Faculty of Nursing and Midwifery

Bachelor of Science (Honours) Nursing – Post-Registration

 SECONDARY RESEARCH PROJECT

SYSTEMATIC APPRAISAL OF PUBLISHED RESEARCH

 

PROTOCOL DOCUMENT

 

 

 

 

 

 

 

 

Background of the Topic Area

COVID-19 is a communicable illness that in the past two years has proven to be a global menace to all people and healthcare industries. The virus is believed to have originated from Wuhan, a city in China, and later spread throughout the world. The virus is transmitted among human beings through touching, coughing, or sneezing and most people demonstrate respiratory symptoms such as shortness of breath, fever, and dry cough. The severity of COVID symptoms varies from one person to another although in serious cases, the disease leads to respiratory disease, organ failure, and eventually, death (Anser et al., 2020).

The spread of COVID-19 increased the burden experienced by healthcare systems since most symptomatic patients sought treatment in hospitals. High infection rates led to crowded hospitals and increased workloads for healthcare professionals. Nurses are always at the frontline during crises that increase the need for medical attention. The role of nurses during the pandemic entails triaging patients to determine those who require emergency treatment, especially respiratory support. Due to interactions with COVID patients, nurses, like other healthcare professionals, are at risk of being infected with the illness (Al Thobaity and Alshammari, 2020). As a result, hospitals implemented infection-prevention measures that entail the use of personal protective equipment (PPE) when working within the healthcare environment. Hospitals also emphasized the use of other COVID-19 prevention protocols such as handwashing and avoiding touching one’s face or eyes especially after being in contact with other people or touching any surfaces (Richterman et al., 2020). In Saudi Arabia, the Ministry of Health developed prevention protocols to be followed by hospitals including training workshops on the use of PPE, increased PPE supply, and sanitation protocols (Alarfaj et al., 2021).

Hospital-acquired infections are a menace in the healthcare system that increases the length of hospital stay and result in negative outcomes for patients.  Examples of these infections include surgical site infections, pressure ulcers, catheter-associated urinary tract infections, and ventilator-associated pneumonia (Voidazan et al., 2020). Prevention protocols for healthcare-associated infections focus on hand hygiene and maintenance of a clean, safe, and hygienic hospital environment. Environmental hygiene is critical for the removal of any disease-causing micro-organisms on surfaces thus reducing the risk of contact with infectious germs (Haque et al., 2020).

Notably, COVID-19 prevention protocols, especially hand hygiene and environmental hygiene, align with the protocols for preventing hospital-acquired infections. However, according to Du et al. (2021) patients, like healthcare providers, are at high risk of acquiring COVID-19 in hospitals. Hu et al. (2020) add that regardless of the precautions taken, hospitalized patients, as well as healthcare workers, are at a higher risk of COVID-19 infections. Healthcare providers and patients can’t distance themselves from each other. Deressa et al. (2021) further explain that in intensive care units, the concern for patients is especially high because chronically-ill patients are at high risk of severe COVID-19 infections. Therefore, it is important to examine COVID-19 as a hospital-acquired infection that impacts patients in long-term and acute care settings to understand causes and determine preventive measures.

Research Aim(s)

The main purpose of the appraisal is to investigate literature on COVID-19 as a hospital-acquired infection to enhance knowledge on factors influencing coronavirus spread in hospitals and the possibility of preventing these infections now and in the future.

 

Research Question(s):

1. What are the factors attributed to COVID-19 infections in hospitals?
2. What are the impacts of hospital-acquired COVID-19 on patient health and outcomes?
3. What measures can be taken to reduce COVID-19 spread in hospitals?

Scoping Exercise

Hospital-acquired infections

These are infections that patients acquire in the treatment process. They are also referred to as nosocomial or healthcare-associated infections and usually appear after 48 hours of admission or within 30 days after visiting a healthcare institution for treatment (Haque et al., 2018).

COVID-19

This term refers to a respiratory illness attributed to a new coronavirus called SARS-CoV-2 that was first detected in 2019. The illness is communicable since the virus is transmitted from an infected person to others via respiratory droplets when talking, sneezing, or coughing. The severity of illness ranges from one person to another although the elderly and chronically ill patients are at high risk of severe illness (Centers for Disease Control and Prevention, n.d.).

There is no universal definition of hospital-acquired COVID-19 infections based on uncertainties regarding the incubation period, the possibility of asymptomatic patients, and the possibility of transmission during the pre-symptomatic stage. Therefore, it is highly likely that some studies will overestimate the exact rate of hospital-acquired COVID-19 infections (Abbas et al., 2021).

 

 

Search Strategy

The research articles for the systematic appraisal will include scientific studies that focus on COVID-19 infections in healthcare institutions including hospitals and other long-term or acute care institutions but excluding nursing homes and other facilities that provide residential care. Other inclusion criteria for the articles will include research articles published in the years 2020 and 2021 since this is the period within which most COVID-19 cases were detected all over the world. The research articles must also be peer-reviewed and only those published in English will be included in the systematic appraisal. Only primary research studies will be included in the appraisal and any systematic reviews and meta-analyses will be excluded.

