Coaching, Collaboration, Cleaning, & Communication: 4C Intervention to Reduce SARS-CoV-2 Transmission

摘要 自新型冠状病毒SARS-CoV-2被发现以来的六个月里，COVID-19在地球仪上迅速蔓延。 在中国武汉的一群社区获得性肺炎患者中首次发现。截至6月10日， 2020年，美国疾病控制和预防中心（CDC）报告了超过190万例COVID-19病例， 美国有112，133人死亡;世界卫生组织（WHO）报告了超过710万例病例和408，025例 全球死亡人数（216个国家）。高龄和基础疾病是ICU的危险因素 因COVID-19感染入院，这意味着疗养院（NH）居民患重症的风险更大。 与此同时，国家卫生机构长期以来在实施有效的感染预防方面面临特殊挑战 计划，包括有限的资源和诊断的挑战，在一个脆弱的功能残疾长期停留 人口到目前为止，在美国，大约三分之一的死亡病例与NH或 其他长期护理设施。预计病毒将在2020年秋季卷土重来，推进我们的 了解SARS-CoV-2在这些设施内对弱势群体的传播， 紧急和进一步的调查。据报道，SARS-CoV-2的环境污染有限， 研究强调了患者、其环境和医疗保健之间传播的潜在重要性 通过直接和间接的联系。根据这一建议，我们计划描述SARS的流行病学特征- 随着时间的推移，NH病房环境中的CoV-2以及传播到近距离和远距离环境的风险， 其明确意图是制定综合、简单的COVID-19感染预防策略。我们将 通过以下目标实现这些目标。具体目标1：描述SARS-CoV的传播特征- 2例急性后护理环境中的病毒，包括病房和常用区域，如护士室 车站、餐饮区和娱乐区。我们将对老年人进行前瞻性纵向研究， 在4个指定COVID-19单位的NH中有活动性COVID-19感染，以描述病毒的风险因素 传输我们假设，包括功能障碍、合并症和COVID-19在内的风险因素 症状的严重程度将与SARS-CoV-2传播到环境中的可能性增加有关 在新冠病毒感染活跃的居民中。具体目标2：采用随机分组研究设计， 我们将测试一种多模式的老龄友好干预措施，包括四个组成部分（4C）：1）教练：感染 预防指导，以观察、教授和审计所有前线人员基于证据的感染预防做法 临床医生; 2）清洁：标准化推荐的环境清洁方案， 环境污染; 3）沟通：患者和家属沟通策略， 实施患者手部卫生和推荐的PPE使用;以及4）协作：快速检测， 与转诊医院合作进行检测和接触者追踪。我们假设， 这种干预将与SARS-CoV-2向环境传播的可能性较低有关。

ABSTRACT COVID-19 has spread rapidly across the globe in the six months since the novel coronavirus SARS-CoV-2 was first detected in a cluster of patients with community-acquired pneumonia in Wuhan, China. As of June 10, 2020, the Centers for Disease Control and Prevention (CDC) reports over 1.9 million COVID-19 cases and 112,133 deaths in the US; the World Health Organization (WHO) reports over 7.1 million cases and 408,025 deaths worldwide (in 216 countries). Advanced age and underlying conditions are risk factors for ICU admission with COVID-19 infection, meaning nursing home (NH) residents are at greater risk for severe illness. At the same time, NHs have long faced special challenges in implementing effective infection prevention programs, including limited resources and diagnostic challenges in a frail functionally disabled long-stay population. To date, approximately one in three deaths from the virus in the US have been linked to NHs or other long-term care facilities. Anticipating that the virus will return in the fall of 2020, advancing our understanding of the transmission of SARS-CoV-2 within these facilities for vulnerable populations deserves urgent and further investigation. Environmental contamination with SARS-CoV-2 that is reported in limited studies highlights the potential importance of transmission between patients, their environment, and healthcare providers via direct and indirect contact. With this proposal, we plan to characterize the epidemiology of SARS- CoV-2 in the NH patient room environment over time and the risk of transmission to near and far environments, with the explicit intent of developing integrated, simple COVID-19 infection prevention strategies. We will achieve these goals through the following aims. Specific Aim 1: Characterize transmission of the SARS-CoV- 2 virus within post-acute care settings including patient rooms and common use areas such as nurses' stations, dining areas and recreation areas. We will conduct a prospective longitudinal study of older adults with active COVID-19 infection at 4 NHs with designated COVID-19 units to describe risk factors for virus transmission. We hypothesize that risk factors including functional disability, comorbidities, and COVID-19 symptom severity will be associated with increased odds of SARS-CoV-2 transmission to the environment among residents with active COVID-19 infections. Specific Aim 2: Using a cluster-randomized study design, we will test a multimodal aging-friendly intervention including four components (4Cs): 1) Coaching: infection prevention coaching to observe, teach, and audit evidence-based infection prevention practices by all frontline clinicians; 2) Cleaning: standardized recommended environmental cleaning protocols with feedback on environmental contamination; 3) Communication: patient and family communication strategy and implementation of patient hand hygiene and recommended PPE use; and 4) Collaboration: rapid testing, re- testing and contact tracing, in collaboration with referral hospitals. We hypothesize that the implementation of this intervention will be associated with lower odds of SARS-CoV-2 transmission to the environment.