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

Abstract: COVID-19 has spread rapidly across the globe in the six months since the novel coronavirus SARS-CoV-2 wasfirst 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 and112,133 deaths in the US; the World Health Organization (WHO) reports over 7.1 million cases and 408,025deaths worldwide (in 216 countries). Advanced age and underlying conditions are risk factors for ICUadmission 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 preventionprograms, including limited resources and diagnostic challenges in a frail functionally disabled long-staypopulation. To date, approximately one in three deaths from the virus in the US have been linked to NHs orother long-term care facilities. Anticipating that the virus will return in the fall of 2020, advancing ourunderstanding of the transmission of SARS-CoV-2 within these facilities for vulnerable populations deservesurgent and further investigation. Environmental contamination with SARS-CoV-2 that is reported in limitedstudies highlights the potential importance of transmission between patients, their environment, and healthcareproviders 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 willachieve 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 adultswith active COVID-19 infection at 4 NHs with designated COVID-19 units to describe risk factors for virustransmission. We hypothesize that risk factors including functional disability, comorbidities, and COVID-19symptom severity will be associated with increased odds of SARS-CoV-2 transmission to the environmentamong 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: infectionprevention coaching to observe, teach, and audit evidence-based infection prevention practices by all frontlineclinicians; 2) Cleaning: standardized recommended environmental cleaning protocols with feedback onenvironmental contamination; 3) Communication: patient and family communication strategy andimplementation 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 ofthis intervention will be associated with lower odds of SARS-CoV-2 transmission to the environment.