The main databases where the search will be conducted include PUBMED, EBSCO Host, EMBASE, psychINFO, CINAHL, and MEDLINE. The search formula will include keywords such as “coronavirus”, “COVID-19”, “SARS-COV-2”, “healthcare-related infections”, “nosocomial infections”, and “hospital-acquired infections”.  These words will be combined to form phrases that will be searched in the above databases. Other platforms such as Google Scholar and SSRN will also be considered to ensure that more research articles on the study title are identified.

After identifying the articles that meet the criteria, the abstracts will be analyzed to determine their relevance to the study title, and only those that directly examine COVID-19 as a healthcare-acquired infection will be included in the appraisal. The full text for the selected articles will then be thoroughly reviewed to further ascertain relevance to the study title. A summary of the selected articles will be developed and the information obtained from the articles will be categorized according to the three research questions. Factors such as study limitations, presence of bias, the strength of research evidence, and implications for nursing practice and healthcare will be considered to determine the validity and reliability of the findings and to assess relevance to the nursing profession.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References

Abbas, M., Robalo Nunes, T., Martischang, R., Zingg, W., Iten, A., Pittet, D. and Harbarth, S. (2021). Nosocomial transmission and outbreaks of coronavirus disease 2019: the need to protect both patients and healthcare workers. Antimicrobial Resistance & Infection Control, 10(1).

Al Thobaity, A. and Alshammari, F. (2020). Nurses on the Frontline against the COVID-19 Pandemic: An Integrative Review. Dubai Medical Journal, 3(3), pp.87-92.

Alarfaj, M., Foula, M., Alshammary, S., Nwesar, F., Eldamati, A., Alomar, A., Abdulmomen, A., Alarfaj, L., Almulhim, A., Alarfaj, O. and Zakaria, H. (2021). Impact of wearing personal protective equipment on the performance and decision-making of surgeons during the COVID-19 pandemic. Medicine, 100(37), p.e27240.

Anser, M., Yousaf, Z., Khan, M., Nassani, A., Alotaibi, S., Qazi Abro, M., Vo, X., and Zaman, K. (2020). Do communicable diseases (including COVID-19) may increase global poverty risk? A cloud on the horizon. Environmental Research, 187, p.109668.

Centers for Disease Control and Prevention, n.d. Disease of the Week – COVID-19. [online] Available at: https://www.cdc.gov/dotw/covid-19/index.html

Deressa, W., Worku, A., Abebe, W., Gizaw, M. and Amogne, W. (2021). Risk perceptions and preventive practices of COVID-19 among healthcare professionals in public hospitals in Addis Ababa, Ethiopia. PLOS ONE, 16(6), p.e0242471.

Du, Q., Zhang, D., Hu, W., Li, X., Xia, Q., Wen, T. and Jia, H. (2021). Nosocomial infection of COVID‑19: A new challenge for healthcare professionals (Review). International Journal of Molecular Medicine, 47(4).

Haque, M., McKimm, J., Sartelli, M., Dhingra, S., Labricciosa, F., Islam, S., Jahan, D., Nusrat, T., Chowdhury, T., Coccolini, F., Iskandar, K., Catena, F. and Charan, J. (2020). Strategies to Prevent Healthcare-Associated Infections: A Narrative Overview. Risk Management and Healthcare Policy, Volume 13, pp.1765-1780.

Haque, M., Sartelli, M., McKimm, J. and Abu Bakar, M. (2018). Healthcare Associated infections; an overview. Infection and Drug Resistance, Volume 11, pp.2321-2333.

Hu, L., Wang, J., Huang, A., Wang, D. and Wang, J. (2020). COVID-19 and improved prevention of hospital-acquired infection. British Journal of Anaesthesia, 125(3), pp.e318-e319.

Richterman, A., Meyerowitz, E. and Cevik, M. (2020). Hospital-Acquired SARS-CoV-2 Infection. JAMA, 324(21), p.2155.

Voidazan, S., Albu, S., Toth, R., Grigorescu, B., Rachita, A. and Moldovan, I. (2020). Healthcare Associated Infections—A New Pathology in Medical Practice? International Journal of Environmental Research and Public Health, 17(3), p.760.

