Jenny Hayes, MSN, RN, CIC, CAIP, CASSPT

Annually, February is the month in which healthy heart awareness is promoted. With this month now behind us, let us not forget the importance of continuing to promote heart health and disease prevention throughout the year. Professionals in infection prevention (IP) have a unique opportunity to raise awareness of the link between infections and heart disease, as many people do not recognize this link.

Heart infections result from microbial invasion of the heart muscle. Most frequently, these microbes are bacterial or viral, but they may also be fungal.

 Although people of advanced age are at higher risk for these infections, younger people may also be at risk, depending on their immune status, comorbid conditions, and personal habits.

Intravenous drug abuse is a leading cause of 

dental hygiene and invasive dental procedures

 may also predispose a younger person to infective endocarditis of both bacterial and 

 in oral flora may become invasive with these dental risks. Pericarditis may be a secondary infection to viral respiratory, gastrointestinal, or fungal infections. Untreated tuberculosis and tick-borne pathogens add to the risk of bacterial pericarditis. SARS-CoV-2, 

 have all been implicated in viral myocarditis.

 Environmental pathogens such as parasites and fungi infections can increase the risk of myocarditis in the high-risk person.

For the hospitalized patient, prevention of bloodstream infections, pneumonia, and urinary tract infections serve to reduce the risk of any heart infection. Strict adherence to insertion practices and care and maintenance bundles for 

central line-associated bloodstream infections (CLABSI)

catheter-associated urinary tract infections (CAUTIs)

 prevent not only single body system infections but also serve as heart disease mitigation strategies. Infection surveillance for all infections allows early identification and treatment of infections that, if not identified early, may lead to serious myocardial compromise.

Mortality risks are not limited to just the acute phase of care. The inflammatory response of an acute infection has been demonstrated to have long-term sequela for risk of heart disease. This is demonstrated in a recent research publication in the 

Journal of the American Heart Association

 This study evaluated infection-related hospitalizations and the incidence of heart failure in a long-term study, with a median follow-up time of 27 years, in a diverse population of adults from 45 to 64 years. It was identified that patients with infection-related hospitalizations were at higher risk for heart failure with reduced ejection fraction when adjusting for risk variables.

 This is one of many more recent studies evaluating the long-term effect of inflammatory responses evoked by infection linked to chronic heart disease. In fact, this increased risk is demonstrated with COVID-19 as well and may have a genetic marker with ABO blood types.

Promoting heart health includes advocating for vaccines, 

 and personal hygiene throughout every month of the year. The IP professional is in a unique position to advocate for these prevention efforts in various health care settings, in the community, with individuals, and by lobbying for public policy. It is a broad net to cast in preventing infection-related heart disease, but it is one that IP professionals are certainly qualified to take on.

Cleveland Clinic. Heart Infection. Cleveland Clinic/Health Library/ Diseases and Conditions. November 8, 2021. Accessed February 28, 2025. 

https://my.clevelandclinic.org/health/diseases/22054-heart-infection

Molinsky RL, Shah A, Yuzefpolskaya M, et al. Infection‐related hospitalization and incident heart failure: The atherosclerosis risk in communities study. 

 2025;14(3). Accessed February 28, 2025. 

Hilser JR, Spencer NJ, Afshari K, et al. COVID-19 is a coronary artery disease risk equivalent and exhibits a genetic interaction with ABO blood type. 

 2024;44(11):2321-2333. Accessed February 20, 2025. 

https://doi.org/10.1161/atvbaha.124.321001

Articles

Silent threats lurk within—heart infections can stem from unnoticed bacteria, viruses, or fungi. Infection preventionists hold the power to stop these hidden killers before they strike.


Infection Prevention Matters in Heart Matters

The doctor is puncturing the left radial artery to get an arterial blood pressure line before the operation.

Patient safety is at the forefront of everything the infection preventionist (IP) is involved with. In this era of value-based purchasing (VBP) and health care transparency, it is no longer acceptable to be good or very good. The expectation is demonstrated excellence. The high morbidity and mortality rates resulting from central line–associated bloodstream infections (CLABSIs) make this a critical VBP infection metric set forth by the Centers for Medicare & Medicaid Services.

