In the era of multidrug resistant organisms spreading to healthcare facilities, as well as in the community, prevention of healthcare-associated infections (HAIs) has become one of the most important issues in the world. HAIs impact morbidity and mortality of patients, increase healthcare costs,^1,2 and are associated with a longer length of stay in the hospital.^3,4 In Japan, HAIs are a salient problem; more than 9% of patients admitted to the intensive care unit (ICU) developed an infection during their ICU stay,⁵ and the numbers of multidrug resistant organism isolates causing HAIs have been increasing annually.⁶

Hand hygiene is the most important strategy for preventing the spread of MDROs and reducing HAIs.⁷ Heightened attention to hand hygiene has occurred because of the recent global outbreak of coronavirus disease 2019 (COVID-19), which first appeared in Wuhan, China.⁸ Because no proven antiviral or vaccine is currently available for the disease, hand hygiene, appropriate cough etiquette, and physical distancing, including school closures, are the only way to prevent spread of the illness.^9,10 The virus appears to be highly contagious and spread by droplet or contact routes. The spread of COVID-19 in healthcare facilities has been significant,¹¹ and it could be a source of further spread of the disease in the community.

Unfortunately, hand hygiene adherence remains low in most settings.¹² The World Health Organization (WHO) created a strategy to improve hand hygiene adherence,¹³ which has been implemented in many countries.¹⁴ This strategy consists of five key components: (1) system change, (2) training/education, (3) evaluation and feedback, (4) reminders in the workplace, and (5) institutional safety climate.¹³ Implementing a multimodal intervention including these five elements has increased hand hygiene adherence among healthcare workers (HCWs) and appears to reduce HAIs in different locations.^15-17 Improving hand hygiene practice among HCWs is considered one of the most important ways to decrease the incidence of HAIs.^15,18,19

There are two types of practice for hand hygiene: either hand washing with soap and water or using alcohol-based hand rub (AHR). The former requires water, soap, a sink, and paper towels, whereas the latter requires only hand rub, which is easy to use and requires one-third the length of time as the former.²⁰ Therefore, AHR is strongly recommended, especially in acute and intensive care settings in hospitals, which require urgent care of patients. Importantly, previous studies demonstrated that greater use of AHR resulted in significant reductions in HAIs.^7,14

In Japan, the data related to hand hygiene adherence is limited. Previous studies at four hospitals in different regions of Japan demonstrated that hand hygiene rates were suboptimal²¹ and lower than reported adherence rates from other international studies.¹⁴ One study at three hospitals showed rates could be improved by a multimodal intervention tailored by each institution.²² A 5-year follow-up study demonstrated the sustainability of the multimodal intervention²³; however, hand hygiene adherence rates remained low at approximately 32%.

We hypothesized that perhaps focusing attention on just one single region (or prefecture) could boost hand hygiene rates. Niigata prefecture is located 200 miles north of Tokyo and is the largest prefecture facing the Japan Sea. There are five major tertiary hospitals in Niigata, and they communicate frequently and discuss infection control issues as a group. To investigate hand hygiene adherence before touching patients, and to evaluate the improvement of hand hygiene adherence induced by a multimodal intervention, we performed a pre- and postintervention study among HCWs at four of these tertiary care hospitals in Niigata.

Participating hospitals

Four tertiary care hospitals in Niigata, Japan, volunteered to participate in the study. The characteristics of the four participating hospitals are summarized in Table 1. All hospitals are public or community based. Hospital A included two units, consisting of a cardiovascular-cerebral ICU and an emergency department (ED), and Hospitals B, C, and D included various units containing surgical or medical wards, an ICU, or an ED. All four hospitals have at least one designated infection-­prevention nurse and an infection-prevention department. In addition, there is an infection control network system among the hospitals, and they communicate well to update the information related to local, domestic, or global infectious diseases through regular seminars and by distributing and exchanging electronic communication.

Preintervention

The preintervention infrastructure and existing activities to improve HCW hand hygiene in each hospital are summarized in Table 1. These activities were developed by each individual hospital and had been in place for at least 6 months before the study intervention. All hospitals used AHR and did direct observation for hand washing in designated wards or units and monitoring of AHR consumption; however, Hospital B did not have a wash basin in each room and no use of portable AHR. Preintervention hand hygiene data were collected from June to August 2018.

Intervention

To improve hand hygiene adherence, we initiated a multimodal intervention from September 2018 to February 2019 based on WHO recommendations¹³ and the findings from prior hand hygiene studies.²² Each facility was provided the same guidance on how to improve hand hygiene adherence and was asked to tailor their intervention to their settings (Table 2 and Appendix Figure). Suggested interventions included feedback regarding hand hygiene adherence observed during the preintervention period, interventions related to AHR, direct observation of and feedback regarding hand hygiene, new posters promoting hand hygiene in the workplace, a 1-month campaign for hand hygiene, seminars for HCWs related to hand hygiene, creation of a handbook for education/training, feedback regarding hand hygiene adherence during the intervention period, and others. The infection control team at each hospital designed the plans and strategies to improve hand hygiene adherence. Postintervention data were collected from February 2019 to March 2019.

Observation of Hand Hygiene Adherence

Hand hygiene adherence before patient contact was evaluated by board-certified infection control nurses. To reduce observation bias, external nurses from other participating hospitals conducted the observations. To minimize intraobserver variation, the same training as the previous study in Japan²¹ was provided. Hand hygiene observations were usually performed during the day Monday to Friday from 8 am to 1 pm because of observers’ availability.

Use of either AHR or soap and water before patient contact was defined as appropriate hand hygiene.^24,25 Hand hygiene adherence before patient contact for each provider-patient encounter was observed and recorded using a data collection form used in the previous studies.^19,26 The following information was obtained: unit name, time of initiation and completion of observations, HCW type (physician or nurse), and the type of hand hygiene (ie, AHR, hand washing with soap and water, or none). The observers kept an appropriate distance from the observed HCWs to avoid interfering with their regular clinical practice. In addition, we informed HCWs in the hospital that their clinical practices were going to be observed; however, they were not informed their hand hygiene adherence was going to be monitored.

Statistical Analysis

Overall hand hygiene adherence rates from the pre- and postintervention periods were compared based on hospitals and HCW subgroups. The Pearson’s chi-square test was used for the comparison of hand hygiene adherence rates between pre- and postintervention periods, and 95% CIs were estimated using binomial distribution. Poisson regression was used to look at changes in hand hygiene adherence with adjustment for HCW type. A two-tailed P value of <.05 was considered statistically significant. The study protocol was reviewed and approved by the ethics committees at all participating hospitals.

Overall Changes

In total, there were 2,018 and 1,630 observations of hand hygiene during the preintervention and postintervention periods, respectively. Most observations were of nurses: 1,643 of the 2,018 preintervention observations (81.4%) and 1,245 of the 1,630 postintervention observations (76.4%).

Findings from the HCW observations are summarized in Figure A. The overall postintervention hand hygiene adherence rate (548 of 1,630 observations; 33.6%; 95% CI, 31.3%-35.9%) was significantly higher than the preintervention rate (453 of 2,018 observations; 22.4%; 95% CI, 20.6%-24.3%; P < .001). This finding persisted after adjustment for the type of HCW (nurse vs physician), with proper hand hygiene adherence occurring 1.55 times more often after the intervention than before (95% CI, 1.37-1.76; P < .001). The overall improvement in hand hygiene adherence rates in the postintervention period was seen in all four hospitals (Figure B). However, the hand hygiene adherence rates of nurses in Hospitals C and D were lower than those in Hospitals A and B both before and after the intervention.

Changes by HCW Type

The rates of hand hygiene adherence in both physicians and nurses were higher in the postintervention period than in the preintervention period. However, the improvement of hand hygiene adherence among nurses—from 415 of 1,643 (25.2%) to 487 of 1,245 (39.1%) for an increase of 13.9 percentage points (95% CI,10.4-17.3)—was greater than that in physicians—from 38 of 375 (10.1%) to 61 of 385 (15.8%) for an increase of 5.7 percentage points (95% CI, 1.0-8.1; P < .001; Figure B). In general, nurse hand hygiene adherence was higher than that in physicians both in the preintervention period, with nurses at 25.2% (95% CI, 23.2%-27.4%) vs physicians at 10.1% (95% CI, 7.1%-13.2%; P < .001), and in the postintervention period, with nurses at 39.1% (95% CI, 36.4%-41.8%) vs physicians at 15.8% (95% CI, 12.2%-19.5%; P < .001).

Changes by Hospital

Overall, improvement of hand hygiene adherence was observed in all hospitals. However, the improvement rates differed in each hospital: They were 6.5 percentage points in Hospital A, 11.3 percentage points in Hospital C, 11.4 percentage points in Hospital D, and 18.4 percentage points in Hospital B. Hospital B achieved the highest postintervention adherence rates (42.6%), along with the highest improvement. The improvements of hand hygiene adherence in physicians were higher in Hospitals B (8.4 percentage points) and D (8.3 percentage points) than they were in Hospitals A (4.1 percentage points) and C (4.0 percentage points).

Interventions performed at each hospital to improve hand hygiene adherence are summarized in Table 2 and the Appendix Figure. All hospitals performed feedback of hand hygiene adherence after the preintervention period. Interventions related to AHR were frequently initiated; self-carry AHR was provided in two hospitals (Hospitals C and D), and location of AHR was moved (Hospitals B and D). In addition, new AHR products that caused less skin irritation were introduced in Hospital B. Direct observation by hospital staff (separate from our study observers) was also done as part of Hospital A and D’s improvement efforts. Other interventions included a 1-month campaign for hand hygiene including a contest for senryu (humorous 17-syllable poems; Table 2; Appendix Table), posters, seminars, and creation of a handbook related to hand hygiene. Posters emphasizing the importance of hand hygiene created by the local hospital infection control teams were put on the wall in several locations near wash basins. Seminars (1-hour lectures to emphasize the importance of hand hygiene) were provided to nurses. A 10-page hand hygiene handbook was created by one local infection control team and provided to nurses.

Our study demonstrated that the overall rate of hand hygiene adherence improved from 22.4% to 33.6% after multimodal intervention; however, the adherence rates even after intervention were suboptimal. The results were comparable with those of a previous study in Japan,²² which underscores how suboptimal HCW hand hygiene in Japan threatens patient safety. Hand hygiene among HCWs is one of the most important methods to prevent HAIs and to reduce spread of multidrug resistant organisms. High adherence has proven challenging because it requires behavior modification. We implemented WHO hand hygiene adherence strategies²⁷ and evaluated the efficacy of a multimodal intervention in hopes of finding the specific factors that could be related to behavior modification for HCWs.

We observed several important relationships between the intervention components and their improvement in hand hygiene adherence. Among the four participating hospitals, Hospital B was the most successful with improvement of hand hygiene adherence from 24.2% to 42.6%. One unique intervention for Hospital B was the introduction of new AHR products for the people who had felt uncomfortable with current products. Frequent hand washing or the use of certain AHR products could irritate skin causing dry or rough hands, which could reduce hand hygiene practices. In Japan, there are several AHR products available. Among them, a few products contain skin moisturizing elements; these products are 10%-20% higher in cost than nonmoisturizing products. The HCWs in our study stated that the new products were more comfortable to use, and they requested to introduce them as daily use products. Thus, use of a product containing a hand moisturizer may reduce some factors negatively affecting hand hygiene practice and improve adherence rates.

Although this study was unable to determine which components are definitively associated with improving hand hygiene adherence, the findings suggest initiation of multiple intervention components simultaneously may provide more motivation for change than initiating only one or two components at a time. It is also possible that certain intervention components were more beneficial than others. Consistent with a previous study, improving hand hygiene adherence cannot be simply achieved by improving infrastructure (eg, introducing portable AHR) alone, but rather depends on altering the behavior of physicians and nurses.

This study was performed at four tertiary care hospitals in Niigata that are affiliated with Niigata University. They are located closely in the region, within 100 km, have quarterly conferences, and use a mutual monitoring system related to infection prevention. The members of infection control communicate regularly, which we thought would optimize improvements in hand hygiene adherence, compared with the circumstances of previous studies. In this setting, HCWs have similar education and share knowledge related to infection control, and the effects of interventions in each hospital were equally evaluated if similar interventions were implemented. In the current study, the interventions at each hospital were similar, and there was limited variety; therefore, specific, novel interventions that could affect hand hygiene adherence significantly were difficult to find.

There are a few possible reasons why hand hygiene adherence rates were low in the current study. First, part of this study was conducted during the summer so that the consciousness and caution for hand hygiene might be lower, compared with that in winter. In general, HCWs become more cautious for hand hygiene practice when they take care of patients diagnosed with influenza or respiratory syncytial virus infection. Second, the infrastructure for hand hygiene practice in the hospitals in Japan is inadequate and not well designed. Because of safety reasons, a single dispenser of AHR is placed at the entrance of each room in general and not at each bedside. The number of private rooms is limited, and most of the rooms in wards have multiple beds per room, with no access to AHR within the room. In fact, the interventions at all four hospitals included a change in the location and/or access of AHR. Easier access to AHR is likely a key step to improving hand hygiene adherence rates. Finally, there was not an active intervention to include hospital or unit leaders. This is important given the involvement of leaders in hand hygiene practice significantly changed the hand adherence rates in a previous study.¹⁹

Given the suboptimal hand hygiene adherence rates in Japan noted in this and previous Japanese studies,^21,22 the spread of COVID-19 within the hospital setting is a concern. Transmission of COVID-19 by asymptomatic carriers has been suggested,¹¹ which emphasizes the importance of regular standard precautions with good hand hygiene practice to prevent further transmission.

Although the hand hygiene rate was suboptimal, we were able to achieve a few sustainable, structural modifications in the clinical environment after the intervention. These include adding AHR in new locations, changing the location of existing AHR to more appropriate locations, and introducing new products. These will remain in the clinical environment and will contribute to hand hygiene adherence in the future.

This study has several limitations. First, the presence of external observers in their clinical settings might have affected the behavior of HCWs.²⁸ Although they were not informed that their hand hygiene adherence was going to be monitored, the existence of an external observer in their clinical setting might have changed normal behavior. Second, the infrastructure and interventions for hand hygiene adherence before the intervention were different in each hospital, so there is a possibility that hospitals with less infrastructure for hand hygiene adherence had more room for improvement with the interventions. Third, we included observations at different units at each hospital, which might affect the results of the study because of the inclusion of different medical settings and HCWs. Fourth, the number of physician hand hygiene observations was limited: We conducted our observations between 8 am and 1 pm on weekdays because of observer availability, and many physicians visited their patients during other times of the day. Finally, we were unable to determine whether the improvements seen in each hospital were caused by specific intervention components. However, it is known that recognizing the importance of hand hygiene varies in different regions and countries in the world, and the goal for hand hygiene interventions is to establish a culture of hand hygiene practice.¹³ Further evaluation is necessary to assess sustainability.

In conclusion, a multimodal intervention to improve hand hygiene adherence successfully improved HCWs’ hand hygiene adherence in Niigata, Japan; however, the adherence rates are still relatively low compared with those reported from other countries. Further intervention is required to improve hand hygiene adherence.

In the era of multidrug resistant organisms spreading to healthcare facilities, as well as in the community, prevention of healthcare-associated infections (HAIs) has become one of the most important issues in the world. HAIs impact morbidity and mortality of patients, increase healthcare costs,^1,2 and are associated with a longer length of stay in the hospital.^3,4 In Japan, HAIs are a salient problem; more than 9% of patients admitted to the intensive care unit (ICU) developed an infection during their ICU stay,⁵ and the numbers of multidrug resistant organism isolates causing HAIs have been increasing annually.⁶

Hand hygiene is the most important strategy for preventing the spread of MDROs and reducing HAIs.⁷ Heightened attention to hand hygiene has occurred because of the recent global outbreak of coronavirus disease 2019 (COVID-19), which first appeared in Wuhan, China.⁸ Because no proven antiviral or vaccine is currently available for the disease, hand hygiene, appropriate cough etiquette, and physical distancing, including school closures, are the only way to prevent spread of the illness.^9,10 The virus appears to be highly contagious and spread by droplet or contact routes. The spread of COVID-19 in healthcare facilities has been significant,¹¹ and it could be a source of further spread of the disease in the community.

Unfortunately, hand hygiene adherence remains low in most settings.¹² The World Health Organization (WHO) created a strategy to improve hand hygiene adherence,¹³ which has been implemented in many countries.¹⁴ This strategy consists of five key components: (1) system change, (2) training/education, (3) evaluation and feedback, (4) reminders in the workplace, and (5) institutional safety climate.¹³ Implementing a multimodal intervention including these five elements has increased hand hygiene adherence among healthcare workers (HCWs) and appears to reduce HAIs in different locations.^15-17 Improving hand hygiene practice among HCWs is considered one of the most important ways to decrease the incidence of HAIs.^15,18,19

There are two types of practice for hand hygiene: either hand washing with soap and water or using alcohol-based hand rub (AHR). The former requires water, soap, a sink, and paper towels, whereas the latter requires only hand rub, which is easy to use and requires one-third the length of time as the former.²⁰ Therefore, AHR is strongly recommended, especially in acute and intensive care settings in hospitals, which require urgent care of patients. Importantly, previous studies demonstrated that greater use of AHR resulted in significant reductions in HAIs.^7,14

In Japan, the data related to hand hygiene adherence is limited. Previous studies at four hospitals in different regions of Japan demonstrated that hand hygiene rates were suboptimal²¹ and lower than reported adherence rates from other international studies.¹⁴ One study at three hospitals showed rates could be improved by a multimodal intervention tailored by each institution.²² A 5-year follow-up study demonstrated the sustainability of the multimodal intervention²³; however, hand hygiene adherence rates remained low at approximately 32%.

We hypothesized that perhaps focusing attention on just one single region (or prefecture) could boost hand hygiene rates. Niigata prefecture is located 200 miles north of Tokyo and is the largest prefecture facing the Japan Sea. There are five major tertiary hospitals in Niigata, and they communicate frequently and discuss infection control issues as a group. To investigate hand hygiene adherence before touching patients, and to evaluate the improvement of hand hygiene adherence induced by a multimodal intervention, we performed a pre- and postintervention study among HCWs at four of these tertiary care hospitals in Niigata.

Participating hospitals

Four tertiary care hospitals in Niigata, Japan, volunteered to participate in the study. The characteristics of the four participating hospitals are summarized in Table 1. All hospitals are public or community based. Hospital A included two units, consisting of a cardiovascular-cerebral ICU and an emergency department (ED), and Hospitals B, C, and D included various units containing surgical or medical wards, an ICU, or an ED. All four hospitals have at least one designated infection-­prevention nurse and an infection-prevention department. In addition, there is an infection control network system among the hospitals, and they communicate well to update the information related to local, domestic, or global infectious diseases through regular seminars and by distributing and exchanging electronic communication.

Preintervention

The preintervention infrastructure and existing activities to improve HCW hand hygiene in each hospital are summarized in Table 1. These activities were developed by each individual hospital and had been in place for at least 6 months before the study intervention. All hospitals used AHR and did direct observation for hand washing in designated wards or units and monitoring of AHR consumption; however, Hospital B did not have a wash basin in each room and no use of portable AHR. Preintervention hand hygiene data were collected from June to August 2018.