MAHSA UNIVERSITY

 FACULTY OF MEDICINE BIOSCIENCE AND NURSING

 BACHELOR OF SCIENCE (Hons) IN NURSING

 [HOSPITAL-ACQUIRED COVID-19 INFECTIONS AND THEIR IMPACTS ON PATIENT OUTCOMES- A SYSTEMATIC REVIEW]

 BY

 [STUDENT NAME]

[STUDENT ID]

 

 

 

JUNE 2022

 

A DISSERTATION SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS OF THE DEGREE OF

BACHELOR OF SCIENCE (Hons) IN NURSING

Table of Contents

Acknowledgements. ii

ABSTRACT. v

CHAPTER ONE – INTRODUCTION.. 1

1.1 Aim of the Research. 2

1.2 Research Questions. 2

CHAPTER TWO – THE LITERATURE OVERVIEW… 2

Table 1: Account of the Search Methodology for Literature Review.. 3

2.1 Transmission Model for Hospital-Acquired COVID-19. 3

2.1.1 Transmission from Asymptomatic Individuals. 4

2.1.2 Transmission from Super-spreaders. 5

2.1.3 COVID-19 transmission Routes in Healthcare Facilities. 5

2.1.4 Susceptible Individuals. 5

3.1 Methodology. 6

3.2 Methods. 8

3.2.1 Search Strategies. 8

Table 2: Search Terms/ Databases and the Number of Hits. 8

3.2.2 Inclusion and Exclusion Criteria. 8

3.2.3 Final Study Selection. 9

Figure 1: Flow Chart Outlining the Selection Process. 10

3.2.4 Data Extraction and Analysis. 11

3.2.5 Conclusion. 11

Tables 3 – 7: Data Extraction Tables. 11

CHAPTER FOUR – REPORTING THE FINDINGS. 20

4.1 Introduction to chapter 20

Table 8: Tabular presentation of ALL included studies. 20

4.2 Study Selection and Characteristics. 21

4.3 Theoretical Issues. 21

4.4 Methodological Limitations. 21

4.6 Approaches to Analysis. 22

4.7 Outcomes/Findings. 22

4.8 Quality Assurance Issues. 23

4.9 Conclusion. 23

CHAPTER FIVE – DISCUSSION.. 24

5.1. What are the main factors associated with COVID-19 infections in healthcare facilities?. 24

5.2. How do hospital-acquired COVID-19 infections impact patient health and outcomes?. 24

5.3. What measures can healthcare facilities implement to reduce the spread of COVID-19 among patients?. 25

5.4. Critical Discussion of the Appraisal Process. 25

5.5. Critical Discussion of the Findings in relation to the wider body of Nursing / Health literature. 26

5.6 Implications for Nursing / Health practice / education / management 26

5.7 Identified Gaps in the Evidence. 27

5.8 Implications for future research. 27

5.9 Critical discussion about the problematic nature of ‘evidence’ and its collection, collation and interpretation. 27

CHAPTER 6 – CONCLUSION.. 28

References. 30

APPENDIX 1: GLOSSARY OF TERMS. 35

APPENDIX 2: ALL EXCLUDED STUDIES. 36

 

ABSTRACT

Aim of the study: to investigate existing primary research studies on hospital-acquired COVID-19 to enhance the body of knowledge and develop strategies for preventing the infections now and in future

Methods: The search terms used to identify the research studies to be included in the appraisal were: “coronavirus”, “COVID-19”, “SARS-COV-2”, “healthcare-related infections”, “nosocomial infections”, and “hospital-acquired infections”.  The words were combined to form phrases that were searched in several databases including PUBMED, MEDLINE, and CINAHL. The selected papers were those relevant to the research topic, peer-reviewed, published in English, and available in full-text online. A total of five papers were selected for the appraisal after meeting the inclusion criteria.

Findings/Key results: COVID-19 is mainly transmitted from patient-to-patient in healthcare facilities. Hospital-acquired COVID-19 increases the length of hospital stay and the risk for mortality among patients.

Conclusion: Healthcare facilities should implement appropriate infection prevention and control measures to minimize the spread of COVID-19 in hospitals.

CHAPTER ONE – INTRODUCTION

The COVID-19 pandemic has led to devastating effects on healthcare systems all over the world. The respiratory disease was traced back to Wuhan, China in 2019, and given its communicable nature, it spread fast to other Chinese provinces and other countries. The pathogen responsible for the outbreak was later named coronavirus. The coronavirus is highly contagious and can remain infectious on surfaces for several days. The main mode of transmission of the illness is respiratory droplets that are released into the air when an infected person coughs. In some cases, the droplets land on surfaces or objects and can easily be transmitted to other people who come in contact with them. The average incubation period for COVID-19 is between five to fourteen days (Wu et al., 2020). As of June 2022, more than 528 million cases have been confirmed worldwide, and more than 6 million deaths have been reported (World Health Organization, 2022). Most people who contract the disease report mild flu-like symptoms that often resolve in a few days. However, some develop respiratory complications that lead to respiratory distress, organ failure, and eventually, death (Hori et al., 2021). Healthcare facilities were forced to admit more patients than their usual capacity as many people sought healthcare following their development of moderate or severe symptoms. Infected people visiting healthcare facilities exposed both patients and healthcare professionals to COVID-19 thus leading to the issue of hospital-acquired infections (Evans et al., 2021).