Critically ill patients, one of the most vulnerable patient groups, often have 1 or more central venous catheters (CVCs) in place and may also have an arterial line and peripheral lines. When a patient has a CVC and an unexplained BSI, the infection is usually attributed to the CVC. But what if the culprit is not the central line but one of the other access points?

Care and Maintenance of Vascular Accesses

When assessing CLABSI prevention, the IP reviews the CLABSI prevention bundles of care for insertion and maintenance to ensure that these practices are incorporated into policy and practice. Much emphasis has been placed on this bundled approach of care with demonstrated success in CLABSI reduction.¹ The same level of attention should also be directed at intra-arterial catheters (IACs) and peripheral intravenous (PIV) catheters.

Without the same level of heightened awareness of care bundles of other vascular catheter infection prevention practices, these additional devices can offer pathogens a portal of entry into the vascular system. Should this occur concurrently with a CVC and without evidence of another infectious source, the BSI will be attributed to the central line. In this scenario, the true CLABSI culprit evades detection.

Contributing to this phenomenon is the use of the CLABSI surveillance definition instead of the more stringent and less practical catheter-related BSI (CRBSI) clinical definition. CRBSI criteria require quantitative cultures of the CVC catheter tip and peripheral blood cultures that produce positive results identifying the same organism within 2 hours. “The incidence of arterial CRBSI has been shown to represent a significant health care burden, although it is commonly underestimated in clinical practice.”

 This underestimation may be relative to the lack of universal availability of laboratory resources for qualitative results.

Table. Drawing Blood From Open and Closed Arterial Line Systems

ABG, arterial blood gases; N/A, not applicable.

A literature review has identified that arterial and peripheral lines are often overlooked sources of BSIs. Buetti et al have identified in their multisocietal expert guidance document that these vascular accesses are not included in surveillance systems despite the increased risk of BSI and suggest that these devices could be included in infection surveillance systems.

 For their retrospective cohort study, Barros, Enfield, and Kadi identified IAC insertion practice variations and noted that reported rates of bacteremia with IACs were higher than observed with PIVs but lower than with CVCs.

 Their study concluded that IAC use actually demonstrated a higher associated risk of hospital-onset bacteremia than the risk with CVCs.

Figure 1, Examples of Open and Closed Systems

The study authors recognize that IAC-associated bacteremia will meet CLABSI criteria and “suggest that IACs be placed with similar precautions to CVCs.”

 The lack of consistent adherence to CDC-recommended practices for the care of IAC lines is also recognized in the narrative review of IAC infection risk by Card et al, and the incidence of these infections is underestimated.

 The Infusion Nursing Society guidelines “recognize the risk of an arterial catheter as a potential source of CLABSI.”

At the Association for Professionals in Infection Control and Epidemiology 2024 Annual Conference & Exposition, a poster presentation demonstrated a significant reduction in CLABSI rates when the use of closed Arterial-line systems (A-line) systems was implemented in phase 2 of their CLABSI reduction study. The poster abstract article is now published in the 

Arterial lines are inserted for blood pressure monitoring and easy access for blood studies. Nurses access them for laboratory blood specimens, and respiratory therapists access them for arterial blood gases. Both open and closed systems are available, with variations by manufacturer (

). A closed system is designed to prevent the entry of infectious organisms into the body. Closed device systems such as urinary catheters with an intact seal and closed ventilator suctioning catheters are other closed systems designed to prevent infection. The same closed system concept applies to arterial catheters.

 showed the procedural steps of drawing blood from both an open and closed arterial line system; these have been summarized and condensed into a comparison chart (

). The chart does not include all the steps but concentrates on the differences the IP might be interested in. Please note that manufacturer-specific steps should be considered.

When reviewing the chart, it should be noted that more manipulation may be required in the open system, both when drawing off the discard and again when flushing the port. In the closed system, the line does not need to be accessed additionally for those steps. The system should be examined for any residual blood present after completing the blood draw, whether by a nurse or respiratory therapist. At times, there may be residual blood in the stopcock port in an open system, which could be a medium for pathogen adherence should the stopcock get contaminated. If present, it should be flushed until clear.

One drawback to the closed system could be the difficulty of removing dried blood from the blood sampling port. This can be avoided by immediately removing blood from the sampling port with an alcohol pad. Also, if the hospital practice is to use alcohol-impregnated caps for the sampling port, it should be determined whether the sampling port can accommodate an alcohol-impregnated cap for the system used.