Intervention

To improve hand hygiene adherence, we initiated a multimodal intervention from September 2018 to February 2019 based on WHO recommendations¹³ and the findings from prior hand hygiene studies.²² Each facility was provided the same guidance on how to improve hand hygiene adherence and was asked to tailor their intervention to their settings (Table 2 and Appendix Figure). Suggested interventions included feedback regarding hand hygiene adherence observed during the preintervention period, interventions related to AHR, direct observation of and feedback regarding hand hygiene, new posters promoting hand hygiene in the workplace, a 1-month campaign for hand hygiene, seminars for HCWs related to hand hygiene, creation of a handbook for education/training, feedback regarding hand hygiene adherence during the intervention period, and others. The infection control team at each hospital designed the plans and strategies to improve hand hygiene adherence. Postintervention data were collected from February 2019 to March 2019.

Observation of Hand Hygiene Adherence

Hand hygiene adherence before patient contact was evaluated by board-certified infection control nurses. To reduce observation bias, external nurses from other participating hospitals conducted the observations. To minimize intraobserver variation, the same training as the previous study in Japan²¹ was provided. Hand hygiene observations were usually performed during the day Monday to Friday from 8 am to 1 pm because of observers’ availability.

Use of either AHR or soap and water before patient contact was defined as appropriate hand hygiene.^24,25 Hand hygiene adherence before patient contact for each provider-patient encounter was observed and recorded using a data collection form used in the previous studies.^19,26 The following information was obtained: unit name, time of initiation and completion of observations, HCW type (physician or nurse), and the type of hand hygiene (ie, AHR, hand washing with soap and water, or none). The observers kept an appropriate distance from the observed HCWs to avoid interfering with their regular clinical practice. In addition, we informed HCWs in the hospital that their clinical practices were going to be observed; however, they were not informed their hand hygiene adherence was going to be monitored.

Statistical Analysis

Overall hand hygiene adherence rates from the pre- and postintervention periods were compared based on hospitals and HCW subgroups. The Pearson’s chi-square test was used for the comparison of hand hygiene adherence rates between pre- and postintervention periods, and 95% CIs were estimated using binomial distribution. Poisson regression was used to look at changes in hand hygiene adherence with adjustment for HCW type. A two-tailed P value of <.05 was considered statistically significant. The study protocol was reviewed and approved by the ethics committees at all participating hospitals.

Overall Changes

In total, there were 2,018 and 1,630 observations of hand hygiene during the preintervention and postintervention periods, respectively. Most observations were of nurses: 1,643 of the 2,018 preintervention observations (81.4%) and 1,245 of the 1,630 postintervention observations (76.4%).

Findings from the HCW observations are summarized in Figure A. The overall postintervention hand hygiene adherence rate (548 of 1,630 observations; 33.6%; 95% CI, 31.3%-35.9%) was significantly higher than the preintervention rate (453 of 2,018 observations; 22.4%; 95% CI, 20.6%-24.3%; P < .001). This finding persisted after adjustment for the type of HCW (nurse vs physician), with proper hand hygiene adherence occurring 1.55 times more often after the intervention than before (95% CI, 1.37-1.76; P < .001). The overall improvement in hand hygiene adherence rates in the postintervention period was seen in all four hospitals (Figure B). However, the hand hygiene adherence rates of nurses in Hospitals C and D were lower than those in Hospitals A and B both before and after the intervention.

Changes by HCW Type

The rates of hand hygiene adherence in both physicians and nurses were higher in the postintervention period than in the preintervention period. However, the improvement of hand hygiene adherence among nurses—from 415 of 1,643 (25.2%) to 487 of 1,245 (39.1%) for an increase of 13.9 percentage points (95% CI,10.4-17.3)—was greater than that in physicians—from 38 of 375 (10.1%) to 61 of 385 (15.8%) for an increase of 5.7 percentage points (95% CI, 1.0-8.1; P < .001; Figure B). In general, nurse hand hygiene adherence was higher than that in physicians both in the preintervention period, with nurses at 25.2% (95% CI, 23.2%-27.4%) vs physicians at 10.1% (95% CI, 7.1%-13.2%; P < .001), and in the postintervention period, with nurses at 39.1% (95% CI, 36.4%-41.8%) vs physicians at 15.8% (95% CI, 12.2%-19.5%; P < .001).

Changes by Hospital

Overall, improvement of hand hygiene adherence was observed in all hospitals. However, the improvement rates differed in each hospital: They were 6.5 percentage points in Hospital A, 11.3 percentage points in Hospital C, 11.4 percentage points in Hospital D, and 18.4 percentage points in Hospital B. Hospital B achieved the highest postintervention adherence rates (42.6%), along with the highest improvement. The improvements of hand hygiene adherence in physicians were higher in Hospitals B (8.4 percentage points) and D (8.3 percentage points) than they were in Hospitals A (4.1 percentage points) and C (4.0 percentage points).

Interventions performed at each hospital to improve hand hygiene adherence are summarized in Table 2 and the Appendix Figure. All hospitals performed feedback of hand hygiene adherence after the preintervention period. Interventions related to AHR were frequently initiated; self-carry AHR was provided in two hospitals (Hospitals C and D), and location of AHR was moved (Hospitals B and D). In addition, new AHR products that caused less skin irritation were introduced in Hospital B. Direct observation by hospital staff (separate from our study observers) was also done as part of Hospital A and D’s improvement efforts. Other interventions included a 1-month campaign for hand hygiene including a contest for senryu (humorous 17-syllable poems; Table 2; Appendix Table), posters, seminars, and creation of a handbook related to hand hygiene. Posters emphasizing the importance of hand hygiene created by the local hospital infection control teams were put on the wall in several locations near wash basins. Seminars (1-hour lectures to emphasize the importance of hand hygiene) were provided to nurses. A 10-page hand hygiene handbook was created by one local infection control team and provided to nurses.

Our study demonstrated that the overall rate of hand hygiene adherence improved from 22.4% to 33.6% after multimodal intervention; however, the adherence rates even after intervention were suboptimal. The results were comparable with those of a previous study in Japan,²² which underscores how suboptimal HCW hand hygiene in Japan threatens patient safety. Hand hygiene among HCWs is one of the most important methods to prevent HAIs and to reduce spread of multidrug resistant organisms. High adherence has proven challenging because it requires behavior modification. We implemented WHO hand hygiene adherence strategies²⁷ and evaluated the efficacy of a multimodal intervention in hopes of finding the specific factors that could be related to behavior modification for HCWs.

We observed several important relationships between the intervention components and their improvement in hand hygiene adherence. Among the four participating hospitals, Hospital B was the most successful with improvement of hand hygiene adherence from 24.2% to 42.6%. One unique intervention for Hospital B was the introduction of new AHR products for the people who had felt uncomfortable with current products. Frequent hand washing or the use of certain AHR products could irritate skin causing dry or rough hands, which could reduce hand hygiene practices. In Japan, there are several AHR products available. Among them, a few products contain skin moisturizing elements; these products are 10%-20% higher in cost than nonmoisturizing products. The HCWs in our study stated that the new products were more comfortable to use, and they requested to introduce them as daily use products. Thus, use of a product containing a hand moisturizer may reduce some factors negatively affecting hand hygiene practice and improve adherence rates.

Although this study was unable to determine which components are definitively associated with improving hand hygiene adherence, the findings suggest initiation of multiple intervention components simultaneously may provide more motivation for change than initiating only one or two components at a time. It is also possible that certain intervention components were more beneficial than others. Consistent with a previous study, improving hand hygiene adherence cannot be simply achieved by improving infrastructure (eg, introducing portable AHR) alone, but rather depends on altering the behavior of physicians and nurses.

This study was performed at four tertiary care hospitals in Niigata that are affiliated with Niigata University. They are located closely in the region, within 100 km, have quarterly conferences, and use a mutual monitoring system related to infection prevention. The members of infection control communicate regularly, which we thought would optimize improvements in hand hygiene adherence, compared with the circumstances of previous studies. In this setting, HCWs have similar education and share knowledge related to infection control, and the effects of interventions in each hospital were equally evaluated if similar interventions were implemented. In the current study, the interventions at each hospital were similar, and there was limited variety; therefore, specific, novel interventions that could affect hand hygiene adherence significantly were difficult to find.

There are a few possible reasons why hand hygiene adherence rates were low in the current study. First, part of this study was conducted during the summer so that the consciousness and caution for hand hygiene might be lower, compared with that in winter. In general, HCWs become more cautious for hand hygiene practice when they take care of patients diagnosed with influenza or respiratory syncytial virus infection. Second, the infrastructure for hand hygiene practice in the hospitals in Japan is inadequate and not well designed. Because of safety reasons, a single dispenser of AHR is placed at the entrance of each room in general and not at each bedside. The number of private rooms is limited, and most of the rooms in wards have multiple beds per room, with no access to AHR within the room. In fact, the interventions at all four hospitals included a change in the location and/or access of AHR. Easier access to AHR is likely a key step to improving hand hygiene adherence rates. Finally, there was not an active intervention to include hospital or unit leaders. This is important given the involvement of leaders in hand hygiene practice significantly changed the hand adherence rates in a previous study.¹⁹

Given the suboptimal hand hygiene adherence rates in Japan noted in this and previous Japanese studies,^21,22 the spread of COVID-19 within the hospital setting is a concern. Transmission of COVID-19 by asymptomatic carriers has been suggested,¹¹ which emphasizes the importance of regular standard precautions with good hand hygiene practice to prevent further transmission.

Although the hand hygiene rate was suboptimal, we were able to achieve a few sustainable, structural modifications in the clinical environment after the intervention. These include adding AHR in new locations, changing the location of existing AHR to more appropriate locations, and introducing new products. These will remain in the clinical environment and will contribute to hand hygiene adherence in the future.

This study has several limitations. First, the presence of external observers in their clinical settings might have affected the behavior of HCWs.²⁸ Although they were not informed that their hand hygiene adherence was going to be monitored, the existence of an external observer in their clinical setting might have changed normal behavior. Second, the infrastructure and interventions for hand hygiene adherence before the intervention were different in each hospital, so there is a possibility that hospitals with less infrastructure for hand hygiene adherence had more room for improvement with the interventions. Third, we included observations at different units at each hospital, which might affect the results of the study because of the inclusion of different medical settings and HCWs. Fourth, the number of physician hand hygiene observations was limited: We conducted our observations between 8 am and 1 pm on weekdays because of observer availability, and many physicians visited their patients during other times of the day. Finally, we were unable to determine whether the improvements seen in each hospital were caused by specific intervention components. However, it is known that recognizing the importance of hand hygiene varies in different regions and countries in the world, and the goal for hand hygiene interventions is to establish a culture of hand hygiene practice.¹³ Further evaluation is necessary to assess sustainability.

In conclusion, a multimodal intervention to improve hand hygiene adherence successfully improved HCWs’ hand hygiene adherence in Niigata, Japan; however, the adherence rates are still relatively low compared with those reported from other countries. Further intervention is required to improve hand hygiene adherence.

In the era of multidrug resistant organisms spreading to healthcare facilities, as well as in the community, prevention of healthcare-associated infections (HAIs) has become one of the most important issues in the world. HAIs impact morbidity and mortality of patients, increase healthcare costs,^1,2 and are associated with a longer length of stay in the hospital.^3,4 In Japan, HAIs are a salient problem; more than 9% of patients admitted to the intensive care unit (ICU) developed an infection during their ICU stay,⁵ and the numbers of multidrug resistant organism isolates causing HAIs have been increasing annually.⁶

Hand hygiene is the most important strategy for preventing the spread of MDROs and reducing HAIs.⁷ Heightened attention to hand hygiene has occurred because of the recent global outbreak of coronavirus disease 2019 (COVID-19), which first appeared in Wuhan, China.⁸ Because no proven antiviral or vaccine is currently available for the disease, hand hygiene, appropriate cough etiquette, and physical distancing, including school closures, are the only way to prevent spread of the illness.^9,10 The virus appears to be highly contagious and spread by droplet or contact routes. The spread of COVID-19 in healthcare facilities has been significant,¹¹ and it could be a source of further spread of the disease in the community.

Unfortunately, hand hygiene adherence remains low in most settings.¹² The World Health Organization (WHO) created a strategy to improve hand hygiene adherence,¹³ which has been implemented in many countries.¹⁴ This strategy consists of five key components: (1) system change, (2) training/education, (3) evaluation and feedback, (4) reminders in the workplace, and (5) institutional safety climate.¹³ Implementing a multimodal intervention including these five elements has increased hand hygiene adherence among healthcare workers (HCWs) and appears to reduce HAIs in different locations.^15-17 Improving hand hygiene practice among HCWs is considered one of the most important ways to decrease the incidence of HAIs.^15,18,19

There are two types of practice for hand hygiene: either hand washing with soap and water or using alcohol-based hand rub (AHR). The former requires water, soap, a sink, and paper towels, whereas the latter requires only hand rub, which is easy to use and requires one-third the length of time as the former.²⁰ Therefore, AHR is strongly recommended, especially in acute and intensive care settings in hospitals, which require urgent care of patients. Importantly, previous studies demonstrated that greater use of AHR resulted in significant reductions in HAIs.^7,14

In Japan, the data related to hand hygiene adherence is limited. Previous studies at four hospitals in different regions of Japan demonstrated that hand hygiene rates were suboptimal²¹ and lower than reported adherence rates from other international studies.¹⁴ One study at three hospitals showed rates could be improved by a multimodal intervention tailored by each institution.²² A 5-year follow-up study demonstrated the sustainability of the multimodal intervention²³; however, hand hygiene adherence rates remained low at approximately 32%.

We hypothesized that perhaps focusing attention on just one single region (or prefecture) could boost hand hygiene rates. Niigata prefecture is located 200 miles north of Tokyo and is the largest prefecture facing the Japan Sea. There are five major tertiary hospitals in Niigata, and they communicate frequently and discuss infection control issues as a group. To investigate hand hygiene adherence before touching patients, and to evaluate the improvement of hand hygiene adherence induced by a multimodal intervention, we performed a pre- and postintervention study among HCWs at four of these tertiary care hospitals in Niigata.

Participating hospitals

Four tertiary care hospitals in Niigata, Japan, volunteered to participate in the study. The characteristics of the four participating hospitals are summarized in Table 1. All hospitals are public or community based. Hospital A included two units, consisting of a cardiovascular-cerebral ICU and an emergency department (ED), and Hospitals B, C, and D included various units containing surgical or medical wards, an ICU, or an ED. All four hospitals have at least one designated infection-­prevention nurse and an infection-prevention department. In addition, there is an infection control network system among the hospitals, and they communicate well to update the information related to local, domestic, or global infectious diseases through regular seminars and by distributing and exchanging electronic communication.

Preintervention

The preintervention infrastructure and existing activities to improve HCW hand hygiene in each hospital are summarized in Table 1. These activities were developed by each individual hospital and had been in place for at least 6 months before the study intervention. All hospitals used AHR and did direct observation for hand washing in designated wards or units and monitoring of AHR consumption; however, Hospital B did not have a wash basin in each room and no use of portable AHR. Preintervention hand hygiene data were collected from June to August 2018.

Intervention

To improve hand hygiene adherence, we initiated a multimodal intervention from September 2018 to February 2019 based on WHO recommendations¹³ and the findings from prior hand hygiene studies.²² Each facility was provided the same guidance on how to improve hand hygiene adherence and was asked to tailor their intervention to their settings (Table 2 and Appendix Figure). Suggested interventions included feedback regarding hand hygiene adherence observed during the preintervention period, interventions related to AHR, direct observation of and feedback regarding hand hygiene, new posters promoting hand hygiene in the workplace, a 1-month campaign for hand hygiene, seminars for HCWs related to hand hygiene, creation of a handbook for education/training, feedback regarding hand hygiene adherence during the intervention period, and others. The infection control team at each hospital designed the plans and strategies to improve hand hygiene adherence. Postintervention data were collected from February 2019 to March 2019.

Observation of Hand Hygiene Adherence

Hand hygiene adherence before patient contact was evaluated by board-certified infection control nurses. To reduce observation bias, external nurses from other participating hospitals conducted the observations. To minimize intraobserver variation, the same training as the previous study in Japan²¹ was provided. Hand hygiene observations were usually performed during the day Monday to Friday from 8 am to 1 pm because of observers’ availability.

Use of either AHR or soap and water before patient contact was defined as appropriate hand hygiene.^24,25 Hand hygiene adherence before patient contact for each provider-patient encounter was observed and recorded using a data collection form used in the previous studies.^19,26 The following information was obtained: unit name, time of initiation and completion of observations, HCW type (physician or nurse), and the type of hand hygiene (ie, AHR, hand washing with soap and water, or none). The observers kept an appropriate distance from the observed HCWs to avoid interfering with their regular clinical practice. In addition, we informed HCWs in the hospital that their clinical practices were going to be observed; however, they were not informed their hand hygiene adherence was going to be monitored.

Statistical Analysis

Overall hand hygiene adherence rates from the pre- and postintervention periods were compared based on hospitals and HCW subgroups. The Pearson’s chi-square test was used for the comparison of hand hygiene adherence rates between pre- and postintervention periods, and 95% CIs were estimated using binomial distribution. Poisson regression was used to look at changes in hand hygiene adherence with adjustment for HCW type. A two-tailed P value of <.05 was considered statistically significant. The study protocol was reviewed and approved by the ethics committees at all participating hospitals.

Overall Changes

In total, there were 2,018 and 1,630 observations of hand hygiene during the preintervention and postintervention periods, respectively. Most observations were of nurses: 1,643 of the 2,018 preintervention observations (81.4%) and 1,245 of the 1,630 postintervention observations (76.4%).

Findings from the HCW observations are summarized in Figure A. The overall postintervention hand hygiene adherence rate (548 of 1,630 observations; 33.6%; 95% CI, 31.3%-35.9%) was significantly higher than the preintervention rate (453 of 2,018 observations; 22.4%; 95% CI, 20.6%-24.3%; P < .001). This finding persisted after adjustment for the type of HCW (nurse vs physician), with proper hand hygiene adherence occurring 1.55 times more often after the intervention than before (95% CI, 1.37-1.76; P < .001). The overall improvement in hand hygiene adherence rates in the postintervention period was seen in all four hospitals (Figure B). However, the hand hygiene adherence rates of nurses in Hospitals C and D were lower than those in Hospitals A and B both before and after the intervention.

Changes by HCW Type

The rates of hand hygiene adherence in both physicians and nurses were higher in the postintervention period than in the preintervention period. However, the improvement of hand hygiene adherence among nurses—from 415 of 1,643 (25.2%) to 487 of 1,245 (39.1%) for an increase of 13.9 percentage points (95% CI,10.4-17.3)—was greater than that in physicians—from 38 of 375 (10.1%) to 61 of 385 (15.8%) for an increase of 5.7 percentage points (95% CI, 1.0-8.1; P < .001; Figure B). In general, nurse hand hygiene adherence was higher than that in physicians both in the preintervention period, with nurses at 25.2% (95% CI, 23.2%-27.4%) vs physicians at 10.1% (95% CI, 7.1%-13.2%; P < .001), and in the postintervention period, with nurses at 39.1% (95% CI, 36.4%-41.8%) vs physicians at 15.8% (95% CI, 12.2%-19.5%; P < .001).

