosed with COVID-19. The isolation observation rate stood at 4.89%. The proportions of suspected and confirmed patients in isolation were 14.56% and 0.97%, respectively (See Table 2).
3.2. Medical Observations of Staff
Three individuals were in close contact with two suspected patients under medical observation. These patients tested negative for the novel coronavirus nucleic acid twice over an interval of more than 24 hours. Additionally, two staff members were in close contact with a confirmed patient under medical observation. Nevertheless, no infections were reported at the end of the medical observation period.
3.3. Hand Hygiene Implementation Rate
Compared to the same period last year, the compliance rate of hand hygiene increased by 32.20% (65.28% vs. 86.30%, P < 0.001), and the consumption of hand disinfectant increased by 1.57-fold at the inpatient department (13.19 mL/bed
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Table 1. Changes in outpatient, emergency, and admission numbers compared to the same lunar time last year.
Note: *P < 0.001.
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Table 2. Suspicious COVID-19 isolation observation situation.
day vs. 5.13 mL/bed day), and increased by 4.42-fold at the clinic (1.68 mL/patient vs. 0.31 mL/patient) (See Table 3).
3.4. Problem Solving
Sixteen problems were listed as of February 12, 2020. Of these, 13 were resolved, and three were under continuous improvement (See Table 4). The problem resolution rate was 81.25%.
4. Discussion
In response to the COVID-19 epidemic, the hospital implemented a series of measures aimed at enhancing the detection of infection sources and ensuring adherence to prevention and control protocols, thereby reducing the risk of nosocomial infections. The period from January 24 to 30, 2020, coincided with the Chinese Spring Festival holiday. Due to the COVID-19 outbreak, the holiday was extended to include the Lantern Festival on February 8, 2020. During this time, there was a notable decrease in outpatient, emergency, and hospital admissions compared to the same period in the previous year. However, there was a significant increase in the rate of fever cases observed in the clinic, suggesting that the strengthened pre-examination and triage measures markedly improved case detection and decreased the likelihood of missed diagnoses. This paper discusses the effective isolation of one COVID-19 case from among 103 individuals undergoing isolation and observation, which helped minimize close contact between patients.
We exercised caution regarding the exposure of medical staff to protect each staff member who came into close contact with suspected or confirmed COVID-19 patients. Every staff member received effective protection and underwent an exposure risk assessment, given any possibility, however slight, of protection failure. We recommended medical observation for those in contact with suspected patients until such patients were ruled out. Ultimately, none of the five cases under medical observation contracted the infection.
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Table 3. Hand hygiene compliance rate compared to the same period last year.
Note: *P < 0.001.
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Table 4. Four lists for solving problems.
Hand hygiene serves as a key indicator of compliance with prevention and control measures. The data on hand hygiene were not specifically collected for this study, as they represent a routine aspect of hospital infection control. It is widely recognized as one of the most effective infection control practices. Additionally, the rate of hand disinfectant usage provides evidence of improved compliance with hand hygiene practices. During the epidemic, the placement of hand disinfectants in the clinic increased compared to the same period in the previous year. Consequently, the residual amounts in dispensers also increased, indicating that the consumption of hand disinfectants in outpatient and emergency departments was higher than the actual consumption reported.
Based on current findings, it is deducible that engineering prevention (physical isolation) served as the foundational method for controlling respiratory droplet-borne diseases. Administrative prevention, encompassing the establishment of systems, risk management, training, supervision and inspection, and multi-department joint prevention and control, acted as a safeguard against the spread of diseases. Personal protection, including the correct use of protective equipment, represented the last line of defense in occupational protection, where precision was critical and errors were unacceptable.
There are no perpetual hard winters and no late springs. The collective efforts of the hospital staff have enabled us to navigate through this challenging period successfully. We have made significant advancements in combating the COVID-19 pandemic, underlining the importance of continuing to analyze and share our experiences. This will enhance prevention and control strategies for similar or emerging infectious diseases in the future. The series of prevention and control measures implemented have proven to be effective, serving as a valuable guide for future emergency responses to epidemics. Additionally, these measures will improve our ability and efficiency in managing public health emergencies. They also offer a reference point for global health security, thereby strengthening the stability and resilience of the global health security system [14] .
Acknowledgements
The Zhejiang Chinese Medicine Science and Technology Plan (2024ZL423) supported this study.
Supplementary Appendix
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Table A1. Graded protection and protection standards of different posts.
Note: 0 Standard prevention: Applicable to medical staff in all treatment places; 1 Primary protection: It is suitable for medical personnel who may contact suspected NCP patients, such as pre-examination and triage clinics, fever clinics, respiratory clinics, and infectious diseases departments; 2 Secondary protection: It is applicable to medical personnel engaged in diagnosis and treatment activities in close contact with suspected or confirmed NCP patients; 3 Tertiary protection: It is applicable to situation when aerosol-generating operations are performed for suspected or confirmed patients during which the patient’s respiratory tract secretions, blood, body fluid may spray or splash, such as sputum suction, airway sampling, tracheal intubation and tracheotomy, etc.