Figure 2. Component Examples Used for Drawing Blood Specimens Drom Open and Closed IAC Systems

It is critical to ensure that all health care personnel who access the IAC have had training specific to the type of IAC in use. PIVs may also contribute to BSIs. The number of PIVs in use should always be kept to a minimum and not left in “just in case.” Those that are needed should be assessed carefully per the hospital’s policy. Comprehensive policies and education should include strict insertion and maintenance bundles of care for all vascular access devices for CLABSI prevention.

Central lines and other intravascular devices can save lives or can contribute to sepsis and death. Their use and maintenance should be meticulous. Access points to the bloodstream must be minimized, and those needed should be safeguarded from infection. This way, the patient can receive the care needed for a safe journey back to health.

1. Gupta P, Thomas M, Patel A, et al. Bundle approach used to achieve zero central line–associated bloodstream infections in an adult coronary intensive care unit. 

2021;10(1):e001200. doi:10.1136/bmjoq-2020-001200

2. Card S, Piersa A, Kaplon A, et al. Infectious risk of arterial lines: a narrative review. 

 2023;37(10):2050-2056. doi:10.1053/j.jvca.2023.06.037

3. Buetti N, Marschall J, Drees M, et al. Strategies to prevent central line–associated bloodstream infections in acute-care hospitals: 2022 update. 

 2022;43(5), 553-569. doi:10.1017/ice.2022.87

4. Barros AJ, Enfield KB, Kadl A. Intraarterial catheter use is associated with increased risk of hospital onset bacteremia: a retrospective cohort study.

 2021;156(6):2321-2324. doi:10.1016/j.chest.2021.01.038

5. Nickel B, Gorski L, Kleidon T, et al. Infusion therapy standards of practice, 9th edition. 

 2024;47(1S suppl 1):S1-S285. doi:10.1097/NAN.0000000000000532

6. Nickel B. Hiding in plain sight: Peripheral intravenous catheter infections.

7. Ray LR, Miller K. Closed systems: are conventional arterial line monitoring and sampling systems contributing to central line associated bloodstream infections (CLABSI(s)? 

 2024;52(suppl 6):S60. doi:10.1016/j.ajic.2024.04.108

8. Elsevier Clinical Skills. Blood Specimen Collection: Arterial Catheter CE/NCPD. Accessed September 12, 2024. 

Infection preventionists focus on patient safety. Reducing CLABSIs requires meticulous care for all vascular access points, not just central lines, to prevent bloodstream infections.

CLABSI Culprits in Critical Care: Looking Beyond the Expected Portal of Entry

Surgical tools (Adobe Stock 18026114 by Dmitry Rukhlenko)

Instrument reprocessing off-site from the facility of use is a concept that has been previously introduced. Many hospital central processing departments (CPDs) sterilize instruments for ambulatory procedural areas under the hospital’s license. Recently, this concept has evolved into off-site sterilization facilities that reprocess instruments for hospitals. Large health care systems often own and operate these facilities and provide service to multiple hospital entities within the system or may be contracted to a third-party off-site sterilization provider. 

Off-site sterilization offers the benefit of additional real estate in the acute care setting. The return on investment (ROI) is realized with the additional hospital capacity for patient beds, procedural areas, and services. For example, some hospital CPDs are located adjacent to the operating rooms (ORs), and relocation of sterilization off site provides the opportunity to expand existing ORs for specialized procedures that require a more significant footprint or add additional ORs. A new hospital building with additional patient beds increases the demand for ORs and other procedural areas. Subsequently, increased volume of reusable medical instruments adds dimension to the proposal for an off-site sterilization plan.

Off-site sterilization offers the benefit of additional real estate in the acute care setting. The return on investment (ROI) is realized with the additional hospital capacity for patient beds, procedural areas, and services.

Real estate conservation is only one aspect of ROI. Consolidation of services also offers the opportunity to decrease labor costs while employing highly trained staff to ensure the product has been properly processed and is safe for patient use. Standardization of instrument sets, processes, and equipment decreases the risk of surgical site infections, resulting in revenue loss in terms of increased length of stay, readmission, and reimbursement from payers.