Changes by Hospital

Overall, improvement of hand hygiene adherence was observed in all hospitals. However, the improvement rates differed in each hospital: They were 6.5 percentage points in Hospital A, 11.3 percentage points in Hospital C, 11.4 percentage points in Hospital D, and 18.4 percentage points in Hospital B. Hospital B achieved the highest postintervention adherence rates (42.6%), along with the highest improvement. The improvements of hand hygiene adherence in physicians were higher in Hospitals B (8.4 percentage points) and D (8.3 percentage points) than they were in Hospitals A (4.1 percentage points) and C (4.0 percentage points).

Interventions performed at each hospital to improve hand hygiene adherence are summarized in Table 2 and the Appendix Figure. All hospitals performed feedback of hand hygiene adherence after the preintervention period. Interventions related to AHR were frequently initiated; self-carry AHR was provided in two hospitals (Hospitals C and D), and location of AHR was moved (Hospitals B and D). In addition, new AHR products that caused less skin irritation were introduced in Hospital B. Direct observation by hospital staff (separate from our study observers) was also done as part of Hospital A and D’s improvement efforts. Other interventions included a 1-month campaign for hand hygiene including a contest for senryu (humorous 17-syllable poems; Table 2; Appendix Table), posters, seminars, and creation of a handbook related to hand hygiene. Posters emphasizing the importance of hand hygiene created by the local hospital infection control teams were put on the wall in several locations near wash basins. Seminars (1-hour lectures to emphasize the importance of hand hygiene) were provided to nurses. A 10-page hand hygiene handbook was created by one local infection control team and provided to nurses.

Our study demonstrated that the overall rate of hand hygiene adherence improved from 22.4% to 33.6% after multimodal intervention; however, the adherence rates even after intervention were suboptimal. The results were comparable with those of a previous study in Japan,²² which underscores how suboptimal HCW hand hygiene in Japan threatens patient safety. Hand hygiene among HCWs is one of the most important methods to prevent HAIs and to reduce spread of multidrug resistant organisms. High adherence has proven challenging because it requires behavior modification. We implemented WHO hand hygiene adherence strategies²⁷ and evaluated the efficacy of a multimodal intervention in hopes of finding the specific factors that could be related to behavior modification for HCWs.

We observed several important relationships between the intervention components and their improvement in hand hygiene adherence. Among the four participating hospitals, Hospital B was the most successful with improvement of hand hygiene adherence from 24.2% to 42.6%. One unique intervention for Hospital B was the introduction of new AHR products for the people who had felt uncomfortable with current products. Frequent hand washing or the use of certain AHR products could irritate skin causing dry or rough hands, which could reduce hand hygiene practices. In Japan, there are several AHR products available. Among them, a few products contain skin moisturizing elements; these products are 10%-20% higher in cost than nonmoisturizing products. The HCWs in our study stated that the new products were more comfortable to use, and they requested to introduce them as daily use products. Thus, use of a product containing a hand moisturizer may reduce some factors negatively affecting hand hygiene practice and improve adherence rates.

Although this study was unable to determine which components are definitively associated with improving hand hygiene adherence, the findings suggest initiation of multiple intervention components simultaneously may provide more motivation for change than initiating only one or two components at a time. It is also possible that certain intervention components were more beneficial than others. Consistent with a previous study, improving hand hygiene adherence cannot be simply achieved by improving infrastructure (eg, introducing portable AHR) alone, but rather depends on altering the behavior of physicians and nurses.

This study was performed at four tertiary care hospitals in Niigata that are affiliated with Niigata University. They are located closely in the region, within 100 km, have quarterly conferences, and use a mutual monitoring system related to infection prevention. The members of infection control communicate regularly, which we thought would optimize improvements in hand hygiene adherence, compared with the circumstances of previous studies. In this setting, HCWs have similar education and share knowledge related to infection control, and the effects of interventions in each hospital were equally evaluated if similar interventions were implemented. In the current study, the interventions at each hospital were similar, and there was limited variety; therefore, specific, novel interventions that could affect hand hygiene adherence significantly were difficult to find.

There are a few possible reasons why hand hygiene adherence rates were low in the current study. First, part of this study was conducted during the summer so that the consciousness and caution for hand hygiene might be lower, compared with that in winter. In general, HCWs become more cautious for hand hygiene practice when they take care of patients diagnosed with influenza or respiratory syncytial virus infection. Second, the infrastructure for hand hygiene practice in the hospitals in Japan is inadequate and not well designed. Because of safety reasons, a single dispenser of AHR is placed at the entrance of each room in general and not at each bedside. The number of private rooms is limited, and most of the rooms in wards have multiple beds per room, with no access to AHR within the room. In fact, the interventions at all four hospitals included a change in the location and/or access of AHR. Easier access to AHR is likely a key step to improving hand hygiene adherence rates. Finally, there was not an active intervention to include hospital or unit leaders. This is important given the involvement of leaders in hand hygiene practice significantly changed the hand adherence rates in a previous study.¹⁹

Given the suboptimal hand hygiene adherence rates in Japan noted in this and previous Japanese studies,^21,22 the spread of COVID-19 within the hospital setting is a concern. Transmission of COVID-19 by asymptomatic carriers has been suggested,¹¹ which emphasizes the importance of regular standard precautions with good hand hygiene practice to prevent further transmission.

Although the hand hygiene rate was suboptimal, we were able to achieve a few sustainable, structural modifications in the clinical environment after the intervention. These include adding AHR in new locations, changing the location of existing AHR to more appropriate locations, and introducing new products. These will remain in the clinical environment and will contribute to hand hygiene adherence in the future.

This study has several limitations. First, the presence of external observers in their clinical settings might have affected the behavior of HCWs.²⁸ Although they were not informed that their hand hygiene adherence was going to be monitored, the existence of an external observer in their clinical setting might have changed normal behavior. Second, the infrastructure and interventions for hand hygiene adherence before the intervention were different in each hospital, so there is a possibility that hospitals with less infrastructure for hand hygiene adherence had more room for improvement with the interventions. Third, we included observations at different units at each hospital, which might affect the results of the study because of the inclusion of different medical settings and HCWs. Fourth, the number of physician hand hygiene observations was limited: We conducted our observations between 8 am and 1 pm on weekdays because of observer availability, and many physicians visited their patients during other times of the day. Finally, we were unable to determine whether the improvements seen in each hospital were caused by specific intervention components. However, it is known that recognizing the importance of hand hygiene varies in different regions and countries in the world, and the goal for hand hygiene interventions is to establish a culture of hand hygiene practice.¹³ Further evaluation is necessary to assess sustainability.

In conclusion, a multimodal intervention to improve hand hygiene adherence successfully improved HCWs’ hand hygiene adherence in Niigata, Japan; however, the adherence rates are still relatively low compared with those reported from other countries. Further intervention is required to improve hand hygiene adherence.

Inspired by the ABIM Foundation’s Choosing Wisely^® campaign, the “Things We Do for No Reason^™”(TWDFNR) series reviews practices that have become common parts of hospital care but may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent clear-cut conclusions or clinical practice standards but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion.

The hospitalist admits a 73-year-old man with non–insulin dependent diabetes and essential hypertension to the general medicine ward for lower extremity cellulitis. The hospitalist uses standard admission orders, encourages him to elevate his leg above his heart, starts intravenous antibiotics, and monitors him throughout the day and night with regular vital signs. On his second day of admission, the patient’s cellulitis clinically improves, and the team prepares for discharge. However, the nurse notes that the patient did not sleep well and has not slept since his 4 am vitals were taken. Now a lethargic and confused patient, the team adds delirium to his problem list.

General medicine floors commonly default frequency for measuring vital signs to every 4 hours (Q4), a practice that dates back more than a century to the time of Florence Nightingale.This custom remains in place to ensure the ability to identify and intervene for those at risk for clinical deterioration and preventable death. Research supports the notion that frequent and consistent vital sign checks can minimize mortality and morbidity in the hospital. In fact, validated scoring systems incorporate vital signs with other clinical findings as a way of quickly identifying a patient with worsening clinical status.¹ Further, trends and trajectories in vital signs may enable us to identify those with impending decompensation.² A 2008 consensus statement made by experts in patient safety encouraged hospitals to use frequent vital sign monitoring of patients when available and affordable.³ These interventions aim to help identify and treat patients with early clinical deterioration to prevent poor outcomes.

The practice of checking vital signs every 4 hours throughout the night dates to long before the modern era of evidence-­based medicine. Research thus far has not focused on the necessity of vital sign checks every 4 hours throughout the night, despite affecting almost every hospitalized patient. Further, patient acuity or need for monitoring does not drive the frequency of overnight vital signs; instead habit and defaults do. We often monitor patients at high risk for clinical deterioration just as frequently as patients at low risk.⁴

While evidence-based medicine influences much of clinical care, “real-world” needs encountered at the bedside often drive early adapters to innovate. Nurses, who spend the most time at the bedside and conduct the most regular patient assessments, have recognized that not all patients need vital signs checked every 4 hours throughout the night. In 2013, Hands et al conducted a chart review of hospital patterns and found that nurses obtained complete vital sign checks on patients less frequently throughout the night than during the day.⁵ Their work further showed that nurses used their clinical judgment to make decisions about risk: Those patients deemed low risk by the nurses received fewer vital sign checks while the sicker patients received monitoring every 4 hours throughout the night.

Few researchers have quantitatively identified reasons why nurses may choose to not conduct frequent observations for some patients, beyond the providers’ own experience and judgment. In one study, Hope et al conducted a qualitative analysis of nurses to better understand their reasoning behind who should and should not receive overnight monitoring.⁶ The results of the analysis revealed that nurses recognize the importance of sleep in support of health and healing and use their clinical judgement when deciding which patients and conditions can forgo frequent observations.Stiver et al conducted trailblazing work that examines the outcomes of decreasing overnight vital sign checks for low-risk hospitalized patients through a randomized pilot study.⁷ In order to ensure patient safety, their group employed regular nurse observations throughout the night without waking the patient. Those patients assigned to less monitoring overnight reported a trend toward better sleep during hospitalization without the occurrence of any adverse events or escalation in care.

Most important, evidence indicates that sleep disruptions in the hospital worsen health and impede healing; further supporting nurses’ instincts and practices. Hospitalized adults without comorbidities who experience inadequate sleep during hospitalization have a higher perception of pain.⁸ Similarly, research has associated hospital-induced sleep deprivation and a higher odds of elevated blood glucose in those without diabetes, or “hyperglycemia of hospitalization.” ⁹ Furthermore, national organizations have recognized the importance of sleep. The American Academy of Nursing, as part of its Choosing Wisely™ campaign, states that, in the hospital, nurses should not disturb a patient’s sleep “unless the patient’s condition or care specifically requires it.”¹⁰

Finally, in the era of COVID-19, any opportunity to support physical distancing and to limit face-to-face interaction could protect our patients and staff from acquiring SARS-CoV-2.

While consistent vital sign checks allow for early identification of those trending toward clinical deterioration, risk stratification of ward patients can identify those who may benefit from overnight Q4 vital sign checks. While clinicians often use their judgment to identify a subset of low-risk patients for de-escalation of overnight care, artificial intelligence such as Modified Early Warning Score (MEWS) and Pediatric Early Warning Signs (PEWS) may have a role to play. These validated systems use physiologic symptoms that present prior to significant vital sign alterations to identify patients at risk for clinical deterioration.¹¹ As an example, one randomized, controlled trial used a risk stratification tool to eliminate overnight monitoring for low-risk patients. Patients slept more soundly and reported fewer noise disruptions and higher satisfaction with the nursing staff. No adverse events were reported for those who were electronically stratified as low risk.¹²Further, forcing clinicians to decide on the need for overnight vitals by removing the Q4 vital sign default in the electronic health records (EHR) may minimize overnight disruptions. The University of Chicago in Illinois has implemented “sleep-friendly” options for vital sign ordering in the EHR for both children and adults. Enhanced order sets force providers to consider whether patients qualify for fewer overnight interventions. This change, alongside staff education and empowerment, reduced interruptions overnight for both populations and improved patient experience.¹³ This patient-centered practice mirrors a recent recommendation from the American Academy of Nursing to minimize sleep disruptions for hospitalized patients by letting low-risk patients sleep.¹⁰

• Use clinical judgment or an existing risk stratification system, such as MEWS or PEWS, to identify patients who may benefit from more or less monitoring.
• Forgo overnight vital sign checks for low-risk patients.
• Check overnight vitals for low-risk patients at 10 pm and 6 am.
• Use pulse oximetry or regular nurse checks as a balancing measure, especially in the pediatric population.

Inspired by the ABIM Foundation’s Choosing Wisely^® campaign, the “Things We Do for No Reason^™”(TWDFNR) series reviews practices that have become common parts of hospital care but may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent clear-cut conclusions or clinical practice standards but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion.

The hospitalist admits a 73-year-old man with non–insulin dependent diabetes and essential hypertension to the general medicine ward for lower extremity cellulitis. The hospitalist uses standard admission orders, encourages him to elevate his leg above his heart, starts intravenous antibiotics, and monitors him throughout the day and night with regular vital signs. On his second day of admission, the patient’s cellulitis clinically improves, and the team prepares for discharge. However, the nurse notes that the patient did not sleep well and has not slept since his 4 am vitals were taken. Now a lethargic and confused patient, the team adds delirium to his problem list.

General medicine floors commonly default frequency for measuring vital signs to every 4 hours (Q4), a practice that dates back more than a century to the time of Florence Nightingale.This custom remains in place to ensure the ability to identify and intervene for those at risk for clinical deterioration and preventable death. Research supports the notion that frequent and consistent vital sign checks can minimize mortality and morbidity in the hospital. In fact, validated scoring systems incorporate vital signs with other clinical findings as a way of quickly identifying a patient with worsening clinical status.¹ Further, trends and trajectories in vital signs may enable us to identify those with impending decompensation.² A 2008 consensus statement made by experts in patient safety encouraged hospitals to use frequent vital sign monitoring of patients when available and affordable.³ These interventions aim to help identify and treat patients with early clinical deterioration to prevent poor outcomes.

The practice of checking vital signs every 4 hours throughout the night dates to long before the modern era of evidence-­based medicine. Research thus far has not focused on the necessity of vital sign checks every 4 hours throughout the night, despite affecting almost every hospitalized patient. Further, patient acuity or need for monitoring does not drive the frequency of overnight vital signs; instead habit and defaults do. We often monitor patients at high risk for clinical deterioration just as frequently as patients at low risk.⁴

While evidence-based medicine influences much of clinical care, “real-world” needs encountered at the bedside often drive early adapters to innovate. Nurses, who spend the most time at the bedside and conduct the most regular patient assessments, have recognized that not all patients need vital signs checked every 4 hours throughout the night. In 2013, Hands et al conducted a chart review of hospital patterns and found that nurses obtained complete vital sign checks on patients less frequently throughout the night than during the day.⁵ Their work further showed that nurses used their clinical judgment to make decisions about risk: Those patients deemed low risk by the nurses received fewer vital sign checks while the sicker patients received monitoring every 4 hours throughout the night.

Few researchers have quantitatively identified reasons why nurses may choose to not conduct frequent observations for some patients, beyond the providers’ own experience and judgment. In one study, Hope et al conducted a qualitative analysis of nurses to better understand their reasoning behind who should and should not receive overnight monitoring.⁶ The results of the analysis revealed that nurses recognize the importance of sleep in support of health and healing and use their clinical judgement when deciding which patients and conditions can forgo frequent observations.Stiver et al conducted trailblazing work that examines the outcomes of decreasing overnight vital sign checks for low-risk hospitalized patients through a randomized pilot study.⁷ In order to ensure patient safety, their group employed regular nurse observations throughout the night without waking the patient. Those patients assigned to less monitoring overnight reported a trend toward better sleep during hospitalization without the occurrence of any adverse events or escalation in care.

Most important, evidence indicates that sleep disruptions in the hospital worsen health and impede healing; further supporting nurses’ instincts and practices. Hospitalized adults without comorbidities who experience inadequate sleep during hospitalization have a higher perception of pain.⁸ Similarly, research has associated hospital-induced sleep deprivation and a higher odds of elevated blood glucose in those without diabetes, or “hyperglycemia of hospitalization.” ⁹ Furthermore, national organizations have recognized the importance of sleep. The American Academy of Nursing, as part of its Choosing Wisely™ campaign, states that, in the hospital, nurses should not disturb a patient’s sleep “unless the patient’s condition or care specifically requires it.”¹⁰

Finally, in the era of COVID-19, any opportunity to support physical distancing and to limit face-to-face interaction could protect our patients and staff from acquiring SARS-CoV-2.

While consistent vital sign checks allow for early identification of those trending toward clinical deterioration, risk stratification of ward patients can identify those who may benefit from overnight Q4 vital sign checks. While clinicians often use their judgment to identify a subset of low-risk patients for de-escalation of overnight care, artificial intelligence such as Modified Early Warning Score (MEWS) and Pediatric Early Warning Signs (PEWS) may have a role to play. These validated systems use physiologic symptoms that present prior to significant vital sign alterations to identify patients at risk for clinical deterioration.¹¹ As an example, one randomized, controlled trial used a risk stratification tool to eliminate overnight monitoring for low-risk patients. Patients slept more soundly and reported fewer noise disruptions and higher satisfaction with the nursing staff. No adverse events were reported for those who were electronically stratified as low risk.¹²Further, forcing clinicians to decide on the need for overnight vitals by removing the Q4 vital sign default in the electronic health records (EHR) may minimize overnight disruptions. The University of Chicago in Illinois has implemented “sleep-friendly” options for vital sign ordering in the EHR for both children and adults. Enhanced order sets force providers to consider whether patients qualify for fewer overnight interventions. This change, alongside staff education and empowerment, reduced interruptions overnight for both populations and improved patient experience.¹³ This patient-centered practice mirrors a recent recommendation from the American Academy of Nursing to minimize sleep disruptions for hospitalized patients by letting low-risk patients sleep.¹⁰

• Use clinical judgment or an existing risk stratification system, such as MEWS or PEWS, to identify patients who may benefit from more or less monitoring.
• Forgo overnight vital sign checks for low-risk patients.
• Check overnight vitals for low-risk patients at 10 pm and 6 am.
• Use pulse oximetry or regular nurse checks as a balancing measure, especially in the pediatric population.

Inspired by the ABIM Foundation’s Choosing Wisely^® campaign, the “Things We Do for No Reason^™”(TWDFNR) series reviews practices that have become common parts of hospital care but may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent clear-cut conclusions or clinical practice standards but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion.

The hospitalist admits a 73-year-old man with non–insulin dependent diabetes and essential hypertension to the general medicine ward for lower extremity cellulitis. The hospitalist uses standard admission orders, encourages him to elevate his leg above his heart, starts intravenous antibiotics, and monitors him throughout the day and night with regular vital signs. On his second day of admission, the patient’s cellulitis clinically improves, and the team prepares for discharge. However, the nurse notes that the patient did not sleep well and has not slept since his 4 am vitals were taken. Now a lethargic and confused patient, the team adds delirium to his problem list.