Hospital-acquired infections include illnesses that patients acquire when receiving treatment that are not present during admission. In many cases, hospital-acquired infections are not life-threatening although they increase the length of hospital stay and the cost of healthcare. However, if appropriate preventive measures are not taken, these infections can worsen the health conditions of patients and increase the risk of mortality (Haque et al., 2018). Hospitals all over the world developed and implemented infection control measures such as the use of personal protective equipment and hand hygiene measures to protect their staff from contracting the illness when taking care of COVID-19 patients. Measures have also been implemented to reduce staff-to-patient infections and patient-to-patient infections. However, despite these efforts, many patients admitted to healthcare facilities for other conditions have acquired COVID-19 during their hospital stays. In 2020 and 2021, many people were reluctant to visit healthcare facilities for fear of hospital-acquired COVID-19 (Evans et al., 2021).

Before the pandemic, hospital-acquired infections such as bloodstream infections already posed serious economic and healthcare burdens to healthcare facilities. Hospital-acquired COVID-19 infections increased the healthcare burden since patients with pre-existing conditions such as diabetes and hypertension are overrepresented in inpatient facilities and are at higher risk of poor outcomes from COVID-19 (Halverson et al., 2022). Very few systematic appraisals have been conducted to examine hospital-acquired COVID-19 infections and their impacts on patient outcomes thus illustrating the need to further consolidate information on hospital-acquired COVID-19 and improve the existing body of knowledge. This systematic appraisal focuses on assessing published research studies that report patient outcomes, including mortality rates for patients who contracted COVID-19 during the pandemic. This information will help to gather insight into the burden of hospital-acquired COVID-19 infections. The findings will be used to inform healthcare facilities of the need for implementing effective infection control measures that must be adhered to by both staff and patients.

1.1 Aim of the Research

The systematic appraisal aims to investigate existing primary research studies on hospital-acquired COVID-19 to enhance the body of knowledge and develop strategies for preventing the infections now and in the future. The specific aims of the research are:

1. To assess transmission of COVID-19 infections in healthcare facilities
2. To determine the impacts of hospital-acquired COVID-19 infections on patient outcomes
3. To determine the measures that can be implemented to reduce the risk of hospital-acquired COVID-19 among patients

1.2 Research Questions

The main research questions that will be examined by the systematic appraisal include:

1. What are the main factors associated with COVID-19 infections in healthcare facilities?
2. How do hospital-acquired COVID-19 infections impact patient health and outcomes?
3. What measures can healthcare facilities implement to reduce the spread of COVID-19 among patients?

CHAPTER TWO – THE LITERATURE OVERVIEW

The literature overview focused on introducing the issue of COVID-19 infections in healthcare facilities including possible transmission routes. The search methodology entailed the use of terms such as COVID 19, healthcare facilities, and hospitals. The main databases searched included PUBMED, MEDLINE, and CINAHL.

 

Table 1: Account of the Search Methodology for Literature Review

Search Terms	Databases Searched	Combination of search terms	Number of hits for each combination of terms
Hospital-acquired, COVID-19, healthcare settings, transmission, patients.	PubMed, Medline, and CINAHL	Transmission of hospital-acquired COVID-19	84 hits
COVID-19, super spreaders	PubMed, Medline, and CINAHL	COVID-19 transmission by super-spreaders	4 hits
COVID-19, asymptomatic patients	PubMed, Medline, and CINAHL	COVID-19 transmission from asymptomatic individuals	143 hits

 

The search methodology yielded a total of 231 hits. Upon reviewing the titles of the studies and their abstracts, only 10 research studies were included as part of the literature review because they were peer-reviewed, available in full text, published in English, and provided information on COVID-19 transmission. The literature review was organized into themes and presented below.

2.1 Transmission Model for Hospital-Acquired COVID-19

Du et al. (2021), in a review that examined hospital-acquired COVID-19 as a significant challenge for healthcare staff, provided an in-depth explanation of the transmission of COVID-19 in healthcare facilities. Du et al. (2021) explained that transmission in hospitals can either be endogenous or exogenous. Exogenous infections are attributed to pathogens within the healthcare environment that patients may come into contact with through contaminated objects or their healthcare providers’ hands. Endogenous infection mostly occurs among patients with compromised immune systems who can easily be infected by pathogens within the healthcare environment or by other infected patients.