The planning stage begins with a high-level process map (or value chain map), then core processes and goals are identified. Key stakeholders at this stage include senior leadership, and this mapping may be part of the business plan proposal, which outlines the ROI. Once the decision is made to move forward with off-site sterilization, a more detailed process map defines the decision points based on the input and output of expected steps.¹ Engaging an infection preventionist (IP) who is certified in infection control in this detailed mapping is essential to the project’s quality and success. 

Assessment of needs is critical in the early planning stages with surgeon engagement. This begins with a current inventory and integrity of surgical sets, single instruments, and instrument manufacturer instructions for use (IFUs). The input of these process data will vary from the output, as outdated instruments lacking IFUs or compromised integrity shall be discarded from inventory. Anticipated surgical volume and types of procedures also impact the output data and are inherent to the detailed map. The goal is to standardize instrument sets to ensure capacities for sterilization cycles. Future projections should be incorporated into a designated time frame encompassing the near future. Five years may be a good starting point for this projection, as new procedures and instruments must be anticipated.

Another detail to be explored in this process map is what volume of sterilization services shall remain on-site and for what instruments. Keeping some sterilization and instrument inventory on-site in an emergency or disaster that precludes transport is essential. A “just-in-time” inventory management model may be used for single instruments for scheduled cases that are reprocessed on-site.

Transportation of instruments requires detailed inputs and outputs to identify variables, both anticipated and unanticipated. The Department of Transportation and states Department of Health regulations provide data inputs to the process design. Tracking instrument sets and air quality of temperature and humidity at holding stages adjacent to loading docks and during transport can be managed with electronic documentation. Variances in environmental conditions are unavoidable, as case carts are exposed to outside conditions²with loading dock and vehicle doors opening and closing. The IP can conduct a risk assessment for variances with a time threshold for any parameter that deviates from air quality standards for instrument handling during the transport and case cart holding stages. This assessment should be detailed as output data in the process map and embedded into subsequent policies and procedures.

The detailed process map should also include instrument tracking. This is conducted using an electronic scanning system to scan the instrument to the patient and, through transport, to scan into decontamination, sterilizer, and then to the case cart for transport back to clean storage in the hospital.

Instrument case carts built with the instrument sets and required soft goods for a surgical case may bypass clean storage and be taken directly outside the OR, where contents are unloaded and placed in the OR for the scheduled case per the just-in-time operations model.

Case carts must have a clean identifier on the outside, which is then changed to biohazard identification after the case when soiled instruments are loaded into it. Instruments must be precleaned at the point of use and sprayed with an enzymatic spray or another wetting agent to keep instruments moist until full decontamination occurs at the off-site reprocessing facility. The IP will review the proposed input processes data and make recommendations to the output data as needed to ensure compliance with the CDC’s Guideline for Disinfection and Sterilization in Healthcare Facilities³and the Association for the Advancement of Medical Instrumentation (AAMI) standards.

The architectural team draws up the design of the instrument processing facility. The IP reviews these plans to ensure the separation of clean and dirty. Heating, ventilation, and air conditioning should be assessed to comply with the American Society of Heating, Refrigerating, and Air-Conditioning Engineers and CDC requirements of directional airflow from clean to dirty and the associated differential air pressures, temperature, and humidity.⁴ Both decontamination and sterilization should have dedicated anterooms to maintain the differential airflow. Water management is also a critical assessment for the IP to ensure that AAMI standards for critical water and steam are achieved. Additional checks include directional instrument flow process from dirty to clean, including separate loading docks for each and placement of handwashing and eyewash stations. A vendor room for delivering instrument sets is best designed adjacent to the decontamination area with a pass-through chamber that prevents disruption of airflows. A separate clean room for loaner sterile instrument sets should be created the same way adjacent to the sterilization area so that cross-contamination does not occur.

The IP role also expands to employee safety. One example is a selection of personal protective equipment by assessing the ASTM rating of masks and AAMI level for gowns for fluid penetration. In addition, IPs can be instrumental in policy development that references instrument processing guidelines and standards, environmental controls, and employee safety. The expertise of IPs bridges the gap between a rogue process map and evidence-based practices that will withstand regulatory surveys. The assessment skills of IPs apply to selecting a third-party vendor for off-site sterilization, should this option be chosen.