General medicine floors commonly default frequency for measuring vital signs to every 4 hours (Q4), a practice that dates back more than a century to the time of Florence Nightingale.This custom remains in place to ensure the ability to identify and intervene for those at risk for clinical deterioration and preventable death. Research supports the notion that frequent and consistent vital sign checks can minimize mortality and morbidity in the hospital. In fact, validated scoring systems incorporate vital signs with other clinical findings as a way of quickly identifying a patient with worsening clinical status.¹ Further, trends and trajectories in vital signs may enable us to identify those with impending decompensation.² A 2008 consensus statement made by experts in patient safety encouraged hospitals to use frequent vital sign monitoring of patients when available and affordable.³ These interventions aim to help identify and treat patients with early clinical deterioration to prevent poor outcomes.

The practice of checking vital signs every 4 hours throughout the night dates to long before the modern era of evidence-­based medicine. Research thus far has not focused on the necessity of vital sign checks every 4 hours throughout the night, despite affecting almost every hospitalized patient. Further, patient acuity or need for monitoring does not drive the frequency of overnight vital signs; instead habit and defaults do. We often monitor patients at high risk for clinical deterioration just as frequently as patients at low risk.⁴

While evidence-based medicine influences much of clinical care, “real-world” needs encountered at the bedside often drive early adapters to innovate. Nurses, who spend the most time at the bedside and conduct the most regular patient assessments, have recognized that not all patients need vital signs checked every 4 hours throughout the night. In 2013, Hands et al conducted a chart review of hospital patterns and found that nurses obtained complete vital sign checks on patients less frequently throughout the night than during the day.⁵ Their work further showed that nurses used their clinical judgment to make decisions about risk: Those patients deemed low risk by the nurses received fewer vital sign checks while the sicker patients received monitoring every 4 hours throughout the night.

Few researchers have quantitatively identified reasons why nurses may choose to not conduct frequent observations for some patients, beyond the providers’ own experience and judgment. In one study, Hope et al conducted a qualitative analysis of nurses to better understand their reasoning behind who should and should not receive overnight monitoring.⁶ The results of the analysis revealed that nurses recognize the importance of sleep in support of health and healing and use their clinical judgement when deciding which patients and conditions can forgo frequent observations.Stiver et al conducted trailblazing work that examines the outcomes of decreasing overnight vital sign checks for low-risk hospitalized patients through a randomized pilot study.⁷ In order to ensure patient safety, their group employed regular nurse observations throughout the night without waking the patient. Those patients assigned to less monitoring overnight reported a trend toward better sleep during hospitalization without the occurrence of any adverse events or escalation in care.

Most important, evidence indicates that sleep disruptions in the hospital worsen health and impede healing; further supporting nurses’ instincts and practices. Hospitalized adults without comorbidities who experience inadequate sleep during hospitalization have a higher perception of pain.⁸ Similarly, research has associated hospital-induced sleep deprivation and a higher odds of elevated blood glucose in those without diabetes, or “hyperglycemia of hospitalization.” ⁹ Furthermore, national organizations have recognized the importance of sleep. The American Academy of Nursing, as part of its Choosing Wisely™ campaign, states that, in the hospital, nurses should not disturb a patient’s sleep “unless the patient’s condition or care specifically requires it.”¹⁰

Finally, in the era of COVID-19, any opportunity to support physical distancing and to limit face-to-face interaction could protect our patients and staff from acquiring SARS-CoV-2.

While consistent vital sign checks allow for early identification of those trending toward clinical deterioration, risk stratification of ward patients can identify those who may benefit from overnight Q4 vital sign checks. While clinicians often use their judgment to identify a subset of low-risk patients for de-escalation of overnight care, artificial intelligence such as Modified Early Warning Score (MEWS) and Pediatric Early Warning Signs (PEWS) may have a role to play. These validated systems use physiologic symptoms that present prior to significant vital sign alterations to identify patients at risk for clinical deterioration.¹¹ As an example, one randomized, controlled trial used a risk stratification tool to eliminate overnight monitoring for low-risk patients. Patients slept more soundly and reported fewer noise disruptions and higher satisfaction with the nursing staff. No adverse events were reported for those who were electronically stratified as low risk.¹²Further, forcing clinicians to decide on the need for overnight vitals by removing the Q4 vital sign default in the electronic health records (EHR) may minimize overnight disruptions. The University of Chicago in Illinois has implemented “sleep-friendly” options for vital sign ordering in the EHR for both children and adults. Enhanced order sets force providers to consider whether patients qualify for fewer overnight interventions. This change, alongside staff education and empowerment, reduced interruptions overnight for both populations and improved patient experience.¹³ This patient-centered practice mirrors a recent recommendation from the American Academy of Nursing to minimize sleep disruptions for hospitalized patients by letting low-risk patients sleep.¹⁰

• Use clinical judgment or an existing risk stratification system, such as MEWS or PEWS, to identify patients who may benefit from more or less monitoring.
• Forgo overnight vital sign checks for low-risk patients.
• Check overnight vitals for low-risk patients at 10 pm and 6 am.
• Use pulse oximetry or regular nurse checks as a balancing measure, especially in the pediatric population.

Older adults with COVID-19, the illness caused by the coronavirus, have several “atypical” symptoms, complicating efforts to ensure they get timely and appropriate treatment, according to physicians.

COVID-19 is typically signaled by three symptoms: a fever, an insistent cough, and shortness of breath. But older adults – the age group most at risk of severe complications or death from this condition – may have none of these characteristics.

Instead, seniors may seem “off” – not acting like themselves – early on after being infected by the coronavirus. They may sleep more than usual or stop eating. They may seem unusually apathetic or confused, losing orientation to their surroundings. They may become dizzy and fall. Sometimes, seniors stop speaking or simply collapse.

“With a lot of conditions, older adults don’t present in a typical way, and we’re seeing that with COVID-19 as well,” said Camille Vaughan, MD, section chief of geriatrics and gerontology at Emory University, Atlanta.

The reason has to do with how older bodies respond to illness and infection.

At advanced ages, “someone’s immune response may be blunted and their ability to regulate temperature may be altered,” said Dr. Joseph Ouslander, a professor of geriatric medicine at Florida Atlantic University in Boca Raton.

“Underlying chronic illnesses can mask or interfere with signs of infection,” he said. “Some older people, whether from age-related changes or previous neurologic issues such as a stroke, may have altered cough reflexes. Others with cognitive impairment may not be able to communicate their symptoms.”

Recognizing danger signs is important: If early signs of COVID-19 are missed, seniors may deteriorate before getting needed care. And people may go in and out of their homes without adequate protective measures, risking the spread of infection.

Quratulain Syed, MD, an Atlanta geriatrician, describes a man in his 80s whom she treated in mid-March. Over a period of days, this patient, who had heart disease, diabetes and moderate cognitive impairment, stopped walking and became incontinent and profoundly lethargic. But he didn’t have a fever or a cough. His only respiratory symptom: sneezing off and on.

The man’s elderly spouse called 911 twice. Both times, paramedics checked his vital signs and declared he was OK. After another worried call from the overwhelmed spouse, Dr. Syed insisted the patient be taken to the hospital, where he tested positive for COVID-19.

“I was quite concerned about the paramedics and health aides who’d been in the house and who hadn’t used PPE [personal protective equipment],” Dr. Syed said.

Dr. Sam Torbati, medical director of the emergency department at Cedars-Sinai Medical Center, Los Angeles, describes treating seniors who initially appear to be trauma patients but are found to have COVID-19.

“They get weak and dehydrated,” he said, “and when they stand to walk, they collapse and injure themselves badly.”

Dr. Torbati has seen older adults who are profoundly disoriented and unable to speak and who appear at first to have suffered strokes.

“When we test them, we discover that what’s producing these changes is a central nervous system effect of coronavirus,” he said.

Laura Perry, MD, of the University of California, San Francisco, saw a patient like this several weeks ago. The woman, in her 80s, had what seemed to be a cold before becoming very confused. In the hospital, she couldn’t identify where she was or stay awake during an examination. Dr. Perry diagnosed hypoactive delirium, an altered mental state in which people become inactive and drowsy. The patient tested positive for coronavirus and is still in the ICU.

Anthony Perry, MD, of the department of geriatric medicine at Rush University Medical Center in Chicago, tells of an 81-year-old woman with nausea, vomiting, and diarrhea who tested positive for COVID-19 in the emergency room. After receiving intravenous fluids, oxygen, and medication for her intestinal upset, she returned home after 2 days and is doing well.

Another 80-year-old Rush patient with similar symptoms – nausea and vomiting, but no cough, fever, or shortness of breath – is in intensive care after getting a positive COVID-19 test and due to be put on a ventilator. The difference? This patient is frail with “a lot of cardiovascular disease,” Dr. Perry said. Other than that, it’s not yet clear why some older patients do well while others do not.

So far, reports of cases like these have been anecdotal. But a few physicians are trying to gather more systematic information.

In Switzerland, Sylvain Nguyen, MD, a geriatrician at the University of Lausanne Hospital Center, put together a list of typical and atypical symptoms in older COVID-19 patients for a paper to be published in the Revue Médicale Suisse. Included on the atypical list are changes in a patient’s usual status, delirium, falls, fatigue, lethargy, low blood pressure, painful swallowing, fainting, diarrhea, nausea, vomiting, abdominal pain, and the loss of smell and taste.

Data come from hospitals and nursing homes in Switzerland, Italy, and France, Dr. Nguyen said in an email.

On the front lines, physicians need to make sure they carefully assess an older patient’s symptoms.

“While we have to have a high suspicion of COVID-19 because it’s so dangerous in the older population, there are many other things to consider,” said Kathleen Unroe, MD, a geriatrician at Indiana University, Indianapolis.

Seniors may also do poorly because their routines have changed. In nursing homes and most assisted living centers, activities have stopped and “residents are going to get weaker and more deconditioned because they’re not walking to and from the dining hall,” she said.

At home, isolated seniors may not be getting as much help with medication management or other essential needs from family members who are keeping their distance, other experts suggested. Or they may have become apathetic or depressed.

“I’d want to know ‘What’s the potential this person has had an exposure [to the coronavirus], especially in the last 2 weeks?’ ” said Dr. Vaughan of Emory. “Do they have home health personnel coming in? Have they gotten together with other family members? Are chronic conditions being controlled? Is there another diagnosis that seems more likely?”

“Someone may be just having a bad day. But if they’re not themselves for a couple of days, absolutely reach out to a primary care doctor or a local health system hotline to see if they meet the threshold for [coronavirus] testing,” Dr. Vaughan advised. “Be persistent. If you get a ‘no’ the first time and things aren’t improving, call back and ask again.”

Kaiser Health News (khn.org) is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

Older adults with COVID-19, the illness caused by the coronavirus, have several “atypical” symptoms, complicating efforts to ensure they get timely and appropriate treatment, according to physicians.

COVID-19 is typically signaled by three symptoms: a fever, an insistent cough, and shortness of breath. But older adults – the age group most at risk of severe complications or death from this condition – may have none of these characteristics.

Instead, seniors may seem “off” – not acting like themselves – early on after being infected by the coronavirus. They may sleep more than usual or stop eating. They may seem unusually apathetic or confused, losing orientation to their surroundings. They may become dizzy and fall. Sometimes, seniors stop speaking or simply collapse.

“With a lot of conditions, older adults don’t present in a typical way, and we’re seeing that with COVID-19 as well,” said Camille Vaughan, MD, section chief of geriatrics and gerontology at Emory University, Atlanta.

The reason has to do with how older bodies respond to illness and infection.

At advanced ages, “someone’s immune response may be blunted and their ability to regulate temperature may be altered,” said Dr. Joseph Ouslander, a professor of geriatric medicine at Florida Atlantic University in Boca Raton.

“Underlying chronic illnesses can mask or interfere with signs of infection,” he said. “Some older people, whether from age-related changes or previous neurologic issues such as a stroke, may have altered cough reflexes. Others with cognitive impairment may not be able to communicate their symptoms.”

Recognizing danger signs is important: If early signs of COVID-19 are missed, seniors may deteriorate before getting needed care. And people may go in and out of their homes without adequate protective measures, risking the spread of infection.

Quratulain Syed, MD, an Atlanta geriatrician, describes a man in his 80s whom she treated in mid-March. Over a period of days, this patient, who had heart disease, diabetes and moderate cognitive impairment, stopped walking and became incontinent and profoundly lethargic. But he didn’t have a fever or a cough. His only respiratory symptom: sneezing off and on.

The man’s elderly spouse called 911 twice. Both times, paramedics checked his vital signs and declared he was OK. After another worried call from the overwhelmed spouse, Dr. Syed insisted the patient be taken to the hospital, where he tested positive for COVID-19.

“I was quite concerned about the paramedics and health aides who’d been in the house and who hadn’t used PPE [personal protective equipment],” Dr. Syed said.

Dr. Sam Torbati, medical director of the emergency department at Cedars-Sinai Medical Center, Los Angeles, describes treating seniors who initially appear to be trauma patients but are found to have COVID-19.

“They get weak and dehydrated,” he said, “and when they stand to walk, they collapse and injure themselves badly.”

Dr. Torbati has seen older adults who are profoundly disoriented and unable to speak and who appear at first to have suffered strokes.

“When we test them, we discover that what’s producing these changes is a central nervous system effect of coronavirus,” he said.

Laura Perry, MD, of the University of California, San Francisco, saw a patient like this several weeks ago. The woman, in her 80s, had what seemed to be a cold before becoming very confused. In the hospital, she couldn’t identify where she was or stay awake during an examination. Dr. Perry diagnosed hypoactive delirium, an altered mental state in which people become inactive and drowsy. The patient tested positive for coronavirus and is still in the ICU.

Anthony Perry, MD, of the department of geriatric medicine at Rush University Medical Center in Chicago, tells of an 81-year-old woman with nausea, vomiting, and diarrhea who tested positive for COVID-19 in the emergency room. After receiving intravenous fluids, oxygen, and medication for her intestinal upset, she returned home after 2 days and is doing well.

Another 80-year-old Rush patient with similar symptoms – nausea and vomiting, but no cough, fever, or shortness of breath – is in intensive care after getting a positive COVID-19 test and due to be put on a ventilator. The difference? This patient is frail with “a lot of cardiovascular disease,” Dr. Perry said. Other than that, it’s not yet clear why some older patients do well while others do not.

So far, reports of cases like these have been anecdotal. But a few physicians are trying to gather more systematic information.

In Switzerland, Sylvain Nguyen, MD, a geriatrician at the University of Lausanne Hospital Center, put together a list of typical and atypical symptoms in older COVID-19 patients for a paper to be published in the Revue Médicale Suisse. Included on the atypical list are changes in a patient’s usual status, delirium, falls, fatigue, lethargy, low blood pressure, painful swallowing, fainting, diarrhea, nausea, vomiting, abdominal pain, and the loss of smell and taste.

Data come from hospitals and nursing homes in Switzerland, Italy, and France, Dr. Nguyen said in an email.

On the front lines, physicians need to make sure they carefully assess an older patient’s symptoms.

“While we have to have a high suspicion of COVID-19 because it’s so dangerous in the older population, there are many other things to consider,” said Kathleen Unroe, MD, a geriatrician at Indiana University, Indianapolis.

Seniors may also do poorly because their routines have changed. In nursing homes and most assisted living centers, activities have stopped and “residents are going to get weaker and more deconditioned because they’re not walking to and from the dining hall,” she said.

At home, isolated seniors may not be getting as much help with medication management or other essential needs from family members who are keeping their distance, other experts suggested. Or they may have become apathetic or depressed.

“I’d want to know ‘What’s the potential this person has had an exposure [to the coronavirus], especially in the last 2 weeks?’ ” said Dr. Vaughan of Emory. “Do they have home health personnel coming in? Have they gotten together with other family members? Are chronic conditions being controlled? Is there another diagnosis that seems more likely?”

“Someone may be just having a bad day. But if they’re not themselves for a couple of days, absolutely reach out to a primary care doctor or a local health system hotline to see if they meet the threshold for [coronavirus] testing,” Dr. Vaughan advised. “Be persistent. If you get a ‘no’ the first time and things aren’t improving, call back and ask again.”

Kaiser Health News (khn.org) is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

Older adults with COVID-19, the illness caused by the coronavirus, have several “atypical” symptoms, complicating efforts to ensure they get timely and appropriate treatment, according to physicians.

COVID-19 is typically signaled by three symptoms: a fever, an insistent cough, and shortness of breath. But older adults – the age group most at risk of severe complications or death from this condition – may have none of these characteristics.

Instead, seniors may seem “off” – not acting like themselves – early on after being infected by the coronavirus. They may sleep more than usual or stop eating. They may seem unusually apathetic or confused, losing orientation to their surroundings. They may become dizzy and fall. Sometimes, seniors stop speaking or simply collapse.

“With a lot of conditions, older adults don’t present in a typical way, and we’re seeing that with COVID-19 as well,” said Camille Vaughan, MD, section chief of geriatrics and gerontology at Emory University, Atlanta.

The reason has to do with how older bodies respond to illness and infection.

At advanced ages, “someone’s immune response may be blunted and their ability to regulate temperature may be altered,” said Dr. Joseph Ouslander, a professor of geriatric medicine at Florida Atlantic University in Boca Raton.

“Underlying chronic illnesses can mask or interfere with signs of infection,” he said. “Some older people, whether from age-related changes or previous neurologic issues such as a stroke, may have altered cough reflexes. Others with cognitive impairment may not be able to communicate their symptoms.”

Recognizing danger signs is important: If early signs of COVID-19 are missed, seniors may deteriorate before getting needed care. And people may go in and out of their homes without adequate protective measures, risking the spread of infection.

Quratulain Syed, MD, an Atlanta geriatrician, describes a man in his 80s whom she treated in mid-March. Over a period of days, this patient, who had heart disease, diabetes and moderate cognitive impairment, stopped walking and became incontinent and profoundly lethargic. But he didn’t have a fever or a cough. His only respiratory symptom: sneezing off and on.

The man’s elderly spouse called 911 twice. Both times, paramedics checked his vital signs and declared he was OK. After another worried call from the overwhelmed spouse, Dr. Syed insisted the patient be taken to the hospital, where he tested positive for COVID-19.

“I was quite concerned about the paramedics and health aides who’d been in the house and who hadn’t used PPE [personal protective equipment],” Dr. Syed said.

Dr. Sam Torbati, medical director of the emergency department at Cedars-Sinai Medical Center, Los Angeles, describes treating seniors who initially appear to be trauma patients but are found to have COVID-19.

“They get weak and dehydrated,” he said, “and when they stand to walk, they collapse and injure themselves badly.”

Dr. Torbati has seen older adults who are profoundly disoriented and unable to speak and who appear at first to have suffered strokes.

“When we test them, we discover that what’s producing these changes is a central nervous system effect of coronavirus,” he said.

Laura Perry, MD, of the University of California, San Francisco, saw a patient like this several weeks ago. The woman, in her 80s, had what seemed to be a cold before becoming very confused. In the hospital, she couldn’t identify where she was or stay awake during an examination. Dr. Perry diagnosed hypoactive delirium, an altered mental state in which people become inactive and drowsy. The patient tested positive for coronavirus and is still in the ICU.

Anthony Perry, MD, of the department of geriatric medicine at Rush University Medical Center in Chicago, tells of an 81-year-old woman with nausea, vomiting, and diarrhea who tested positive for COVID-19 in the emergency room. After receiving intravenous fluids, oxygen, and medication for her intestinal upset, she returned home after 2 days and is doing well.