2.1.1 Transmission from Asymptomatic Individuals.

As per Du et al. (2021), human-to-human transmission among COVID-19 patients is possible even among asymptomatic cases which include individuals who test positive for COVID-19 but do not exhibit any clinical manifestations of the illness. Asymptomatic patients in most cases do not seek any healthcare services which allow them to engage in normal day-to-day activities. Lack of symptoms such as coughing and sneezing among asymptomatic cases limit the transmissibility of COVID-19. In a review that assessed the proportion of asymptomatic COVID-19 patients, Ma et al. (2021) reported that more than 40 percent of confirmed COVID-19 patients present with mild symptoms or no symptoms at all. The percentage of asymptomatic cases may also be higher given that many patients recover from the illness without being aware that they had it. Yu et al. (2020) conducted a multicenter retrospective study that described the progression and characteristics of asymptomatic cases and mentioned that in healthcare facilities, there are many instances where asymptomatic patients have been admitted for other healthcare conditions. In some cases, these patients develop mild or moderate symptoms during their inpatient stay. The main factors that predict symptom development for such patients include the presence of comorbidities and patient age. Asymptomatic patients with illnesses such as hypertension and diabetes are more likely to develop significant symptoms during the hospital stay. Moreover, older patients with weaker immune systems may also develop moderate to severe COVID-19 infection.

Asymptomatic nosocomial COVID-19 is also common in healthcare facilities. In a study that assessed asymptomatic patients admitted to healthcare facilities, Passarelli et al. (2020) stated that the cases are more difficult to detect especially if the patient tested negative for COVID-19 upon admission. Therefore, patients staying in healthcare facilities for longer than 10 days should be frequently tested for COVID-19 to facilitate early detection of nosocomial infection.

Apart from asymptomatic patients, nosocomial COVID-19 is also attributed to visitors, especially those with asymptomatic disease. Passarelli et al. (2021) assessed transmission from asymptomatic visitors to their inpatient contacts and determined that many visitors put patients’ health at risk. Healthcare facilities require visitors to adhere to protocols such as wearing face masks. However, in most cases, masking leads to a false perception of total protection, and other protective measures such as avoiding direct skin contact, proper hand hygiene practices, and social distancing are neglected. The use of full protecting equipment is often neglected among hospital visitors. Passarelli et al. (2020) recommended the restriction of physical contact and time during visitation. Additionally, hospitals should develop measures that promote active screening for all visitors entering healthcare facilities.

2.1.2 Transmission from Super-spreaders

COVID-19 super-spreaders are individuals who can easily infect a large number of people and are often catalysts for disease outbreaks in both community and healthcare settings. As per Chen et al. (2021), the spread of coronavirus was largely driven by super spreading. 60 percent of people who test positive for COVID-19 do not infect anyone. Only about 20 percent of COVID-19 infections result in 80 percent of all secondary cases thus illustrating the severe impacts of super spreading. Majra et al. (2021) add that in places frequented by many people who do not adhere to proper hygiene and use of protective equipment, super spreading is common. Additionally, lack of proper ventilation contributes significantly to transmission, especially in enclosed spaces such as hospital wards. COVID-19 can also be easily transmitted between distant locations especially when there is airflow via ventilation systems, the opening of doors and windows, and the movement of a large number of people. When assessing hospital-onset cases, Illingworth et al. (2021) determined that super-spreaders cause most nosocomial COVID-19 outbreaks.  Illingworth et al. (2021) also concluded that super-spreader patients present a higher risk of an outbreak in comparison to super-spreader healthcare workers.

2.1.3 COVID-19 transmission Routes in Healthcare Facilities

It is generally understood that COVID-19 transmission occurs via direct contact and air droplets released when an infected individual coughs, sneezes, or talks. However, SARS-CoV-2 RNA can also be detected in fecal specimens implying that the virus can be spread via excretion (Wu et al., 2021). In neonatal settings, there is no evidence of vertical transmission from mother to child, even among women who contracted COVID-19 during the late stages of their pregnancies (Passarelli et al., 2021).

2.1.4 Susceptible Individuals

All patients can be infected with COVID-19 in inpatient settings although some patients present a higher risk than others. Elderly patients with underlying illnesses including cardiovascular illnesses, hypertension, and diabetes are at high risk of infection and poor outcomes. Additionally, patients admitted to skilled care facilities and nursing homes with illnesses such as cancer and severe heart disease are at very high risk (Wu et al, 2020; Ma et al., 2021).

 

 

2.2 Summary

The literature review provided evidence of COVID-19 transmission pathways in healthcare facilities. Patients can be infected by asymptomatic individuals as well as super spreaders. Asymptomatic individuals present a greater challenge because it is not easy to tell whether they are infected. Asymptomatic cases may include patients, healthcare professionals, and visitors to healthcare facilities. Super spreaders, on the other hand, can easily infect a large number of people hence they present a significant risk. Notably, super spreaders account for most COVID-19 secondary infections. Transmission occurs when patients come into contact with infected air droplets. Patients with chronic illnesses are at a higher risk of severe infection. The main transmission method involved in hospital-acquired infection will be examined in the systematic appraisal and the impacts of COVID-19 on patient outcomes will also be assessed.

CHAPTER THREE – CONDUCTING THE APPRAISAL – METHODOLOGY & METHOD

This chapter will focus on assessing evidence-based practice and its importance in the nursing field. The chapter will also examine systematic reviews as a form of secondary data analysis, including the advantages and disadvantages. The chapter will also present the methods used to conduct the systematic appraisal including the search strategy, inclusion and exclusion criteria, study selection, data extraction, and analysis.