Although the details of a process map and design for off-site sterilization should be narrower to meet the confines of this article, they can easily be further researched by the interested reader.

1. Discover the power of visual process mapping with our comprehensive guide. Creately. Updated December 11, 2022. Accessed March 24, 2023. 

https://creately.com/guides/process-mapping-guide/

2. Parker R, Baumgardner G, Klacik SG. Sterilization-related challenges of off-site transportation of medical equipment. Association for the Advancement of Medical Instrumentation. June 2, 2021. Accessed March 30, 2023. 

https://array.aami.org/content/news/sterilization-related-challenges-off-site-transportation-medical-equipment

3. Appendix B. Air. Guidelines for Environmental Infection Control in Health-Care Facilities (2003). CDC. Reviewed July 22, 2019. Accessed March 23, 2023. 

https://www.cdc.gov/infectioncontrol/guidelines/environmental/appendix/air.html

4. Disinfection and sterilization. CDC. Reviewed May 24, 2019. Accessed March 24, 2023. 

https://www.cdc.gov/infectioncontrol/guidelines/disinfection/index.html

Off-site sterilization frees up hospital space for patient care, improving hospital return on investment. This article explains why and how to go about setting up the service. 

A Road Map to Off-Site Sterilization 

Occupational risk of sharps injuries transcends health care from local and community settings to a global stage. Although often preventable, sharps injuries occur in high-income countries at an alarming rate, and low- and middle-income countries (LMICs) with higher endemic rates of blood-borne pathogens and/or limited resources pose a setting of increased risk for this professional hazard. In response to this often unrecognized or underreported issue, the International Sharps Injury Prevention Society (ISIPS) has designated the month of December as International Sharps Injury Prevention Awareness Month. This calendar designation offers recognition of sharps safety as a global health issue.

The World Health Organization (WHO) highlights the importance of this global perspective of occupational risk by offering data sets that disclose 1.5 million new cases of HIV, hepatitis B, and hepatitis C from 2019 to2020. Coupled with this data, the WHO data sets also identified disruption to health care services for prevention, detection, and treatment of HIV and hepatitis in the setting of the COVID-19 pandemic.

Although rates of HIV have slowly trended down in the United States over the past decade, rates have increased in LMICs. This offers an acute demonstration of disparities in health care access and resources.

Global politics compound the problem of health care inequities and occupational risk of sharps injury. Mass migration and civil unrest hinders access to health care as well as accurate current communicable disease trends. HIV and hepatitis can easily escape detection in this population, and receiving countries may struggle with availability of sharps safety products for vaccination at border crossings.

The ISIPS website offers an extensive listing of available sharps safety products and manufacturers.2 Unfortunately, health care disparities may prevent the use of the identified safety-engineered products. However, not all products are created equal.

The International Safety Center EPINet data unveils that 30.2% of 975 sharps injuries occurred with use of a sharps safety device. The safety mechanism was properly activated in approximately 10% of 290 cases.

This same report identifies that needle stick injuries (NSIs) with use of disposable syringes account for 27% of sharps injuries, and that it is nurses who incur the highest occupational risk in this category. Additional data in this report identifies intramuscular and subcutaneous injections as the primary source of NSIs. The data set predated the COVID-19 pandemic, which potentiated an increased risk of NSIs with mass vaccination in unfamiliar and nontraditional settings, such as tents or large arenas.

Future considerations in safe injection practices for mass vaccination during a pandemic might include dissolvable micro-needle dermal patches. A method of vaccine administration such as this may improve vaccination rates among needle-phobic clientele. In addition, vaccination efforts could be enhanced in LMICs with fewer required resources for large volume transport and storage.

No health care worker is immune from the dangers of handling sharps. Physicians hold a rate just under that of nurses, mostly related to use of scalpels, but are less likely to report these injuries. The actual number of all sharps injuries for all health care professionals may easily be double that of which is reported.

In the United States, the Needlestick Safety and Prevention Act was borne from the Safe Needles Save Lives campaign, launched by the American Nurses Association, and was enacted in November 2020. This law mandated that the Occupational Safety and Health Administration (OSHA) revise the OSHA blood-borne pathogens standard to include safety-engineered sharp devices. The revision also included the requirement that hospitals develop a blood-borne pathogen exposure control plan with annual updates and a requirement for a sharps injury log to track and trend occurrences to identify contributing factors. This standard offers a global model of prevention to also include use of personal protective equipment and work practice controls.