Another 80-year-old Rush patient with similar symptoms – nausea and vomiting, but no cough, fever, or shortness of breath – is in intensive care after getting a positive COVID-19 test and due to be put on a ventilator. The difference? This patient is frail with “a lot of cardiovascular disease,” Dr. Perry said. Other than that, it’s not yet clear why some older patients do well while others do not.

So far, reports of cases like these have been anecdotal. But a few physicians are trying to gather more systematic information.

In Switzerland, Sylvain Nguyen, MD, a geriatrician at the University of Lausanne Hospital Center, put together a list of typical and atypical symptoms in older COVID-19 patients for a paper to be published in the Revue Médicale Suisse. Included on the atypical list are changes in a patient’s usual status, delirium, falls, fatigue, lethargy, low blood pressure, painful swallowing, fainting, diarrhea, nausea, vomiting, abdominal pain, and the loss of smell and taste.

Data come from hospitals and nursing homes in Switzerland, Italy, and France, Dr. Nguyen said in an email.

On the front lines, physicians need to make sure they carefully assess an older patient’s symptoms.

“While we have to have a high suspicion of COVID-19 because it’s so dangerous in the older population, there are many other things to consider,” said Kathleen Unroe, MD, a geriatrician at Indiana University, Indianapolis.

Seniors may also do poorly because their routines have changed. In nursing homes and most assisted living centers, activities have stopped and “residents are going to get weaker and more deconditioned because they’re not walking to and from the dining hall,” she said.

At home, isolated seniors may not be getting as much help with medication management or other essential needs from family members who are keeping their distance, other experts suggested. Or they may have become apathetic or depressed.

“I’d want to know ‘What’s the potential this person has had an exposure [to the coronavirus], especially in the last 2 weeks?’ ” said Dr. Vaughan of Emory. “Do they have home health personnel coming in? Have they gotten together with other family members? Are chronic conditions being controlled? Is there another diagnosis that seems more likely?”

“Someone may be just having a bad day. But if they’re not themselves for a couple of days, absolutely reach out to a primary care doctor or a local health system hotline to see if they meet the threshold for [coronavirus] testing,” Dr. Vaughan advised. “Be persistent. If you get a ‘no’ the first time and things aren’t improving, call back and ask again.”

Kaiser Health News (khn.org) is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

A study from China showed that the presence of SARS-CoV-2 lasts significantly longer in stool samples from COVID-19 patients than in respiratory and serum samples.

CDC/John Hierholzer, MD

However, the virus also persists longer with higher loads and later peaks in the respiratory tissue of patients with severe disease than in those with mild disease, according to an analysis of 96 consecutively admitted patients with laboratory confirmed SARS-CoV-2 infection.

The retrospective study cohort data were collected from Jan. 19 to March 20 at a designated hospital for patients with COVID-19 in Zhejiang province. Among the patients, 22 had mild disease, and 74 had severe disease, according to the researchers.

Infection was confirmed in all patients by testing sputum and saliva samples. Viral RNA was detected in the stool of 59% of the patients and in the serum of 41% of patients. Only one of the patients had a positive urine sample. The median duration of virus in stool (22 days) was significantly longer than in respiratory (18 days; P = .002) and serum samples (16 days; P < .001).

In addition, the median duration of virus in the respiratory samples of patients with severe disease (21 days) was significantly longer than in patients with mild disease (14 days; P = .04).

“In the mild group, the viral loads peaked in respiratory samples in the second week from disease onset, whereas viral load continued to be high during the third week in the severe group,” the authors stated.

Virus duration was also longer in patients older than 60 years and in men.

The longer duration of SARS-CoV-2 in stool samples highlights the need to strengthen the management of stool samples in the prevention and control of the epidemic, especially for patients in the later stages of the disease, the authors advised.

“Compared with patients with mild disease, those with severe disease showed longer duration of SARS-CoV-2 in respiratory samples, higher viral load, and a later shedding peak. These findings suggest that reducing viral loads through clinical means and strengthening management during each stage of severe disease should help to prevent the spread of the virus,” the researchers concluded.

The study was funded by the China National Mega-Projects for Infectious Diseases and the National Natural Science Foundation of China. The authors reported they had no disclosures.

mlesney@mdedge.com

SOURCE: Zheng S et al. BMJ. 2020;369:m1443.

A study from China showed that the presence of SARS-CoV-2 lasts significantly longer in stool samples from COVID-19 patients than in respiratory and serum samples.

CDC/John Hierholzer, MD

However, the virus also persists longer with higher loads and later peaks in the respiratory tissue of patients with severe disease than in those with mild disease, according to an analysis of 96 consecutively admitted patients with laboratory confirmed SARS-CoV-2 infection.

The retrospective study cohort data were collected from Jan. 19 to March 20 at a designated hospital for patients with COVID-19 in Zhejiang province. Among the patients, 22 had mild disease, and 74 had severe disease, according to the researchers.

Infection was confirmed in all patients by testing sputum and saliva samples. Viral RNA was detected in the stool of 59% of the patients and in the serum of 41% of patients. Only one of the patients had a positive urine sample. The median duration of virus in stool (22 days) was significantly longer than in respiratory (18 days; P = .002) and serum samples (16 days; P < .001).

In addition, the median duration of virus in the respiratory samples of patients with severe disease (21 days) was significantly longer than in patients with mild disease (14 days; P = .04).

“In the mild group, the viral loads peaked in respiratory samples in the second week from disease onset, whereas viral load continued to be high during the third week in the severe group,” the authors stated.

Virus duration was also longer in patients older than 60 years and in men.

The longer duration of SARS-CoV-2 in stool samples highlights the need to strengthen the management of stool samples in the prevention and control of the epidemic, especially for patients in the later stages of the disease, the authors advised.

“Compared with patients with mild disease, those with severe disease showed longer duration of SARS-CoV-2 in respiratory samples, higher viral load, and a later shedding peak. These findings suggest that reducing viral loads through clinical means and strengthening management during each stage of severe disease should help to prevent the spread of the virus,” the researchers concluded.

The study was funded by the China National Mega-Projects for Infectious Diseases and the National Natural Science Foundation of China. The authors reported they had no disclosures.

mlesney@mdedge.com

SOURCE: Zheng S et al. BMJ. 2020;369:m1443.

A study from China showed that the presence of SARS-CoV-2 lasts significantly longer in stool samples from COVID-19 patients than in respiratory and serum samples.

CDC/John Hierholzer, MD

However, the virus also persists longer with higher loads and later peaks in the respiratory tissue of patients with severe disease than in those with mild disease, according to an analysis of 96 consecutively admitted patients with laboratory confirmed SARS-CoV-2 infection.

The retrospective study cohort data were collected from Jan. 19 to March 20 at a designated hospital for patients with COVID-19 in Zhejiang province. Among the patients, 22 had mild disease, and 74 had severe disease, according to the researchers.

Infection was confirmed in all patients by testing sputum and saliva samples. Viral RNA was detected in the stool of 59% of the patients and in the serum of 41% of patients. Only one of the patients had a positive urine sample. The median duration of virus in stool (22 days) was significantly longer than in respiratory (18 days; P = .002) and serum samples (16 days; P < .001).

In addition, the median duration of virus in the respiratory samples of patients with severe disease (21 days) was significantly longer than in patients with mild disease (14 days; P = .04).

“In the mild group, the viral loads peaked in respiratory samples in the second week from disease onset, whereas viral load continued to be high during the third week in the severe group,” the authors stated.

Virus duration was also longer in patients older than 60 years and in men.

The longer duration of SARS-CoV-2 in stool samples highlights the need to strengthen the management of stool samples in the prevention and control of the epidemic, especially for patients in the later stages of the disease, the authors advised.

“Compared with patients with mild disease, those with severe disease showed longer duration of SARS-CoV-2 in respiratory samples, higher viral load, and a later shedding peak. These findings suggest that reducing viral loads through clinical means and strengthening management during each stage of severe disease should help to prevent the spread of the virus,” the researchers concluded.

The study was funded by the China National Mega-Projects for Infectious Diseases and the National Natural Science Foundation of China. The authors reported they had no disclosures.

mlesney@mdedge.com

SOURCE: Zheng S et al. BMJ. 2020;369:m1443.

The first time that the Rev. Michael Mercier, BCC (a board-certified chaplain), provided spiritual care for a patient hospitalized with COVID-19 in March, he found himself engaged in a bit of soul-searching. Even though he donned a mask, gloves, and gown, he could get no closer than the hospital room doorway to interact with the patient because of infection-control measures.

Bill Murphy/Lifespan

“It went against all my natural instincts and my experience as a chaplain,” said Rev. Mercier, who serves as director of spiritual care for Rhode Island Hospital, Hasbro Children’s Hospital, Miriam Hospital, and Newport Hospital, which are operated by Lifespan, Rhode Island’s largest health system. “The first instinct is to be physically present in the room with the person who’s dying, to have the family gathered around the bedside.”

Prior to standing in the doorway that day, he’d been on the phone with family members, “just listening to their fear and their anxiety that they could not be with their loved one when their loved one was dying,” he said. “I validated their feelings. I also urged them to work with me and the nurse to bring a phone into the room, hold it to the patient’s ear, and they were able to say their goodbyes and how much they loved the person.”

The patient was a devout Roman Catholic, he added, and the family requested that the Prayer of Commendation and the Apostolic Pardon be performed. Rev. Mercier arranged for a Catholic priest to carry out this request. “The nurse told the patient what was going on, and the priest offered the prayers and the rituals from the doorway,” Rev. Mercier said. “It was a surreal experience. For me, it was almost entirely phone based, and it was mostly with the family because the patient couldn’t talk too much.”

To add to the sense of detachment in a situation like that, doctors, nurses, and chaplains caring for COVID-19 patients are wearing masks and face shields, and sometimes the sickest patients are intubated, which can complicate efforts to communicate. “I’m surprised at how we find the mask as somewhat of a barrier,” said Carolanne B. Hauck, BCC, director of chaplaincy care & education and volunteer services at Lancaster (Pa.) General Hospital, which is part of the Penn Medicine system. “By that I mean, often for us, sitting at the bedside and really being able to see someone’s face and have them see our face – with our masks, that’s just not happening. We’re also having briefer visits when we’re visiting with COVID patients.”

COVID-19 may have quarantined some traditional ways of providing spiritual care, but hospital chaplains are relying on technology more than ever in their efforts to meet the needs of patients and their families, including the use of iPads, FaceTime, and video conferencing programs like Zoom and BlueJeans.

“We’ve used Zoom to talk with family members that live out of state,” Rev. Mercier said. “Most of the time, I get an invitation to join a Zoom meeting, but now I need to become proficient in utilizing Zoom to set up those end-of-life family meetings. There’s a lot of learning on the fly, how to use these technologies in a way that’s helpful for everybody. That’s the biggest thing I’m learning: Connection is connection during this time of high stress and anxiety, and we just have to get creative.”

Courtesy Rabbi Neal J. Loevinger

Hospital chaplains may be using smartphones and other gadgets to communicate with patients and their families more than they did in the pre-COVID-19 world, but their basic job has not changed, said Rabbi Neal J. Loevinger, BCC, director of spiritual care services at Vassar Brothers Medical Center in Poughkeepsie, N.Y., part of a seven-hospital system operated by Nuvance Health. “We offer the hope of a caring presence,” said Rabbi Loevinger, who is also a member of the board of directors for Neshama: Association of Jewish Chaplains. “If someone is in a hole, our job is to climb down into the hole with them and say, ‘We’re going to get out of this hole together.’ We can’t promise that someone’s going to get better. We can’t promise that everything’s going to be all right. What we can promise is that we will not abandon you. We can promise that there will be someone accompanying you in any way we can through this crisis.”

Ms. Hauck remembered a phone conversation with the granddaughter of a patient hospitalized with COVID-19 who was nearing the end of her life. The granddaughter told her a story about how her grandmother and her best friend made a pact with each other that, when one was dying, the other would come to her side and pray the Rosary with her. “The granddaughter got tearful and said, ‘That can’t happen now,’ ” said Ms. Hauck, who oversees a staff of 9 chaplains and 10 per diem chaplains. “I made a promise that I would do my best to be at the bedside and pray the Rosary with her grandmother.”

The nurses were aware of the request, and about a day later, Ms. Hauck received a call at 1 a.m., indicating that the patient was close to dying. She drove to Lancaster General, put on her personal protective equipment, made it to the patient’s bedside, and began to pray the Rosary with her, with a nurse in the room. “The nurse said to me, ‘Carolanne, all of her stats are going up,’ and the patient actually became a little more alert,” she recalled. “We talked a little bit, and I asked, ‘Would you like to pray the Rosary now?’ She shook her head yes, and said, ‘Hail Mary, full of grace ...’ and those were the last words that she spoke. I finished the prayers for her, and then she died. It was very meaningful knowing that I could honor that wish for her, but more importantly, that I could do that for the family, who otherwise would have been at her side saying the Rosary with her. We have a recognition of how hard it is to leave someone at the hospital and not be at their bedside.”

Hospital chaplains are also supporting interdisciplinary teams of physicians, nurses, and other staff, as they navigate the provision of care in the wake of a pandemic. “They are under a great deal of stress – not only from being at work but with all the role changes that have happened in their home life,” Ms. Wetsch-Johnson said. “Some of them now are being the teacher at home and having to care for children. They have a lot that they come in with. My job is to help them so that they can go do their job. Regularly what I do is check in with the units and ask, ‘How are you doing today? What’s going on for you?’ Because people need to know that someone’s there to be with them and walk with them and listen to them.”

Courtesy Mary Wetsch-Johnson

On any given day, it’s not uncommon for hospital staff members to spontaneously pull aside chaplains to vent, pray, or just to talk. “They process their own fears and anxieties about working in this kind of environment,” Rev. Mercier said. “They’re scared for themselves. They think, ‘Could I get the virus? Could I spread the virus to my family?’ Or, they may express the care and concern they have for their patients. Oftentimes, it’s a mixture of both. Those spontaneous conversations are often the most powerful.”

Ms. Hauck noted that some nurses and clinicians at Lancaster General Hospital “are doing work they may have not done before,” she said. “Some of them are experiencing death for the first time, so we help them to navigate that. One of the best things we can do is hear the anxiety they have or the sadness they have when a patient dies. Also, maybe the frustration that they couldn’t do more in some cases and helping them to see that sometimes their best is good enough.”

She recalled one younger patient with COVID-19 who fell seriously ill. “It was really affecting a lot of people on the unit because of the patient’s age,” she said. “When we saw that the patient was getting better and would be discharged, there was such a sense of relief. I’m not sure that patient will ever understand how that helped us. It was comforting to us to know that people are getting better. It is something we celebrate.”

As chaplains adjust to their “new normal,” carving out time for self-care is key. Ms. Hauck and her staff periodically meet on Zoom with a psychotherapist “who understands what we do, asks us really good questions, and reminds us to take care of ourselves,” she said. “Personally, I’m making sure I get my exercise in, I pack a healthy lunch. We do check in with each other. Part of our handoff at every shift provides for an opportunity to debrief about how your day was.”

Rev. Mercier’s self check-in includes deep-breathing meditation and reciting certain prayers throughout the day. “The deep breathing helps me center and refocus with my body, while the prayers remind me of my connection to the Divine,” he said. “It also reminds me that in the midst of the fear and the anxiety, I fear for myself. It’s hard not to be concerned that I could be infected. I have a family at home and could spread this to them. The prayer practices are a reminder to me that it’s okay to feel those fears and anxieties. Sometimes the spiritual practice helps me find that place of acceptance. That enables me to keep moving forward.”

Ms. Wetsch-Johnson described the sense of upendedness caused by the COVID-19 pandemic as a “ripple in the water that’s going to have long-lasting effects on the delivery of health care. People are taking the time to listen to one another. I’ve seen people in all departments be more compassionate with one another. I’ve seen managers go out of their way to make sure their staff are deeply cared for. I think that will have a ripple effect. That’s my hope, that we will continue to be more compassionate, more loving, and more understanding.”

Rabbi Loevinger hopes that even the most reticent physicians remember that chaplains serve as their advocate, too, especially during times of crisis. “This has been a time of unprecedented ethical wrestling in our hospitals, where there’s been a real concern that doctors, nurses, and respiratory therapists are going to be faced with morally distressing situations regarding insufficient PPE, or insufficient ventilator or dialysis machine supply to support everybody that needs to be supported,” he said. “Chaplains are a key part of the process of making ethical decisions, but also supporting physicians who are in distress over [being in] situations they never had imagined. Physicians don’t like to talk about the fact that a lot of the decisions they make are really heartbreaking. But if chaplains understand anything, it’s that being brokenhearted is part of the human condition, and that we can be part of the answer for keeping physicians morally and spiritually grounded in their work. We always invite that conversation.”

For Rev. Mercier, serving in a time of crisis reminds him of the importance of providing care as a team, “not just for patients and families, but for one another,” he said. “One of the lessons we can learn is, how can we build that connection with one another, to support and care for one another? How can we make sure that no one feels alone while working in the hospital?”

He draws inspiration from a saying credited to St. John of the Cross, which reads, “I saw the river through which every soul must pass, and the name of that river is suffering. I saw the boat that carries each soul across that river, and the name of that boat is love.”

“It’s that image that’s sticking with me, not just for myself as a chaplain but for all of my colleagues in the hospital,” said Rev. Mercier, who also pastors Tabernacle Baptist Church in Hope, R.I. “We’re in that river with the patients right now, suffering, and we’re doing our best to help them get to the other side – whatever the other side may look like.”

dbrunk@mdedge.com

Correction, 4/30/20: An earlier version of the caption for the photo with Mary Wetsch-Johnson misstated the location. The photo was taken outside St. Elizabeth Hospital in Enumclaw, Wash.

The first time that the Rev. Michael Mercier, BCC (a board-certified chaplain), provided spiritual care for a patient hospitalized with COVID-19 in March, he found himself engaged in a bit of soul-searching. Even though he donned a mask, gloves, and gown, he could get no closer than the hospital room doorway to interact with the patient because of infection-control measures.

Bill Murphy/Lifespan

“It went against all my natural instincts and my experience as a chaplain,” said Rev. Mercier, who serves as director of spiritual care for Rhode Island Hospital, Hasbro Children’s Hospital, Miriam Hospital, and Newport Hospital, which are operated by Lifespan, Rhode Island’s largest health system. “The first instinct is to be physically present in the room with the person who’s dying, to have the family gathered around the bedside.”

Prior to standing in the doorway that day, he’d been on the phone with family members, “just listening to their fear and their anxiety that they could not be with their loved one when their loved one was dying,” he said. “I validated their feelings. I also urged them to work with me and the nurse to bring a phone into the room, hold it to the patient’s ear, and they were able to say their goodbyes and how much they loved the person.”

The patient was a devout Roman Catholic, he added, and the family requested that the Prayer of Commendation and the Apostolic Pardon be performed. Rev. Mercier arranged for a Catholic priest to carry out this request. “The nurse told the patient what was going on, and the priest offered the prayers and the rituals from the doorway,” Rev. Mercier said. “It was a surreal experience. For me, it was almost entirely phone based, and it was mostly with the family because the patient couldn’t talk too much.”