3.1 Methodology

Evidence-based practice (EBP) is an approach where nurses utilize current research evidence to improve the quality of care provided to patients to improve patient outcomes (Li et al., 2019). Nurses critically appraise research evidence and use it to inform their care. EBP also integrates the patients’ unique circumstances and values along with the nurse’s expertise. The main benefits of EBP in the nursing profession include building the body of knowledge and bridging the gap between nursing research, education, and practice. EBP also helps to standardize nursing practices. Any clinical decisions made by nurses should, therefore, be based on the most recent and best available research (Abu-Baker et al., 2021).

Systematic reviews refer to summaries of medical literature that follow specific methods to search and identify literature on specific topics, critically appraise this literature, and synthesize the findings to come up with conclusions. Generally, systematic reviews synthesize the findings obtained by many primary research studies focusing on the same topic by applying strategies that minimize random errors and biases. Systematic reviews begin with the formulation of a research question, the development of a reproducible and comprehensive search strategy, and the identification of relevant studies. There must also be inclusion and exclusion criteria for the studies and a balanced and unbiased summary of all the findings obtained in the studies should be presented. The systematic review process entails secondary data analysis which is defined as the process of analyzing data that was collected by others (Tawfik et al., 2019).

The secondary data analysis process provides researchers with the opportunity to make use of available data sets when investigating specific research questions which save resources and time. When conducting secondary data analysis, it is important to evaluate the relevance of the existing research data to the current research question. This includes examining the research design, data collection method, and operationalization of concepts. It is also important to establish the credibility of the research (Panchenko and Samovilova, 2020).

The main advantages of systematic reviews include the use of a systematic method to select relevant studies which reduce bias. The methodology and search strategies used are also described hence the review can be replicated. Additionally, systematic reviews are more rigorous that literature reviews and also reduce implicit researcher bias. The use of broad search strategies and uniform exclusion and inclusion criteria ensure that researchers access studies beyond their networks and subject areas. Moreover, systematic reviews facilitate the generation of more objective and clearer answers to the identified research questions. However, there are many challenges that one may encounter when completing systematic reviews. First, the reviews require access to peer-reviewed journals often contained in a wide range of academic databases which may be time-consuming, especially for students who are forced to look beyond their institution’s databases. Secondly, systematic reviews can also be of poor quality since there are no universal protocols for conducting them. Their quality depends on the authors’ evaluation of evidence hence issues associated with conflicts of interest and bias may arise. Thirdly, there is a risk of redundancy since it is common to find several systematic reviews on specific topics. Finally, systematic reviews often focus on putting together fragments of information obtained from different primary studies without considering the differences in the studies (Ahn and Kang, 2018).

Secondary data analysis methods like systematic reviews need less monetary resources and time to complete since the data can be accessed at little to no cost. Unlike primary studies, secondary data analysis needs less research time since researchers do not look for study participants or engage in real research. The main limitation of secondary data analysis is that the available data may not answer the specific research question. It may be difficult to access data collected within a specific geographical location or time. Moreover, researchers may be forced to alter their research questions or limit the analysis if they fail to access the data they need. Notably, researchers using secondary data do not know whether the data collection process was carried out well and if the findings were unbiased (Wickham, 2019).

3.2 Methods

The purpose of the systematic appraisal is to assess COVID-19 as a hospital-acquired infection and determine the main impacts on patient outcomes. The research questions for the current systematic appraisal are:

1. What are the main factors associated with COVID-19 infections in healthcare facilities?
2. How do hospital-acquired COVID-19 infections impact patient health and outcomes?
3. What measures can healthcare facilities implement to reduce the spread of COVID-19 among patients?

3.2.1 Search Strategies

The main search terms included “coronavirus”, “COVID-19”, “SARS-COV-2”, “healthcare-related infections”, “nosocomial infections”, and “hospital-acquired infections”.  The words were combined to form phrases that were searched in several databases including PUBMED, MEDLINE, and CINAHL.

Table 2: Search Terms/ Databases and the Number of Hits

Search terms	Databases	Number of Hits
“coronavirus”, “COVID-19”, “SARS-COV-2”, “healthcare-related infections”, “nosocomial infections”, and “hospital-acquired infections”.	PUBMED   MEDLINE   CINAHL	5022 hits   801 hits   1399 hits
		7222 hits in total

 

3.2.2 Inclusion and Exclusion Criteria

The only studies that were included were those that examined COVID-19 as a hospital-acquired infection in healthcare institutions including acute care institutions and hospitals. The selected articles were also those published in the years 2020, 2021, and 2022, were peer-reviewed and were published in English. Additionally, only primary research studies were included in the appraisal and any meta-analyses or systematic reviews were excluded. Studies that were not published in English were also excluded. Moreover, articles that did not have full texts or relevant data required to assess the research questions were also excluded.