The Centers for Disease Control and Prevention contributes to a global model of sharps injury prevention with a comprehensive workbook to guide design, implementation, and evaluation of a sharpsinjury prevention program. Federal and state regulatory guidelines are presented as well as the cost of sharps injuries. The workbook user is offered operational guidance to include a multidisciplinary approach to selection of safety-engineered needles and other sharp devices. Embedded tool kits guide the user through the steps of operations, with the goal of establishing a culture of safety. Data analytics for assessing sharp injury prevention interventions are presented methodically, offering uncomplicated learnings to even the novice learner.

Environmental factors, such as lighting and noise, predispose the health care providerto these injuries. Even nondirect patient care employees, such as environmental or food service personnel, may be at risk when a direct care provider does not properly dispose used sharps. It is essential to assess the downstream effect of sharps handling when developing a sharps safety program.

Sharps safety is not limited to just health care settings or health care workers. Persons in the community may require the use of lancets or needles and syringes for monitoring and treatment of diabetes or other medical conditions. Municipal workers in waste management and/or recycling may also beat risk for sharps injuries. Children and other community members might incur a sharps injury when devices are not properly disposed.

It is critical that home care patients are educated about proper disposal of lancets and needles in sharps containers that are approved by the Food and Drug Administration and that community regulations are followed for disposal of container at the fill level. Other countries may have similar designated sharps containers as determined by regulatory authorities. In resource-limited countries or communities, external supports are required to safely manage sharps. Nations that align with WHO may serve as external resources.

The designated International Sharps Injury Prevention Awareness Month of December coincides with closure to the calendar year, and for many health care and political organizations, marks the end of a fiscal year. This offers an opportune time to assess local, national, and international resources and engage health care and political stakeholders in sharps injury prevention measures for the coming year. Finally, raising awareness on the importance of global health care equity is of paramount importance in reducing sharps injuries.

JENNY HAYES, MSN, RN, CIC, CAIP, CASSPT, has 15 years of experience as an infection preventionist, serving both in-patient and ambulatory care populations in multidisciplinary settings. She is an infection preventionist at the Hospital of the University of Pennsylvania.

Global progress report on HIV, viral hepatitis and sexually transmitted infections, 2021. World Health Organization. July 15, 2021. Accessed October 30, 2021. https://www.who.int/publications/i/item/9789240027077

Safety products categories. International Sharps Injury Prevention Society. Accessed October 29, 2021. http://isips.org/safety-products/safety-product-categories/

EPINet Report for needlestick and sharp object injuries. International Safety Center. July 19, 2017. Accessed November 1, 2021. https://internationalsafetycenter.org/wp-content/uploads/2018/06/Official-2016-NeedleSummary.pdf

O’Shea J, Prausnitz MR, Rouphael N. Dissolvable microneedle patches to enable increased access to vaccines against SARS-CoV-2 and future pandemic outbreaks. 

. 2021;9(4):320. doi:10.3390/vaccines9040320

Needlestick Safety and Prevention Act, HR 5178, 106th Congress (2000) Accessed October 28, 2021. https://www.cdc.gov/sharpssafety/pdf/Neelestick%20Saftety%20and%20Prevention%20Act.pdf

Sharps safety for healthcare settings. Centers for Disease Control and Prevention. February 11, 2015. Accessed October 27, 2021. https://www.cdc.gov/sharpssafety/index.html

No health care worker is immune from the dangers of handling sharps. Physicians hold a rate just under   that of nurses, mostly related to use of scalpels, but are less likely to report these injuries.

How to Keep Sharps Safety a Cut Above

The emergence of the SARS-CoV-2 virus swiftly effected change in every facet of society, with health care delivery being the frontline to the COVID-19 pandemic. This agent of change spared no population. Rapid process changes infiltrated neonatal intensive care units (NICUs) to protect the most vulnerable newborn babies who made their entry into the world during a global pandemic. Just as the virus has adapted to its global host with variant strains, health care delivery in the NICU has adapted with evolving and sustainable practices.