To add to the sense of detachment in a situation like that, doctors, nurses, and chaplains caring for COVID-19 patients are wearing masks and face shields, and sometimes the sickest patients are intubated, which can complicate efforts to communicate. “I’m surprised at how we find the mask as somewhat of a barrier,” said Carolanne B. Hauck, BCC, director of chaplaincy care & education and volunteer services at Lancaster (Pa.) General Hospital, which is part of the Penn Medicine system. “By that I mean, often for us, sitting at the bedside and really being able to see someone’s face and have them see our face – with our masks, that’s just not happening. We’re also having briefer visits when we’re visiting with COVID patients.”

COVID-19 may have quarantined some traditional ways of providing spiritual care, but hospital chaplains are relying on technology more than ever in their efforts to meet the needs of patients and their families, including the use of iPads, FaceTime, and video conferencing programs like Zoom and BlueJeans.

“We’ve used Zoom to talk with family members that live out of state,” Rev. Mercier said. “Most of the time, I get an invitation to join a Zoom meeting, but now I need to become proficient in utilizing Zoom to set up those end-of-life family meetings. There’s a lot of learning on the fly, how to use these technologies in a way that’s helpful for everybody. That’s the biggest thing I’m learning: Connection is connection during this time of high stress and anxiety, and we just have to get creative.”

Courtesy Rabbi Neal J. Loevinger

Hospital chaplains may be using smartphones and other gadgets to communicate with patients and their families more than they did in the pre-COVID-19 world, but their basic job has not changed, said Rabbi Neal J. Loevinger, BCC, director of spiritual care services at Vassar Brothers Medical Center in Poughkeepsie, N.Y., part of a seven-hospital system operated by Nuvance Health. “We offer the hope of a caring presence,” said Rabbi Loevinger, who is also a member of the board of directors for Neshama: Association of Jewish Chaplains. “If someone is in a hole, our job is to climb down into the hole with them and say, ‘We’re going to get out of this hole together.’ We can’t promise that someone’s going to get better. We can’t promise that everything’s going to be all right. What we can promise is that we will not abandon you. We can promise that there will be someone accompanying you in any way we can through this crisis.”

Ms. Hauck remembered a phone conversation with the granddaughter of a patient hospitalized with COVID-19 who was nearing the end of her life. The granddaughter told her a story about how her grandmother and her best friend made a pact with each other that, when one was dying, the other would come to her side and pray the Rosary with her. “The granddaughter got tearful and said, ‘That can’t happen now,’ ” said Ms. Hauck, who oversees a staff of 9 chaplains and 10 per diem chaplains. “I made a promise that I would do my best to be at the bedside and pray the Rosary with her grandmother.”

The nurses were aware of the request, and about a day later, Ms. Hauck received a call at 1 a.m., indicating that the patient was close to dying. She drove to Lancaster General, put on her personal protective equipment, made it to the patient’s bedside, and began to pray the Rosary with her, with a nurse in the room. “The nurse said to me, ‘Carolanne, all of her stats are going up,’ and the patient actually became a little more alert,” she recalled. “We talked a little bit, and I asked, ‘Would you like to pray the Rosary now?’ She shook her head yes, and said, ‘Hail Mary, full of grace ...’ and those were the last words that she spoke. I finished the prayers for her, and then she died. It was very meaningful knowing that I could honor that wish for her, but more importantly, that I could do that for the family, who otherwise would have been at her side saying the Rosary with her. We have a recognition of how hard it is to leave someone at the hospital and not be at their bedside.”

Hospital chaplains are also supporting interdisciplinary teams of physicians, nurses, and other staff, as they navigate the provision of care in the wake of a pandemic. “They are under a great deal of stress – not only from being at work but with all the role changes that have happened in their home life,” Ms. Wetsch-Johnson said. “Some of them now are being the teacher at home and having to care for children. They have a lot that they come in with. My job is to help them so that they can go do their job. Regularly what I do is check in with the units and ask, ‘How are you doing today? What’s going on for you?’ Because people need to know that someone’s there to be with them and walk with them and listen to them.”

Courtesy Mary Wetsch-Johnson

On any given day, it’s not uncommon for hospital staff members to spontaneously pull aside chaplains to vent, pray, or just to talk. “They process their own fears and anxieties about working in this kind of environment,” Rev. Mercier said. “They’re scared for themselves. They think, ‘Could I get the virus? Could I spread the virus to my family?’ Or, they may express the care and concern they have for their patients. Oftentimes, it’s a mixture of both. Those spontaneous conversations are often the most powerful.”

Ms. Hauck noted that some nurses and clinicians at Lancaster General Hospital “are doing work they may have not done before,” she said. “Some of them are experiencing death for the first time, so we help them to navigate that. One of the best things we can do is hear the anxiety they have or the sadness they have when a patient dies. Also, maybe the frustration that they couldn’t do more in some cases and helping them to see that sometimes their best is good enough.”

She recalled one younger patient with COVID-19 who fell seriously ill. “It was really affecting a lot of people on the unit because of the patient’s age,” she said. “When we saw that the patient was getting better and would be discharged, there was such a sense of relief. I’m not sure that patient will ever understand how that helped us. It was comforting to us to know that people are getting better. It is something we celebrate.”

As chaplains adjust to their “new normal,” carving out time for self-care is key. Ms. Hauck and her staff periodically meet on Zoom with a psychotherapist “who understands what we do, asks us really good questions, and reminds us to take care of ourselves,” she said. “Personally, I’m making sure I get my exercise in, I pack a healthy lunch. We do check in with each other. Part of our handoff at every shift provides for an opportunity to debrief about how your day was.”

Rev. Mercier’s self check-in includes deep-breathing meditation and reciting certain prayers throughout the day. “The deep breathing helps me center and refocus with my body, while the prayers remind me of my connection to the Divine,” he said. “It also reminds me that in the midst of the fear and the anxiety, I fear for myself. It’s hard not to be concerned that I could be infected. I have a family at home and could spread this to them. The prayer practices are a reminder to me that it’s okay to feel those fears and anxieties. Sometimes the spiritual practice helps me find that place of acceptance. That enables me to keep moving forward.”

Ms. Wetsch-Johnson described the sense of upendedness caused by the COVID-19 pandemic as a “ripple in the water that’s going to have long-lasting effects on the delivery of health care. People are taking the time to listen to one another. I’ve seen people in all departments be more compassionate with one another. I’ve seen managers go out of their way to make sure their staff are deeply cared for. I think that will have a ripple effect. That’s my hope, that we will continue to be more compassionate, more loving, and more understanding.”

Rabbi Loevinger hopes that even the most reticent physicians remember that chaplains serve as their advocate, too, especially during times of crisis. “This has been a time of unprecedented ethical wrestling in our hospitals, where there’s been a real concern that doctors, nurses, and respiratory therapists are going to be faced with morally distressing situations regarding insufficient PPE, or insufficient ventilator or dialysis machine supply to support everybody that needs to be supported,” he said. “Chaplains are a key part of the process of making ethical decisions, but also supporting physicians who are in distress over [being in] situations they never had imagined. Physicians don’t like to talk about the fact that a lot of the decisions they make are really heartbreaking. But if chaplains understand anything, it’s that being brokenhearted is part of the human condition, and that we can be part of the answer for keeping physicians morally and spiritually grounded in their work. We always invite that conversation.”

For Rev. Mercier, serving in a time of crisis reminds him of the importance of providing care as a team, “not just for patients and families, but for one another,” he said. “One of the lessons we can learn is, how can we build that connection with one another, to support and care for one another? How can we make sure that no one feels alone while working in the hospital?”

He draws inspiration from a saying credited to St. John of the Cross, which reads, “I saw the river through which every soul must pass, and the name of that river is suffering. I saw the boat that carries each soul across that river, and the name of that boat is love.”

“It’s that image that’s sticking with me, not just for myself as a chaplain but for all of my colleagues in the hospital,” said Rev. Mercier, who also pastors Tabernacle Baptist Church in Hope, R.I. “We’re in that river with the patients right now, suffering, and we’re doing our best to help them get to the other side – whatever the other side may look like.”

dbrunk@mdedge.com

Correction, 4/30/20: An earlier version of the caption for the photo with Mary Wetsch-Johnson misstated the location. The photo was taken outside St. Elizabeth Hospital in Enumclaw, Wash.

The first time that the Rev. Michael Mercier, BCC (a board-certified chaplain), provided spiritual care for a patient hospitalized with COVID-19 in March, he found himself engaged in a bit of soul-searching. Even though he donned a mask, gloves, and gown, he could get no closer than the hospital room doorway to interact with the patient because of infection-control measures.

Bill Murphy/Lifespan

“It went against all my natural instincts and my experience as a chaplain,” said Rev. Mercier, who serves as director of spiritual care for Rhode Island Hospital, Hasbro Children’s Hospital, Miriam Hospital, and Newport Hospital, which are operated by Lifespan, Rhode Island’s largest health system. “The first instinct is to be physically present in the room with the person who’s dying, to have the family gathered around the bedside.”

Prior to standing in the doorway that day, he’d been on the phone with family members, “just listening to their fear and their anxiety that they could not be with their loved one when their loved one was dying,” he said. “I validated their feelings. I also urged them to work with me and the nurse to bring a phone into the room, hold it to the patient’s ear, and they were able to say their goodbyes and how much they loved the person.”

The patient was a devout Roman Catholic, he added, and the family requested that the Prayer of Commendation and the Apostolic Pardon be performed. Rev. Mercier arranged for a Catholic priest to carry out this request. “The nurse told the patient what was going on, and the priest offered the prayers and the rituals from the doorway,” Rev. Mercier said. “It was a surreal experience. For me, it was almost entirely phone based, and it was mostly with the family because the patient couldn’t talk too much.”

To add to the sense of detachment in a situation like that, doctors, nurses, and chaplains caring for COVID-19 patients are wearing masks and face shields, and sometimes the sickest patients are intubated, which can complicate efforts to communicate. “I’m surprised at how we find the mask as somewhat of a barrier,” said Carolanne B. Hauck, BCC, director of chaplaincy care & education and volunteer services at Lancaster (Pa.) General Hospital, which is part of the Penn Medicine system. “By that I mean, often for us, sitting at the bedside and really being able to see someone’s face and have them see our face – with our masks, that’s just not happening. We’re also having briefer visits when we’re visiting with COVID patients.”

COVID-19 may have quarantined some traditional ways of providing spiritual care, but hospital chaplains are relying on technology more than ever in their efforts to meet the needs of patients and their families, including the use of iPads, FaceTime, and video conferencing programs like Zoom and BlueJeans.

“We’ve used Zoom to talk with family members that live out of state,” Rev. Mercier said. “Most of the time, I get an invitation to join a Zoom meeting, but now I need to become proficient in utilizing Zoom to set up those end-of-life family meetings. There’s a lot of learning on the fly, how to use these technologies in a way that’s helpful for everybody. That’s the biggest thing I’m learning: Connection is connection during this time of high stress and anxiety, and we just have to get creative.”

Courtesy Rabbi Neal J. Loevinger

Hospital chaplains may be using smartphones and other gadgets to communicate with patients and their families more than they did in the pre-COVID-19 world, but their basic job has not changed, said Rabbi Neal J. Loevinger, BCC, director of spiritual care services at Vassar Brothers Medical Center in Poughkeepsie, N.Y., part of a seven-hospital system operated by Nuvance Health. “We offer the hope of a caring presence,” said Rabbi Loevinger, who is also a member of the board of directors for Neshama: Association of Jewish Chaplains. “If someone is in a hole, our job is to climb down into the hole with them and say, ‘We’re going to get out of this hole together.’ We can’t promise that someone’s going to get better. We can’t promise that everything’s going to be all right. What we can promise is that we will not abandon you. We can promise that there will be someone accompanying you in any way we can through this crisis.”

Ms. Hauck remembered a phone conversation with the granddaughter of a patient hospitalized with COVID-19 who was nearing the end of her life. The granddaughter told her a story about how her grandmother and her best friend made a pact with each other that, when one was dying, the other would come to her side and pray the Rosary with her. “The granddaughter got tearful and said, ‘That can’t happen now,’ ” said Ms. Hauck, who oversees a staff of 9 chaplains and 10 per diem chaplains. “I made a promise that I would do my best to be at the bedside and pray the Rosary with her grandmother.”

The nurses were aware of the request, and about a day later, Ms. Hauck received a call at 1 a.m., indicating that the patient was close to dying. She drove to Lancaster General, put on her personal protective equipment, made it to the patient’s bedside, and began to pray the Rosary with her, with a nurse in the room. “The nurse said to me, ‘Carolanne, all of her stats are going up,’ and the patient actually became a little more alert,” she recalled. “We talked a little bit, and I asked, ‘Would you like to pray the Rosary now?’ She shook her head yes, and said, ‘Hail Mary, full of grace ...’ and those were the last words that she spoke. I finished the prayers for her, and then she died. It was very meaningful knowing that I could honor that wish for her, but more importantly, that I could do that for the family, who otherwise would have been at her side saying the Rosary with her. We have a recognition of how hard it is to leave someone at the hospital and not be at their bedside.”

Hospital chaplains are also supporting interdisciplinary teams of physicians, nurses, and other staff, as they navigate the provision of care in the wake of a pandemic. “They are under a great deal of stress – not only from being at work but with all the role changes that have happened in their home life,” Ms. Wetsch-Johnson said. “Some of them now are being the teacher at home and having to care for children. They have a lot that they come in with. My job is to help them so that they can go do their job. Regularly what I do is check in with the units and ask, ‘How are you doing today? What’s going on for you?’ Because people need to know that someone’s there to be with them and walk with them and listen to them.”

Courtesy Mary Wetsch-Johnson

On any given day, it’s not uncommon for hospital staff members to spontaneously pull aside chaplains to vent, pray, or just to talk. “They process their own fears and anxieties about working in this kind of environment,” Rev. Mercier said. “They’re scared for themselves. They think, ‘Could I get the virus? Could I spread the virus to my family?’ Or, they may express the care and concern they have for their patients. Oftentimes, it’s a mixture of both. Those spontaneous conversations are often the most powerful.”

Ms. Hauck noted that some nurses and clinicians at Lancaster General Hospital “are doing work they may have not done before,” she said. “Some of them are experiencing death for the first time, so we help them to navigate that. One of the best things we can do is hear the anxiety they have or the sadness they have when a patient dies. Also, maybe the frustration that they couldn’t do more in some cases and helping them to see that sometimes their best is good enough.”

She recalled one younger patient with COVID-19 who fell seriously ill. “It was really affecting a lot of people on the unit because of the patient’s age,” she said. “When we saw that the patient was getting better and would be discharged, there was such a sense of relief. I’m not sure that patient will ever understand how that helped us. It was comforting to us to know that people are getting better. It is something we celebrate.”

As chaplains adjust to their “new normal,” carving out time for self-care is key. Ms. Hauck and her staff periodically meet on Zoom with a psychotherapist “who understands what we do, asks us really good questions, and reminds us to take care of ourselves,” she said. “Personally, I’m making sure I get my exercise in, I pack a healthy lunch. We do check in with each other. Part of our handoff at every shift provides for an opportunity to debrief about how your day was.”

Rev. Mercier’s self check-in includes deep-breathing meditation and reciting certain prayers throughout the day. “The deep breathing helps me center and refocus with my body, while the prayers remind me of my connection to the Divine,” he said. “It also reminds me that in the midst of the fear and the anxiety, I fear for myself. It’s hard not to be concerned that I could be infected. I have a family at home and could spread this to them. The prayer practices are a reminder to me that it’s okay to feel those fears and anxieties. Sometimes the spiritual practice helps me find that place of acceptance. That enables me to keep moving forward.”

Ms. Wetsch-Johnson described the sense of upendedness caused by the COVID-19 pandemic as a “ripple in the water that’s going to have long-lasting effects on the delivery of health care. People are taking the time to listen to one another. I’ve seen people in all departments be more compassionate with one another. I’ve seen managers go out of their way to make sure their staff are deeply cared for. I think that will have a ripple effect. That’s my hope, that we will continue to be more compassionate, more loving, and more understanding.”

Rabbi Loevinger hopes that even the most reticent physicians remember that chaplains serve as their advocate, too, especially during times of crisis. “This has been a time of unprecedented ethical wrestling in our hospitals, where there’s been a real concern that doctors, nurses, and respiratory therapists are going to be faced with morally distressing situations regarding insufficient PPE, or insufficient ventilator or dialysis machine supply to support everybody that needs to be supported,” he said. “Chaplains are a key part of the process of making ethical decisions, but also supporting physicians who are in distress over [being in] situations they never had imagined. Physicians don’t like to talk about the fact that a lot of the decisions they make are really heartbreaking. But if chaplains understand anything, it’s that being brokenhearted is part of the human condition, and that we can be part of the answer for keeping physicians morally and spiritually grounded in their work. We always invite that conversation.”

For Rev. Mercier, serving in a time of crisis reminds him of the importance of providing care as a team, “not just for patients and families, but for one another,” he said. “One of the lessons we can learn is, how can we build that connection with one another, to support and care for one another? How can we make sure that no one feels alone while working in the hospital?”

He draws inspiration from a saying credited to St. John of the Cross, which reads, “I saw the river through which every soul must pass, and the name of that river is suffering. I saw the boat that carries each soul across that river, and the name of that boat is love.”

“It’s that image that’s sticking with me, not just for myself as a chaplain but for all of my colleagues in the hospital,” said Rev. Mercier, who also pastors Tabernacle Baptist Church in Hope, R.I. “We’re in that river with the patients right now, suffering, and we’re doing our best to help them get to the other side – whatever the other side may look like.”

dbrunk@mdedge.com

Correction, 4/30/20: An earlier version of the caption for the photo with Mary Wetsch-Johnson misstated the location. The photo was taken outside St. Elizabeth Hospital in Enumclaw, Wash.

Women who use copper IUDs and concurrently use menstrual cups face a higher than expected rate of IUD expulsion, results from a prospective study showed.

Citing menstrual cup use for menstrual hygiene as “increasingly popular,” researchers led by Jill Long, MD, MPH, studied women participating in a prospective contraceptive efficacy trial of two copper IUDs to evaluate the relationship between menstrual cup use and IUD expulsion over a period of 24 months. The findings were released ahead of the study’s scheduled presentation at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists. ACOG canceled the meeting and released abstracts for press coverage.

In the ongoing 3-year trial, which also was published in Obstetrics & Gynecology, 1,092 women were randomized to one of two copper IUDs. Dr. Long, project officer for the Contraceptive Clinical Trials Network, a project of the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Md. and colleagues conducted follow-up visits at 6 weeks after insertion in the first year, and then 3, 6, and 12 months after insertion. At the 9-month mark, the study counseling was amended to advise patients against concurrent use of the menstrual cup because of a higher risk of IUD expulsions noted in women using the cup.

Among the 1,092 women studied, 266 (24%) reported menstrual cup use. At 24 months after initiating enrollment, 43 cup users (17%) and 43 nonusers (5%) experienced expulsion (odds ratio, 3.81). Fourteen menstrual cup users with expulsion (30%) reported that the event occurred during menstrual cup removal. Dr. Long and colleagues found that, at year 1 of the study, expulsion rates among menstrual cup users and nonusers were 14% and 5%, respectively (P < .001). At the end of year 2, these rates rose to 23% and 7% (P < .001). The study won second place among abstracts in the category of current clinical and basic investigation.