3.2.3 Final Study Selection

The initial search resulted in 7222 hits in total for all the databases. After refining the search terms, a total of 1007 hits remained although most were not primary research articles. The titles and abstracts for the identified studies were screened against the inclusion criteria and those which did not meet the criteria were eliminated. A total of 15 studies remained. The full texts for the remaining studies were then retrieved and screened against the quality criteria. A total of 5 studies met the criteria.  The selection process is illustrated in the flowchart below:

Figure 1: Flow Chart Outlining the Selection Process

Appraisal Question: Hospital-acquired COVID-19 infections and their impacts on patient outcomes

7,222 citations – most not research or unrelated

Scoping exercise

Initial search

 

 

                       

                       

5 suitable papers

1,007 citations Many not research

Refine research terms

3.2.4 Data Extraction and Analysis

The data was extracted using a standardized data collection table that will be presented below. The main data that was extracted included basic information which was the title of the studies, year of publication, authors, the type of study, the characteristics of the study participants, and the results. Recommendations for measures that can reduce the rate of hospital-acquired COVID-19 infections were also included. The data was analyzed by carefully evaluating the identified literature, assessing their strengths and implications to the field of nursing, and identifying their limitations.

3.2.5 Conclusion

The selection process resulted in the identification of five studies. The findings obtained from the five studies will be presented in the next chapter after which they will be discussed.

Tables 3 – 7: Data Extraction Tables

 

Data Extraction
Authors, date & country and focus of study	Study design	Participants, recruitment  & sampling methodology	Exposure – disease or risk factors	Outcome measures	Results	Comments
Rickman et al. (2020). The United Kingdom Nosocomial COVID-19 transmission.	Retrospective study Length of follow-up: 3 weeks. The design is appropriate for the aims of the study. No theoretical framework was described.	Participants: patients admitted to a tertiary healthcare facility were included in the study. A total of 435 COVID-19 cases were identified. Representative of the defined population?: Only patients admitted to one hospital were involved in the study hence the participants are not a good representative of the defined population. All patients admitted to a tertiary inpatient facility with COVID-19 between 2nd March and 12th April 2020 were included.	The main exposure factor was the COVID-19 disease. No theoretical models were used to clarify the exposure factor.	Data was mainly collected from the electronic hospital system. Objective measures. Laboratory test: SARS-CoV-2 PCR test that is accurate and reliable. Confounding factors: none mentioned	After the 3-week follow-up period, 56 percent of patients with nosocomial COVID-19 had been discharged, 36 percent died, and 8 percent remained inpatients. Exposure to COVID-19 in healthcare facilities may lead to poor outcomes	The study findings align with available information on the impacts of nosocomial COVID-19.

 

Data Extraction
Authors, date & country and focus of study	Study design	Participants, recruitment  & sampling methodology	Exposure – disease or risk factors	Outcome measures	Results	Comments
Carter et al. (2020). The United Kingdom and Italy Focus: examine risk of mortality for patients with hospital-acquired COVID-19 in comparison to community-acquired	Observational cohort study clearly explained. Length of follow-up: Not defined. Study design was appropriate, no theoretical framework was used	A multicenter study that included 1564 participants from 10 hospitals in Italy and the U.K. Participants were still not a good representative of the COVID-19 population. Recruitment was based on patient admission with a COVID-19 diagnosis There was no mention of informed consent	COVID-19 was the main exposure factor There was no mention of theoretical models  underpinning relationships	Data collection methods: Observing patients to determine clinical prognosis. Objective measures. Instruments: Clinical Frailty Scale (CFS): a valid and reliable tool COVID-19 lab test: accurate and reliable Confounding factors: smoking status, current and previous health history, age, and frailty.	Median survival time was higher among community-acquired cases in comparison to nosocomial cases. However, mortality rates were higher among community-acquired cases. The analysis clearly reported for the findings were clearly reported by the researchers.	The study was approved by an Ethics committee implying that all ethical requirements were met.

 

Data Extraction
Authors, date & country and focus of study	Study design	Participants, recruitment  & sampling methodology	Exposure – disease or risk factors	Outcome measures	Results	Comments
Mo et al. (2021). The United Kingdom Study conducted in 4 teaching hospitals	Observational cohort study, clearly explained Length of follow up: January to October, 2020. No theoretical framework used.	Participants: 66,184 hospitalized patients, 920 tested positive for COVID-19. Recruitment: patients admitted to the hospitals within the time period were recruited, continuous symptomatic testing taken to identify nosocomial COVID-19 cases. Participants were a good representative of the defined population	Exposure factor: COVID-19 disease. No mention of theoretical models  underpinning relationships	Data obtained from electronic health records of the four teaching hospitals. Objective measures used. Test: SARS-CoV-2 PCR test which is accurate and reliable. Confounding factors: none mentioned.	Nosocomial COVID-19 is mainly transmitted from patient-to-patient. Analysis is clearly reported and the follow-up is long enough and complete. Analysis clearly reported.	The findings obtained match the available evidence.