The NICU at the Hospital of the University of Pennsylvania provides care to a level 3 NICU patient population. The American Academy of Pediatrics defines a level 3 NICU as a hospital setting that offers expertise of care providers and specialized equipment needed to provide “comprehensive care for infants born < 32 weeks gestation and weighing < 1500 g and infants born at all gestational ages and birth weights with critical illness.”1 Four open bays comprise the 38-bed unit with only 2 negative pressure capable isolation rooms located in 1 of the bays. The NICU includes a separate resuscitation space adjacent to the labor and delivery (L&D) unit with 3 available bed spaces. To adapt to potential census fluctuations, many bed spaces are capable of accommodating overflow and multiple gestation infants in a single-bed space footprint.

Operational challenges in the NICU were quickly unveiled with the emergence of COVID-19. Staff illness or exposures to COVID-19 from community and workplace venues resulted in prolonged furlough periods.Severe supply chain shortages in personal protective equipment (PPE) and disinfectant products compounded these operational challenges, prompting conservation and reuse.2 The NICU was thrust into a crisis capacity mode from a baseline of conventional capacity operations.3 Unlike other areas of the hospital, the NICU could not reduce admissions or defer scheduled procedures. This prompted emergent planning for contingency operations.4

To continue safe delivery of care, immediate process changes were developed by a collaborative multidisciplinary team. Expert guidance was enlisted from the NICU and L&D nursing leadership and physician provider teams along with hospital partners from infection prevention and control, lab and pathology services, perioperative services, environmental services (EVS), facilities, and materials management (MM). Internal and external supply chain shortages of disinfectant products prompted EVS and MM to forge a plan to make and distribute disinfectant wipes.

Infection prevention in the NICU begins in the L&D setting. Prior to the availability of universal COVID-19 testing for the antepartum population upon admission, the patient history and physical (H&P) included screening for community exposure to COVID-19 and presence of signs or symptoms of COVID-19 infection.5 Any positive findings on the H&P resulted in a person under investigation (PUI) for COVID-19 status with laboratory testing to confirm diagnosis.6

Three negative pressure L&D rooms were designated for PUIs or COVID-19–positive patients. An operating room (OR) for cesarean-section deliveries was also designated for this patient population, with terminal cleaning commencing at the end of the case or upon discharge of the patient from the L&D room. A hospital nursing team of subject-matter experts (SMEs) was deployed to enhance PPE training with donning and doffing procedures as well as safe handling of N95 masks that were reused.7

An infant who was born to a mother who was a PUI required airborne and contact isolation pending the maternal COVID-19 result. This challenged the limitation of 2 NICU isolation rooms, prompting the conversion of the adjacent open bay to a negative pressure airflow to accommodate a third infant who would require isolation. Precipitous deliveries leave little time for the NICU to prepare for an admission, requiring airborne isolation resources to be in a state of readiness.

The admission of a third patient to the negative pressure bay requires imminent transfer of up to 4 other patients to other locations in the NICU. For this reason, the goal is to preserve this open bay for the most stable patients. Testing of the infant of the COVID-19–positive mother requires 2 negative COVID-19 tests 2 days apart. This time delay adds to the challenge of ensuring available isolation beds.

See the below slideshow for a demonstration of donning and doffing of PPE for the NICU (Photographer: Kelly Convery; Nurse donning and doffing: Christina Minnissale; Nurse in isolation room: Melanie Gabriel)

Donning and Doffing for the NICU

Because of the highly specialized nature of the neonatal population, the NICU adapted the hospital nursing SME model and implemented a unit specific team of SMEs. This core group of RNs served as trained observers for appropriate donning and doffing of PPE in the delivery room and during the admission and stabilization of the infant in the isolation bed space. This role quickly evolved into a dedicated resource for the interprofessional staff of the NICU. The acronym COPE was coined by a team member, Jennifer Roman, BSN, RN, CBC, to describe the team of COVID-19 operations and patient-care experts. In this role, nurses served as communication liaisons for unit leadership to disseminate the rapid evolution of guidance in the initial wave of the pandemic, which led to rapid process changes.

