key: cord-0834133-qvn3cmu5 authors: Kharrat, Ashraf; Neish, Angela; Diambomba, Yenge; Jain, Amish title: Non-COVID Co-Morbidity: Potential Indirect Consequences of the SARS-CoV-2 Pandemic in a Neonatal Intensive Care Unit date: 2020-12-19 journal: J Hosp Infect DOI: 10.1016/j.jhin.2020.12.010 sha: 796fc4f22b58949603bc492a8706171b93cd38de doc_id: 834133 cord_uid: qvn3cmu5 nan The emergence of SARS-CoV-2 has had an unparalleled impact on healthcare across the globe. Neonatal intensive care units (NICUs) faced new challenges, albeit of a different nature than pediatric and adult critical care, especially with regards to clinical workflows and parentinfant interactions [1] . These include uncertainty in dealing with exposure risk for maternal and neonatal populations, re-organization of process and operations aimed at minimizing risks to staff and patients, and frequently changing clinical landscapes. Here, we share our experience from a tertiary NICU, where the bedside changes necessitated from a hospital-level response to supply shortage during the COVID pandemic was temporarily associated with an unprecedented increase in nosocomial infections (NIs) from non-SARS-CoV-2 pathogens, threatening to undermine a year's worth of quality improvement (QI) efforts. NIs are one of the most serious preventable complication in the NICU [2] . Preterm infants, in particular, are susceptible to NIs because of their immature immune system and prolonged need for indwelling catheters [3] . Practice bundles to minimize NIs constitute a significant part of NICU QI work [4] . In March 2019, recognizing the rising rates of NIs in our NICU, we commissioned a NI Task Force. One of the key components of our multi-pronged strategy was the roll-out of several education campaigns on performing hand hygiene prior to entering infants' immediate care environment. Alcohol-based hand rubs (ABHRs) were placed at multiple easily accessible points in the 'path' between caregivers and patients; 4 dedicated ABHR units were located in each patient room and several wall-mounted units were installed throughout the NICU. Over the next 14 months, our QI work was associated with a significant and sustained reduction in our unit's NI rates. In May 2020, as part of hospital-mandated resource management, hospital-level availability of ABHR and routinely used cleaning supplies were reduced across all clinical units and common areas. Over the next several weeks, we experienced a major NI outbreak (16 infections over 6 weeks). These were unprecedented numbers for our unit. The NI Task Force held an emergency meeting to strategize a solution, and a root cause analysis was performed. The following contributors were discussed: 1) ABHR availability. a. ABHR units in the NICU were reduced from 4 to 1 per patient room, and 50% of wall-mounted ABHR units were decommissioned. Surface cleaning wipes were also reduced from 1 per patient room to shared supply between multiple rooms. 2) Service attendant (SA) workflows. a. Due to the decommissioning of ABHR units, the available NICU stock was depleted more rapidly, and refilling of empty wall-mounted units by SAs was delayed due to lack of immediate access to supply. Task Force leadership ensured a protected central supply, and sensitization of SAs to urgent NICU needs. 3) Milk bank. a. Hand hygiene re-education of milk bank personnel and protection of sanitizing supply was enacted. 4) Personal protective equipment (PPE). a. Use of clean gloves for routine patient care was discussed. While the hospital's PPE stores were acceptable during this time, concerns were raised that we would rapidly deplete our glove supply through this approach, which did not have any demonstrable evidence-based benefit. 5) Other. a. Scheduling of nurses, physicians and respiratory therapists was reviewed; there were no staffing issues at the time. The NICU visitor policy (parents only) was also discussed and the existing practice was found to be noncontributory. The team decided to prioritize advocating for increasing ABHR units for the NICU with hospital administration. The following day, the number of ABHR units in the NICU were doubled and the process for replacing empty ABHR and surface cleaning wipes was streamlined. Multiple interdisciplinary huddles to educate staff regarding the current situation, inform of the recommissioned ABHR units, and to re-enforce hand hygiene were conducted. Fortunately, these measures were associated with a return of our NI rates to baseline (Figure 1 ). The COVID pandemic has placed extraordinary demands on healthcare systems worldwide. Similar unintended consequences of the pandemic have been seen in other settings, including delayed diagnosis of common diseases such as type-I diabetes [5] and an increase in stillbirth rates [6] . Our centre's experience with infection prevention has provided much food for thought as we continue our fight through this pandemic. NICUs, despite having one of the lowest COVID-related caseloads among all intensive care units, are not immune to secondary adverse effects. The required allocation of resources and administrative attention to pandemic-related activities may result in unintended consequences for other vulnerable patient populations. These may be preventable, to some extent, by ongoing vigilance and concerted efforts to reinforce best practices. We hope our experience will generate awareness of these potential challenges in the care of the preterm infants during this ongoing pandemic, and help neonatal clinicians and hospital administrators to anticipate and ameliorate some of the downstream impacts which may not be immediately recognized. The impact of COVID-19 infection on labor and delivery, newborn nursery, and neonatal intensive care unit: prospective observational data from a single hospital system. American journal of perinatology Neonatal sepsis. The Lancet Simple strategies to reduce healthcare associated infections in the neonatal intensive care unit: line, tube, and hand hygiene Care bundles to reduce central line-associated bloodstream infections in the neonatal unit: a systematic review and meta-analysis Unintended Consequences of COVID-19: Remember General Pediatrics. The Journal of Pediatrics Change in the incidence of stillbirth and preterm delivery during the COVID-19 pandemic Sep 9 -30 No hand sanitizer solution available to re-stock wall mounted dispensers. Delays in re-filling empty dispensers; several remained empty Jun 8: Emergency NI Task Force meeting Hand sanitizer availability in the NICU doubled Decommissioned hand sanitizer units re-activated. Daily 4 hour hand hygiene audits initiated. Workflow for replacement of empty dispensers streamlined