“This outstanding abstract reflects an important study with results that should lead to changes in the way providers counsel patients about IUDs, namely that the risk of IUD expulsion is significantly higher in women who use menstrual cups than in those who use other menstrual hygiene products,” Eve Espey, MD, MPH, who was not affiliated with the study, said in an interview.

According to Dr. Espey, who chairs the department of obstetrics and gynecology at the University of New Mexico, Albuquerque, key strengths of the study include its prospective methodology and the relatively large number of patients with concurrent IUD and menstrual cup use.

“A limitation is the nonrandomized design for the current study’s aim, which would require randomizing women using the IUD to menstrual cup use versus nonuse,” said Dr. Espey, who is a member of the Ob.Gyn News editorial advisory board.* “Another limitation is that only copper IUDs were used, but it is plausible that this result would apply to other IUDs as well. The study is innovative and important in being the first prospective study to evaluate the association between menstrual cup use and IUD expulsion.”

Dr. Long and two coauthors reported having no financial disclosures, but the remaining three authors reported having numerous potential conflicts of interest. Dr. Espey reported having no financial disclosures.

SOURCE: Long J et al. Obstet Gynecol. 2020 May;135.1S. doi: 10.1097/01.AOG.0000662872.89062.83.

*The article was updated on 4/28/2020.
 

Women who use copper IUDs and concurrently use menstrual cups face a higher than expected rate of IUD expulsion, results from a prospective study showed.

Citing menstrual cup use for menstrual hygiene as “increasingly popular,” researchers led by Jill Long, MD, MPH, studied women participating in a prospective contraceptive efficacy trial of two copper IUDs to evaluate the relationship between menstrual cup use and IUD expulsion over a period of 24 months. The findings were released ahead of the study’s scheduled presentation at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists. ACOG canceled the meeting and released abstracts for press coverage.

In the ongoing 3-year trial, which also was published in Obstetrics & Gynecology, 1,092 women were randomized to one of two copper IUDs. Dr. Long, project officer for the Contraceptive Clinical Trials Network, a project of the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Md. and colleagues conducted follow-up visits at 6 weeks after insertion in the first year, and then 3, 6, and 12 months after insertion. At the 9-month mark, the study counseling was amended to advise patients against concurrent use of the menstrual cup because of a higher risk of IUD expulsions noted in women using the cup.

Among the 1,092 women studied, 266 (24%) reported menstrual cup use. At 24 months after initiating enrollment, 43 cup users (17%) and 43 nonusers (5%) experienced expulsion (odds ratio, 3.81). Fourteen menstrual cup users with expulsion (30%) reported that the event occurred during menstrual cup removal. Dr. Long and colleagues found that, at year 1 of the study, expulsion rates among menstrual cup users and nonusers were 14% and 5%, respectively (P < .001). At the end of year 2, these rates rose to 23% and 7% (P < .001). The study won second place among abstracts in the category of current clinical and basic investigation.

“This outstanding abstract reflects an important study with results that should lead to changes in the way providers counsel patients about IUDs, namely that the risk of IUD expulsion is significantly higher in women who use menstrual cups than in those who use other menstrual hygiene products,” Eve Espey, MD, MPH, who was not affiliated with the study, said in an interview.

According to Dr. Espey, who chairs the department of obstetrics and gynecology at the University of New Mexico, Albuquerque, key strengths of the study include its prospective methodology and the relatively large number of patients with concurrent IUD and menstrual cup use.

“A limitation is the nonrandomized design for the current study’s aim, which would require randomizing women using the IUD to menstrual cup use versus nonuse,” said Dr. Espey, who is a member of the Ob.Gyn News editorial advisory board.* “Another limitation is that only copper IUDs were used, but it is plausible that this result would apply to other IUDs as well. The study is innovative and important in being the first prospective study to evaluate the association between menstrual cup use and IUD expulsion.”

Dr. Long and two coauthors reported having no financial disclosures, but the remaining three authors reported having numerous potential conflicts of interest. Dr. Espey reported having no financial disclosures.

SOURCE: Long J et al. Obstet Gynecol. 2020 May;135.1S. doi: 10.1097/01.AOG.0000662872.89062.83.

*The article was updated on 4/28/2020.
 

Women who use copper IUDs and concurrently use menstrual cups face a higher than expected rate of IUD expulsion, results from a prospective study showed.

Citing menstrual cup use for menstrual hygiene as “increasingly popular,” researchers led by Jill Long, MD, MPH, studied women participating in a prospective contraceptive efficacy trial of two copper IUDs to evaluate the relationship between menstrual cup use and IUD expulsion over a period of 24 months. The findings were released ahead of the study’s scheduled presentation at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists. ACOG canceled the meeting and released abstracts for press coverage.

In the ongoing 3-year trial, which also was published in Obstetrics & Gynecology, 1,092 women were randomized to one of two copper IUDs. Dr. Long, project officer for the Contraceptive Clinical Trials Network, a project of the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Md. and colleagues conducted follow-up visits at 6 weeks after insertion in the first year, and then 3, 6, and 12 months after insertion. At the 9-month mark, the study counseling was amended to advise patients against concurrent use of the menstrual cup because of a higher risk of IUD expulsions noted in women using the cup.

Among the 1,092 women studied, 266 (24%) reported menstrual cup use. At 24 months after initiating enrollment, 43 cup users (17%) and 43 nonusers (5%) experienced expulsion (odds ratio, 3.81). Fourteen menstrual cup users with expulsion (30%) reported that the event occurred during menstrual cup removal. Dr. Long and colleagues found that, at year 1 of the study, expulsion rates among menstrual cup users and nonusers were 14% and 5%, respectively (P < .001). At the end of year 2, these rates rose to 23% and 7% (P < .001). The study won second place among abstracts in the category of current clinical and basic investigation.

“This outstanding abstract reflects an important study with results that should lead to changes in the way providers counsel patients about IUDs, namely that the risk of IUD expulsion is significantly higher in women who use menstrual cups than in those who use other menstrual hygiene products,” Eve Espey, MD, MPH, who was not affiliated with the study, said in an interview.

According to Dr. Espey, who chairs the department of obstetrics and gynecology at the University of New Mexico, Albuquerque, key strengths of the study include its prospective methodology and the relatively large number of patients with concurrent IUD and menstrual cup use.

“A limitation is the nonrandomized design for the current study’s aim, which would require randomizing women using the IUD to menstrual cup use versus nonuse,” said Dr. Espey, who is a member of the Ob.Gyn News editorial advisory board.* “Another limitation is that only copper IUDs were used, but it is plausible that this result would apply to other IUDs as well. The study is innovative and important in being the first prospective study to evaluate the association between menstrual cup use and IUD expulsion.”

Dr. Long and two coauthors reported having no financial disclosures, but the remaining three authors reported having numerous potential conflicts of interest. Dr. Espey reported having no financial disclosures.

SOURCE: Long J et al. Obstet Gynecol. 2020 May;135.1S. doi: 10.1097/01.AOG.0000662872.89062.83.

*The article was updated on 4/28/2020.
 

Physicians and their sponsoring health care facilities shouldn’t have to worry about visa technicalities as they work on the front lines during the COVID-19 pandemic, said health care leaders and immigration reform advocates.

In a press call hosted by the National Immigration Forum, speakers highlighted the need for fast and flexible solutions to enable health care workers, including physicians, to contribute to efforts to combat the pandemic.

Nationwide, over one in five physicians are immigrants, according to data from the Forum. That figure is over one in three in New York, New Jersey, and California, three states hard-hit by COVID-19 cases.

Many physicians stand willing and able to serve where they’re needed, but visa restrictions often block the ability of immigrant physicians to meet COVID-19 surges across the country, said Amit Vashist, MD, senior vice president and chief clinical officer for Ballad Health, Johnson City, Tenn., and a member of the public policy committee of the Society of Hospital Medicine. Ballad Health is an integrated health care system that serves 29 counties in the rural Southeast.

“This pandemic is a war with an invisible enemy, and immigrant physicians have been absolutely critical to providing quality care, especially on the front lines – but current visa restrictions have limited the ability to deploy these physicians in communities with the greatest need,” said Dr. Vashist during the press conference.

Visa requirements currently tie a non-US citizen resident physician to a particular institution and facility, limiting the ability to meet demand flexibly. “Federal agencies and Congress should provide additional flexibility in visa processing to allow for automatic renewals and expediting processing so immigrant medical workers can focus on treating the sick and not on their visa requirements,” said Dr. Vashist.

Dr. Vashist noted that, when he speaks with the many Ballad Health hospitalists who are waiting on permanent residency or citizenship, many of them also cite worries about the fate of their families should they themselves fall ill. Depending on the physician’s visa status, the family may face deportation without recourse if the physician should die.

“Tens of thousands of our physicians continue to endure years, even decades of waiting to obtain a permanent residency in the United States and at the same time, relentlessly and fearlessly serve their communities including in this COVID-19 pandemic,” said Dr. Vashist. “It’s time we take care of them and their long-term immigration needs, and give them the peace of mind that they so desperately deserve,” he added.

Frank Trinity, chief legal officer for the Association of American Medical Colleges, also participated in the call. “For decades,” he said, the United States “has relied on physicians from other countries, especially in rural and underserved areas.”

One of these physicians, Mihir Patel, MD, FHM, a hospitalist at Ballad Health, came to the United States in 2005, but 15 years later is still waiting for the green card that signifies U.S. permanent residency status. He is the corporate director of Ballad’s telemedicine program and is now also the medical director of the health system’s COVID-10 Strike Team.

“During the COVID crisis, these restrictions can cause significant negative impact for small rural hospitals,” Dr. Patel said. “There are physicians on a visa who cannot legally work outside their primary facilities – even though they are willing to do so.”

Regarding the pandemic, Mr. Trinity expressed concerns about whether the surge of patients would “outstrip our workforce.” He noted that, with an unprecedented number of desperately ill patients needing emergency care all across the country, “now is the time for our government to take every possible action to ensure that these highly qualified and courageous health professionals are available in the fight against the coronavirus.”

Mr. Trinity outlined five governmental actions AAMC is proposing to allow immigrant physicians to participate fully in the battle against COVID-19. The first would be to approve a blanket extension of visa deadlines. The second would be to expedite processing of visa extension applications, including reinstating expedited processing of physicians currently holding H-1B visa status.

The third action proposed by AAMC is to provide flexibility to visa sponsors during the emergency so that an individual whose visa is currently limited to a particular program can provide care at another location or by means of telehealth.

Fourth, AAMC proposes streamlined entry for the 4,200 physicians who are matched into residency programs so that they may begin their residencies on time or early.

Finally, Mr. Trinity said that AAMC is proposing that work authorizations be maintained for the 29,000 physicians who are currently not U.S. citizens and actively participating in the health care workforce.

Jacinta Ma, the Forum’s vice president of policy and advocacy, said immigrants are a critical component of the U.S. health care workforce as a whole.

“With immigrants accounting for 17% of health care workers amid the COVID-19 pandemic, it’s clear that they are vital to our communities,” she said. “Congress and the Trump administration both have an opportunity to advance solutions that protect immigrants, and remove immigration-related barriers for immigrant medical professionals by ensuring that immigrant doctors, nurses, home health care workers, researchers, and others can continue their vital work during this pandemic while being afforded adequate protection from COVID-19.”
 

Physicians and their sponsoring health care facilities shouldn’t have to worry about visa technicalities as they work on the front lines during the COVID-19 pandemic, said health care leaders and immigration reform advocates.

In a press call hosted by the National Immigration Forum, speakers highlighted the need for fast and flexible solutions to enable health care workers, including physicians, to contribute to efforts to combat the pandemic.

Nationwide, over one in five physicians are immigrants, according to data from the Forum. That figure is over one in three in New York, New Jersey, and California, three states hard-hit by COVID-19 cases.

Many physicians stand willing and able to serve where they’re needed, but visa restrictions often block the ability of immigrant physicians to meet COVID-19 surges across the country, said Amit Vashist, MD, senior vice president and chief clinical officer for Ballad Health, Johnson City, Tenn., and a member of the public policy committee of the Society of Hospital Medicine. Ballad Health is an integrated health care system that serves 29 counties in the rural Southeast.

“This pandemic is a war with an invisible enemy, and immigrant physicians have been absolutely critical to providing quality care, especially on the front lines – but current visa restrictions have limited the ability to deploy these physicians in communities with the greatest need,” said Dr. Vashist during the press conference.

Visa requirements currently tie a non-US citizen resident physician to a particular institution and facility, limiting the ability to meet demand flexibly. “Federal agencies and Congress should provide additional flexibility in visa processing to allow for automatic renewals and expediting processing so immigrant medical workers can focus on treating the sick and not on their visa requirements,” said Dr. Vashist.

Dr. Vashist noted that, when he speaks with the many Ballad Health hospitalists who are waiting on permanent residency or citizenship, many of them also cite worries about the fate of their families should they themselves fall ill. Depending on the physician’s visa status, the family may face deportation without recourse if the physician should die.

“Tens of thousands of our physicians continue to endure years, even decades of waiting to obtain a permanent residency in the United States and at the same time, relentlessly and fearlessly serve their communities including in this COVID-19 pandemic,” said Dr. Vashist. “It’s time we take care of them and their long-term immigration needs, and give them the peace of mind that they so desperately deserve,” he added.

Frank Trinity, chief legal officer for the Association of American Medical Colleges, also participated in the call. “For decades,” he said, the United States “has relied on physicians from other countries, especially in rural and underserved areas.”

One of these physicians, Mihir Patel, MD, FHM, a hospitalist at Ballad Health, came to the United States in 2005, but 15 years later is still waiting for the green card that signifies U.S. permanent residency status. He is the corporate director of Ballad’s telemedicine program and is now also the medical director of the health system’s COVID-10 Strike Team.

“During the COVID crisis, these restrictions can cause significant negative impact for small rural hospitals,” Dr. Patel said. “There are physicians on a visa who cannot legally work outside their primary facilities – even though they are willing to do so.”

Regarding the pandemic, Mr. Trinity expressed concerns about whether the surge of patients would “outstrip our workforce.” He noted that, with an unprecedented number of desperately ill patients needing emergency care all across the country, “now is the time for our government to take every possible action to ensure that these highly qualified and courageous health professionals are available in the fight against the coronavirus.”

Mr. Trinity outlined five governmental actions AAMC is proposing to allow immigrant physicians to participate fully in the battle against COVID-19. The first would be to approve a blanket extension of visa deadlines. The second would be to expedite processing of visa extension applications, including reinstating expedited processing of physicians currently holding H-1B visa status.

The third action proposed by AAMC is to provide flexibility to visa sponsors during the emergency so that an individual whose visa is currently limited to a particular program can provide care at another location or by means of telehealth.

Fourth, AAMC proposes streamlined entry for the 4,200 physicians who are matched into residency programs so that they may begin their residencies on time or early.

Finally, Mr. Trinity said that AAMC is proposing that work authorizations be maintained for the 29,000 physicians who are currently not U.S. citizens and actively participating in the health care workforce.

Jacinta Ma, the Forum’s vice president of policy and advocacy, said immigrants are a critical component of the U.S. health care workforce as a whole.

“With immigrants accounting for 17% of health care workers amid the COVID-19 pandemic, it’s clear that they are vital to our communities,” she said. “Congress and the Trump administration both have an opportunity to advance solutions that protect immigrants, and remove immigration-related barriers for immigrant medical professionals by ensuring that immigrant doctors, nurses, home health care workers, researchers, and others can continue their vital work during this pandemic while being afforded adequate protection from COVID-19.”
 

Physicians and their sponsoring health care facilities shouldn’t have to worry about visa technicalities as they work on the front lines during the COVID-19 pandemic, said health care leaders and immigration reform advocates.

In a press call hosted by the National Immigration Forum, speakers highlighted the need for fast and flexible solutions to enable health care workers, including physicians, to contribute to efforts to combat the pandemic.

Nationwide, over one in five physicians are immigrants, according to data from the Forum. That figure is over one in three in New York, New Jersey, and California, three states hard-hit by COVID-19 cases.

Many physicians stand willing and able to serve where they’re needed, but visa restrictions often block the ability of immigrant physicians to meet COVID-19 surges across the country, said Amit Vashist, MD, senior vice president and chief clinical officer for Ballad Health, Johnson City, Tenn., and a member of the public policy committee of the Society of Hospital Medicine. Ballad Health is an integrated health care system that serves 29 counties in the rural Southeast.

“This pandemic is a war with an invisible enemy, and immigrant physicians have been absolutely critical to providing quality care, especially on the front lines – but current visa restrictions have limited the ability to deploy these physicians in communities with the greatest need,” said Dr. Vashist during the press conference.

Visa requirements currently tie a non-US citizen resident physician to a particular institution and facility, limiting the ability to meet demand flexibly. “Federal agencies and Congress should provide additional flexibility in visa processing to allow for automatic renewals and expediting processing so immigrant medical workers can focus on treating the sick and not on their visa requirements,” said Dr. Vashist.

Dr. Vashist noted that, when he speaks with the many Ballad Health hospitalists who are waiting on permanent residency or citizenship, many of them also cite worries about the fate of their families should they themselves fall ill. Depending on the physician’s visa status, the family may face deportation without recourse if the physician should die.

“Tens of thousands of our physicians continue to endure years, even decades of waiting to obtain a permanent residency in the United States and at the same time, relentlessly and fearlessly serve their communities including in this COVID-19 pandemic,” said Dr. Vashist. “It’s time we take care of them and their long-term immigration needs, and give them the peace of mind that they so desperately deserve,” he added.

Frank Trinity, chief legal officer for the Association of American Medical Colleges, also participated in the call. “For decades,” he said, the United States “has relied on physicians from other countries, especially in rural and underserved areas.”

One of these physicians, Mihir Patel, MD, FHM, a hospitalist at Ballad Health, came to the United States in 2005, but 15 years later is still waiting for the green card that signifies U.S. permanent residency status. He is the corporate director of Ballad’s telemedicine program and is now also the medical director of the health system’s COVID-10 Strike Team.

“During the COVID crisis, these restrictions can cause significant negative impact for small rural hospitals,” Dr. Patel said. “There are physicians on a visa who cannot legally work outside their primary facilities – even though they are willing to do so.”

Regarding the pandemic, Mr. Trinity expressed concerns about whether the surge of patients would “outstrip our workforce.” He noted that, with an unprecedented number of desperately ill patients needing emergency care all across the country, “now is the time for our government to take every possible action to ensure that these highly qualified and courageous health professionals are available in the fight against the coronavirus.”

Mr. Trinity outlined five governmental actions AAMC is proposing to allow immigrant physicians to participate fully in the battle against COVID-19. The first would be to approve a blanket extension of visa deadlines. The second would be to expedite processing of visa extension applications, including reinstating expedited processing of physicians currently holding H-1B visa status.

The third action proposed by AAMC is to provide flexibility to visa sponsors during the emergency so that an individual whose visa is currently limited to a particular program can provide care at another location or by means of telehealth.

Fourth, AAMC proposes streamlined entry for the 4,200 physicians who are matched into residency programs so that they may begin their residencies on time or early.

Finally, Mr. Trinity said that AAMC is proposing that work authorizations be maintained for the 29,000 physicians who are currently not U.S. citizens and actively participating in the health care workforce.

Jacinta Ma, the Forum’s vice president of policy and advocacy, said immigrants are a critical component of the U.S. health care workforce as a whole.