The COPE team was tasked with remaining knowledgeable on current processes, readily guiding the interprofessional team to unit resources and protocols and providing direct and indirect support to staff. In order to sustain preparedness, the COPE team created specific checklists and supply par levels that are utilized by all staff members to ensure isolation admission spaces are always at the ready. Identifying appropriate supply par levels and paring down admission supplies to the necessities also aided preserving supplies and minimizing waste during the terminal cleaning process of isolation spaces.

This population based SME team allowed for streamlined and systematic information communication to the unit staff members. The COPE team members were able to filter out the overwhelming volume of information being shared hospital-wide, much of which did not pertain to the specialized neonatal patient population, and provide concise, timely, and pertinent information to the neonatal team.

Ongoing assessments of patient and staff safety prevailed as more information about the transmission of SARS-CoV-2 virus and supply chain challenges became available. The interdepartmental collaboration and frequent virtual communications sustained the contingency plans and required resources through the peak of the pandemic, providing a pathway to a new conventional capacity operations model. Increased testing capacity and widespread vaccination for the SARS-Cov-2 virus has alleviated the contingency capacity operations with improved supply chain and decreased staffing burdens.

Sustained changes in the delivery of care in the NICU have forged new conventional capacity operations in the setting of the COVID-19 pandemic. Negative pressure in L&D rooms is no longer a requirement because updated information became available. A designated OR remains in use for COVID-19 positive patients as intubation may take place. Terminal cleaning procedures follow use of the L&D room or designated OR used for a COVID-19–positive patient. Infant resuscitation continues to be performed in the delivery room or in the OR. Delivery teams for COVID-19–positive patients continue to be limited to essential personnel with N95 masks used in aerosolizing procedures. The responding neonatal team has expanded to include pre-pandemic staff level participation.

Due to the increased potential for a neonate to require an aerosolizing procedure including initial resuscitation steps, neonatal responders continue to utilize N95 masks and viral filters for all neonatal respiratory equipment in L&D. Clean supply carts are maintained outside the room with a “clean” team member to hand off the supplies as needed to the delivery team. A daily checklist for supplies in each NICU isolation room is utilized to ensure capacity for airborne and contact isolation. Universal testing for hospital admissions continues. Visitors and employees are screened for symptoms of COVID-19 infection or exposure to sick contacts upon entry to the facility.

COPE team members continue to provide the necessary emotional support for the interprofessional staff during times of extraordinary stress and anxiety.8 The team serves as a sounding board for the other staff members and were able to bring forth staff concerns to unit based leadership for discussion and potential solution creation. Having dedicated “experts” who were specific to the unique population and space constrains of the NICU alleviated much of the staff worry, anxiety, and concern related to providing safe patient care. The COPE team continues to support the NICU interprofessional staff and has helped sustain unit readiness throughout several waves of COVID-19.

Surveillance for all hospital acquired infections as required by the state of Pennsylvania continued throughout the pandemic. No central line associated bloodstream infections (CLABSIs) were identified in over 400 days, nor were any other device-associated infections identified. There was no increase in nondevice–associated infections. Recent hand hygiene observations conducted by college co-op/volunteer students on all shifts revealed 95% compliance in 175 observations for 1 month.

This infection surveillance data indicates proven success in both contingency and new capacity models, with COVID-19 serving as an agent of change to facilitate improvement in infection prevention. A recently published study demonstrates the increased risk of maternal complications and preterm birth when COVID-19 infection occurs in pregnancy.9 This is a critical reminder that contingency planning and sustained operations are essential to the needs of our maternal and NICU population.

MICHELLE FERRANT, DNP, CNS, RN, RNC-NIC, ACCNS-N, CBC, is a clinical nurse specialist in the level III Intensive Care Nursery at the Hospital of the University of Pennsylvania.

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https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/strategies-optimize-ppe-shortages.html

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https://files.asprtracie.hhs.gov/documents/hospital-operations-toolkit-for-covid-19-patient-care-crisis-standards-of-care.pdf

COVID-19 sustainable response planning. Centers for Disease Control and Prevention. Updated January 4, 2021. Accessed July 30, 2021. 

https://www.cdc.gov/coronavirus/2019-ncov/global-covid-19/sustainable-response-planning.html

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Testing of the infant of the COVID-19–positive mother requires 2 negative COVID-19 tests 2 days apart. This time delay adds to the challenge of ensuring available isolation beds.