“With immigrants accounting for 17% of health care workers amid the COVID-19 pandemic, it’s clear that they are vital to our communities,” she said. “Congress and the Trump administration both have an opportunity to advance solutions that protect immigrants, and remove immigration-related barriers for immigrant medical professionals by ensuring that immigrant doctors, nurses, home health care workers, researchers, and others can continue their vital work during this pandemic while being afforded adequate protection from COVID-19.”
 

The risk of lung cancer in never smokers who develop chronic obstructive pulmonary disease (COPD) is actually higher than it is in ever smokers who do not have COPD, an observational cohort study has shown.

Patients with COPD who had never smoked had more than double the risk of developing lung cancer (with an adjusted hazard ratio [HR] of 2.67), compared to individuals without COPD who had never smoked.

This was slightly higher than the increased risk seen in individuals who had smoked but who did not have COPD. This group had an almost double the risk of developing lung cancer (adjusted HR, 1.97), again compared to never smokers, the investigators added.

The highest risk of lung cancer was in patients who had COPD and who had smoked; this group had a sixfold risk of developing lung cancer (adjusted HR, 6.19) compared with never smokers without COPD, they note.

“COPD was a strong independent risk factor for lung cancer incidence in never smokers,” conclude the authors, led by Hye Yun Park, MD, Samsung Medical Center, Seoul, South Korea.

“Future studies should evaluate whether COPD patients are candidates for lung cancer screening, irrespective of smoking status,” they suggest.

The study was published March 10 in the journal Thorax.

It was based on an analysis of data from the National Health Insurance (NHS) Service National Sample Cohort between January 2002 and December 2013.

“We included all men and women, 40 to 84 years of age, who underwent at least one health screening examination provided by the NHS during the study period,” Park and colleagues explain.

Overall, the cohort included 338,548 men and women. Participants were followed-up for a median of 7 years.

Over the study interval, 1834 participants developed lung cancer.

This article first appeared on Medscape.com.

The risk of lung cancer in never smokers who develop chronic obstructive pulmonary disease (COPD) is actually higher than it is in ever smokers who do not have COPD, an observational cohort study has shown.

Patients with COPD who had never smoked had more than double the risk of developing lung cancer (with an adjusted hazard ratio [HR] of 2.67), compared to individuals without COPD who had never smoked.

This was slightly higher than the increased risk seen in individuals who had smoked but who did not have COPD. This group had an almost double the risk of developing lung cancer (adjusted HR, 1.97), again compared to never smokers, the investigators added.

The highest risk of lung cancer was in patients who had COPD and who had smoked; this group had a sixfold risk of developing lung cancer (adjusted HR, 6.19) compared with never smokers without COPD, they note.

“COPD was a strong independent risk factor for lung cancer incidence in never smokers,” conclude the authors, led by Hye Yun Park, MD, Samsung Medical Center, Seoul, South Korea.

“Future studies should evaluate whether COPD patients are candidates for lung cancer screening, irrespective of smoking status,” they suggest.

The study was published March 10 in the journal Thorax.

It was based on an analysis of data from the National Health Insurance (NHS) Service National Sample Cohort between January 2002 and December 2013.

“We included all men and women, 40 to 84 years of age, who underwent at least one health screening examination provided by the NHS during the study period,” Park and colleagues explain.

Overall, the cohort included 338,548 men and women. Participants were followed-up for a median of 7 years.

Over the study interval, 1834 participants developed lung cancer.

This article first appeared on Medscape.com.

The risk of lung cancer in never smokers who develop chronic obstructive pulmonary disease (COPD) is actually higher than it is in ever smokers who do not have COPD, an observational cohort study has shown.

Patients with COPD who had never smoked had more than double the risk of developing lung cancer (with an adjusted hazard ratio [HR] of 2.67), compared to individuals without COPD who had never smoked.

This was slightly higher than the increased risk seen in individuals who had smoked but who did not have COPD. This group had an almost double the risk of developing lung cancer (adjusted HR, 1.97), again compared to never smokers, the investigators added.

The highest risk of lung cancer was in patients who had COPD and who had smoked; this group had a sixfold risk of developing lung cancer (adjusted HR, 6.19) compared with never smokers without COPD, they note.

“COPD was a strong independent risk factor for lung cancer incidence in never smokers,” conclude the authors, led by Hye Yun Park, MD, Samsung Medical Center, Seoul, South Korea.

“Future studies should evaluate whether COPD patients are candidates for lung cancer screening, irrespective of smoking status,” they suggest.

The study was published March 10 in the journal Thorax.

It was based on an analysis of data from the National Health Insurance (NHS) Service National Sample Cohort between January 2002 and December 2013.

“We included all men and women, 40 to 84 years of age, who underwent at least one health screening examination provided by the NHS during the study period,” Park and colleagues explain.

Overall, the cohort included 338,548 men and women. Participants were followed-up for a median of 7 years.

Over the study interval, 1834 participants developed lung cancer.

This article first appeared on Medscape.com.

A multidisciplinary team of researchers has created a national registry to study how COVID-19 affects pregnant women and their newborns.

“Pregnant women are generally considered healthy, but they are also a vulnerable group, and we currently have no data on COVID-19 in pregnancy,” coprincipal investigator Yalda Afshar, MD, PhD, an ob.gyn. at UCLA Health in Los Angeles, said in an interview.

“We expect this registry to provide data that will be critical in helping to improve care for pregnant women during this global pandemic,” Dr. Afshar, a fellow with UCLA Biodesign, stated in a news release.

The Pregnancy Coronavirus Outcomes Registry is enrolling pregnant women and those who have been pregnant or post partum within the past 6 weeks and who have either received a confirmed diagnosis of COVID-19 or are being evaluated for COVID-19.

Women are being recruited through their health care provider. A study coordinator contacts the participants by telephone. Women can also join the registry on their own without a referral by visiting the registry website.

The registry collects data on COVID-19 symptoms, clinical course, pregnancy, and neonatal outcomes and follows women from enrollment through the second and third trimesters and the postpartum period. The goal is to follow the mothers and babies for up to 1 year.
 

Hundreds of women already enrolled

Dr. Afshar noted that these kinds of registries often take months to design and to receive funding, but with COVID-19, “there was no time for that. We had to get it up and running ASAP.”

She said the team has been “blown away” by how quickly people have come forward to join the registry. Within 2 weeks of going live, the registry had enrolled more than 400 participants from across the United States. “At this rate, I think we will easily get 1,000 participants in a month or so,” Dr. Afshar said.

“With the global reach of this disease, the findings resulting from this work have the potential to impact millions of lives in an entire generation,” Johnese Spisso, CEO of UCLA Health, said in the news release.

Dr. Afshar noted that, although the impact of COVID-19 on pregnancy remains unknown, history suggests the disease will make some pregnancies and deliveries more challenging. “We know that in previous outbreaks of the regular flu, for example, there have been more deaths and poorer outcomes among pregnant women compared with nonpregnant women.”

Dr. Afshar is overseeing the study with colleagues at the University of California, Los Angeles, and the University of California, San Francisco, where the registry data will be coordinated.

“In addition to gaining a better understanding of the course of the disease, we will investigate disease transmission to determine if it can be passed from a mother to her baby in utero and during the postpartum period, such as in breast milk,” UCSF’s Stephanie Gaw, MD, PhD, who is leading the biospecimen core of the study, said in the release.

Health care providers interested in more information about the registry may send an email to PRIORITYCOVID19@ucsf.edu. A YouTube video on the registry is also available.

Dr. Afshar disclosed no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

A multidisciplinary team of researchers has created a national registry to study how COVID-19 affects pregnant women and their newborns.

“Pregnant women are generally considered healthy, but they are also a vulnerable group, and we currently have no data on COVID-19 in pregnancy,” coprincipal investigator Yalda Afshar, MD, PhD, an ob.gyn. at UCLA Health in Los Angeles, said in an interview.

“We expect this registry to provide data that will be critical in helping to improve care for pregnant women during this global pandemic,” Dr. Afshar, a fellow with UCLA Biodesign, stated in a news release.

The Pregnancy Coronavirus Outcomes Registry is enrolling pregnant women and those who have been pregnant or post partum within the past 6 weeks and who have either received a confirmed diagnosis of COVID-19 or are being evaluated for COVID-19.

Women are being recruited through their health care provider. A study coordinator contacts the participants by telephone. Women can also join the registry on their own without a referral by visiting the registry website.

The registry collects data on COVID-19 symptoms, clinical course, pregnancy, and neonatal outcomes and follows women from enrollment through the second and third trimesters and the postpartum period. The goal is to follow the mothers and babies for up to 1 year.
 

Hundreds of women already enrolled

Dr. Afshar noted that these kinds of registries often take months to design and to receive funding, but with COVID-19, “there was no time for that. We had to get it up and running ASAP.”

She said the team has been “blown away” by how quickly people have come forward to join the registry. Within 2 weeks of going live, the registry had enrolled more than 400 participants from across the United States. “At this rate, I think we will easily get 1,000 participants in a month or so,” Dr. Afshar said.

“With the global reach of this disease, the findings resulting from this work have the potential to impact millions of lives in an entire generation,” Johnese Spisso, CEO of UCLA Health, said in the news release.

Dr. Afshar noted that, although the impact of COVID-19 on pregnancy remains unknown, history suggests the disease will make some pregnancies and deliveries more challenging. “We know that in previous outbreaks of the regular flu, for example, there have been more deaths and poorer outcomes among pregnant women compared with nonpregnant women.”

Dr. Afshar is overseeing the study with colleagues at the University of California, Los Angeles, and the University of California, San Francisco, where the registry data will be coordinated.

“In addition to gaining a better understanding of the course of the disease, we will investigate disease transmission to determine if it can be passed from a mother to her baby in utero and during the postpartum period, such as in breast milk,” UCSF’s Stephanie Gaw, MD, PhD, who is leading the biospecimen core of the study, said in the release.

Health care providers interested in more information about the registry may send an email to PRIORITYCOVID19@ucsf.edu. A YouTube video on the registry is also available.

Dr. Afshar disclosed no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

A multidisciplinary team of researchers has created a national registry to study how COVID-19 affects pregnant women and their newborns.

“Pregnant women are generally considered healthy, but they are also a vulnerable group, and we currently have no data on COVID-19 in pregnancy,” coprincipal investigator Yalda Afshar, MD, PhD, an ob.gyn. at UCLA Health in Los Angeles, said in an interview.

“We expect this registry to provide data that will be critical in helping to improve care for pregnant women during this global pandemic,” Dr. Afshar, a fellow with UCLA Biodesign, stated in a news release.

The Pregnancy Coronavirus Outcomes Registry is enrolling pregnant women and those who have been pregnant or post partum within the past 6 weeks and who have either received a confirmed diagnosis of COVID-19 or are being evaluated for COVID-19.

Women are being recruited through their health care provider. A study coordinator contacts the participants by telephone. Women can also join the registry on their own without a referral by visiting the registry website.

The registry collects data on COVID-19 symptoms, clinical course, pregnancy, and neonatal outcomes and follows women from enrollment through the second and third trimesters and the postpartum period. The goal is to follow the mothers and babies for up to 1 year.
 

Hundreds of women already enrolled

Dr. Afshar noted that these kinds of registries often take months to design and to receive funding, but with COVID-19, “there was no time for that. We had to get it up and running ASAP.”

She said the team has been “blown away” by how quickly people have come forward to join the registry. Within 2 weeks of going live, the registry had enrolled more than 400 participants from across the United States. “At this rate, I think we will easily get 1,000 participants in a month or so,” Dr. Afshar said.

“With the global reach of this disease, the findings resulting from this work have the potential to impact millions of lives in an entire generation,” Johnese Spisso, CEO of UCLA Health, said in the news release.

Dr. Afshar noted that, although the impact of COVID-19 on pregnancy remains unknown, history suggests the disease will make some pregnancies and deliveries more challenging. “We know that in previous outbreaks of the regular flu, for example, there have been more deaths and poorer outcomes among pregnant women compared with nonpregnant women.”

Dr. Afshar is overseeing the study with colleagues at the University of California, Los Angeles, and the University of California, San Francisco, where the registry data will be coordinated.

“In addition to gaining a better understanding of the course of the disease, we will investigate disease transmission to determine if it can be passed from a mother to her baby in utero and during the postpartum period, such as in breast milk,” UCSF’s Stephanie Gaw, MD, PhD, who is leading the biospecimen core of the study, said in the release.

Health care providers interested in more information about the registry may send an email to PRIORITYCOVID19@ucsf.edu. A YouTube video on the registry is also available.

Dr. Afshar disclosed no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

Certain species of anaerobic bacteria have been linked to dramatic increases in colorectal cancer (CRC), often within a year of infection, although whether or not the bacteria are causal has yet to be determined, say Danish researchers.

“We are not convinced that all the bacteria are directly involved in CRC development — they could just be innocent bystanders that invade the blood stream when the cancer [itself] has caused a breach in the intestinal wall,” lead author Ulrik Justesen, MD, Odense University Hospital, Denmark, told Medscape Medical News in an email.

“But an algorithm for colonoscopy based on the [infecting] species, which could then be supplemented with specific characteristics [of the bacteria] along with age, is certainly a realistic perspective,” he added.

The study was to have be presented at the European Congress of Clinical Microbiology and Infectious Diseases (ECCMID) in Paris, France, but the conference was canceled due to COVID-19.

Another study suggesting a link between bacteria and CRC was published earlier this year in Nature, as reported at the time by Medscape Medical News. That study, from the Netherlands, suggests that a strain of Escherichia coli may be involved in the development of CRC.
 

Population-Based Study

The latest study from Denmark was a population-based study involving over 2 million people.

From this large cohort, blood culture data from the years 2007 and 2016 were analyzed.

“We combined blood culture data with the national register for colorectal cancer — the Danish Colorectal Cancer Group Database — and identified incident CRC after bacteraemia,” the investigators state.

The risk for incident CRC was investigated specifically for the anaerobic bacteria Bacteroides spp, Clostridium spp, and Fusobacterium spp.

Incident rates were then compared to those from nonanaerobic bacteria, including the Streptococcus bovis group, Escherichia coli, and Staphylococcus aureus, as well as from negative blood samples.

“We included 45,760 bacteraemia episodes, of which 492 or 1.1% were diagnosed with CRC after the bacteraemia; 241 ― 0.5% ― within 1 year,” the researchers report.

The risk for CRC was notably increased in association with most anaerobic species, compared with negative blood cultures and with E coli and S aureus cultures, for which the risk was similar to that of negative blood cultures.

For example, infection with C septicum was associated with a 42 times greater risk for CRC within 1 year of infection and a 21 times greater risk overall with no time limitation.

Infection with B ovatus was linked to a 13 times greater risk for CRC within 1 year and a six times greater risk overall with no time limitation.

This article first appeared on Medscape.com.

Certain species of anaerobic bacteria have been linked to dramatic increases in colorectal cancer (CRC), often within a year of infection, although whether or not the bacteria are causal has yet to be determined, say Danish researchers.

“We are not convinced that all the bacteria are directly involved in CRC development — they could just be innocent bystanders that invade the blood stream when the cancer [itself] has caused a breach in the intestinal wall,” lead author Ulrik Justesen, MD, Odense University Hospital, Denmark, told Medscape Medical News in an email.

“But an algorithm for colonoscopy based on the [infecting] species, which could then be supplemented with specific characteristics [of the bacteria] along with age, is certainly a realistic perspective,” he added.

The study was to have be presented at the European Congress of Clinical Microbiology and Infectious Diseases (ECCMID) in Paris, France, but the conference was canceled due to COVID-19.

Another study suggesting a link between bacteria and CRC was published earlier this year in Nature, as reported at the time by Medscape Medical News. That study, from the Netherlands, suggests that a strain of Escherichia coli may be involved in the development of CRC.
 

Population-Based Study

The latest study from Denmark was a population-based study involving over 2 million people.

From this large cohort, blood culture data from the years 2007 and 2016 were analyzed.

“We combined blood culture data with the national register for colorectal cancer — the Danish Colorectal Cancer Group Database — and identified incident CRC after bacteraemia,” the investigators state.

The risk for incident CRC was investigated specifically for the anaerobic bacteria Bacteroides spp, Clostridium spp, and Fusobacterium spp.

Incident rates were then compared to those from nonanaerobic bacteria, including the Streptococcus bovis group, Escherichia coli, and Staphylococcus aureus, as well as from negative blood samples.

“We included 45,760 bacteraemia episodes, of which 492 or 1.1% were diagnosed with CRC after the bacteraemia; 241 ― 0.5% ― within 1 year,” the researchers report.

The risk for CRC was notably increased in association with most anaerobic species, compared with negative blood cultures and with E coli and S aureus cultures, for which the risk was similar to that of negative blood cultures.

For example, infection with C septicum was associated with a 42 times greater risk for CRC within 1 year of infection and a 21 times greater risk overall with no time limitation.

Infection with B ovatus was linked to a 13 times greater risk for CRC within 1 year and a six times greater risk overall with no time limitation.

This article first appeared on Medscape.com.

Certain species of anaerobic bacteria have been linked to dramatic increases in colorectal cancer (CRC), often within a year of infection, although whether or not the bacteria are causal has yet to be determined, say Danish researchers.

“We are not convinced that all the bacteria are directly involved in CRC development — they could just be innocent bystanders that invade the blood stream when the cancer [itself] has caused a breach in the intestinal wall,” lead author Ulrik Justesen, MD, Odense University Hospital, Denmark, told Medscape Medical News in an email.

“But an algorithm for colonoscopy based on the [infecting] species, which could then be supplemented with specific characteristics [of the bacteria] along with age, is certainly a realistic perspective,” he added.

The study was to have be presented at the European Congress of Clinical Microbiology and Infectious Diseases (ECCMID) in Paris, France, but the conference was canceled due to COVID-19.

Another study suggesting a link between bacteria and CRC was published earlier this year in Nature, as reported at the time by Medscape Medical News. That study, from the Netherlands, suggests that a strain of Escherichia coli may be involved in the development of CRC.
 

Population-Based Study

The latest study from Denmark was a population-based study involving over 2 million people.

From this large cohort, blood culture data from the years 2007 and 2016 were analyzed.

“We combined blood culture data with the national register for colorectal cancer — the Danish Colorectal Cancer Group Database — and identified incident CRC after bacteraemia,” the investigators state.

The risk for incident CRC was investigated specifically for the anaerobic bacteria Bacteroides spp, Clostridium spp, and Fusobacterium spp.

Incident rates were then compared to those from nonanaerobic bacteria, including the Streptococcus bovis group, Escherichia coli, and Staphylococcus aureus, as well as from negative blood samples.

“We included 45,760 bacteraemia episodes, of which 492 or 1.1% were diagnosed with CRC after the bacteraemia; 241 ― 0.5% ― within 1 year,” the researchers report.

The risk for CRC was notably increased in association with most anaerobic species, compared with negative blood cultures and with E coli and S aureus cultures, for which the risk was similar to that of negative blood cultures.

For example, infection with C septicum was associated with a 42 times greater risk for CRC within 1 year of infection and a 21 times greater risk overall with no time limitation.

Infection with B ovatus was linked to a 13 times greater risk for CRC within 1 year and a six times greater risk overall with no time limitation.

This article first appeared on Medscape.com.