 

 

Data Extraction
Authors, date & country and focus of study	Study design	Participants, recruitment  & sampling methodology	Exposure – disease or risk factors	Outcome measures	Results	Comments
Melancon et al. (2022), Study completed in Canada Focus of the study: To assess mortality rates among non-hospital acquired and hospital-acquired COVID-19 cases.	Retrospective single center cohort study, design was clearly explained and appropriate for the aims of the study. There was no mention of a theoretical framework.	Participants: 697 patients with COVID-19 Recruitment and sampling: Only patients with COVID-19 in the hospital were recruited for the study. Patients were not a good representative of the COVID-19 population. Informed consent was not mentioned.	Exposure factor: COVID-19 disease. No mention of theoretical models  underpinning relationships	Data collection methods: data collected from electronic health records of the hospital using objective measures. Testing: SARS-CoV-2 PCR test, accurate and reliable Confounding factors: comorbidities	Mortality rates were higher among hospital-acquired COVID-19 cases in comparison to community-acquired cases. The analysis was clearly reported.	Informed consent was not mentioned although the study was approved by an ethics board.

 

 

 

Data Extraction
Authors, date & country and focus of study	Study design	Participants, recruitment  & sampling methodology	Exposure – disease or risk factors	Outcome measures	Results	Comments
Ridwan et al. (2021) Country- Canada   Focus of study: to assess the incidence of nosocomial COVID-19 after cardiac surgery.	Single-center study, data was collected retrospectively. Length of follow-up: not clearly defined. Is it appropriate for the aims of the study?: Yes Theoretical framework explicit?- No theoretical framework described	Participants: 597 patients who underwent surgery in a tertiary cardiac center were assessed in the study, only 4 patients were infected with COVID-19 during their inpatient stay. Representative of the defined population?: No No consent issues	Exposure factor: COVID-19 disease. No mention of theoretical models  underpinning relationships	Data collected from the electronic records and objective measures were used.   Testing: SARS-CoV-2 PCR test, accurate and reliable   Confounding factors: previous and current medical history, comorbidities.	Only four patients were infected with nosocomial COVID-19. Two patients died from COVID-related complications, one patient has a prolonged hospital stay. Analysis clearly reported. Follow-up was not clearly defined.	The findings matched the available evidence. Cardiac patients often have many comorbid disorders which put them at risk of poor outcomes if infected with COVID-19.

 

CHAPTER FOUR – REPORTING THE FINDINGS

4.1 Introduction to chapter

This chapter will discuss the findings obtained from the selected research studies. The characteristics of all the studies will be described and quality assurance issues will be identified.

Table 8: Tabular presentation of ALL included studies

Authors, date, and country	Study design and Sampling methods	Treatment/ Intervention	Outcome measures
Ridwan et al. (2021)   Canada	single-center study design	-Dexamethasone -Antiviral medications such as remdesivir	Mortality and length of hospital stay
(Rickman et al., 2020)   The United Kingdom	Retrospective study	-Constant patient screening -Use of personal protective equipment. -Training and support to the staff.	Mortality Length of hospital stay
(Mo et al., 2021)   The United Kingdom	Observational cohort study.	None mentioned	-Mortality -Length of hospital stay
(Carter et al., 2020)   The United Kingdom and Italy	observational cohort study	None mentioned	-Mortality -Length of hospital stay
Melancon et al. (2022)   Canada	Single-center retrospective cohort study	Corticosteroid treatment, hydroxychloroquin. However, the effectiveness of treatment strategies was not examined.	Mortality

 

4.2 Study Selection and Characteristics

Two studies were conducted in the U.K., one study was conducted in both the U.K. and Italy and two studies were conducted in Canada. Four studies utilized a cohort study design while one study analyzed data from existing patient records.  All the studies focused on analyzing COVID-19 acquired by patients in healthcare facilities. One study obtained data from national records of patient admissions and discharges while the remaining four studies were focused on specific hospitals. A total of 3620 patients tested positive for COVID-19 in the studies and 1,438 cases were hospital-acquired. Out of all the hospital-acquired cases, 550 patients died.

4.3 Theoretical Issues

The studies did not follow any theoretical frameworks hence there are no theoretical issues to be examined.

4.4 Methodological Limitations

There are several methodological limitations presented in the studies. Rickman et al. (2020) used a retrospective study design and this presented several limitations. The information used during the study was based on the review of patient charts which were not originally designed to collect the data for the research hence critical information was missing. For instance, it was difficult to detect transmission of COVID-19 among patients in other contexts apart from their admission location. It was also impossible to determine if contact with staff members contributed to nosocomial COVID-19. Carter et al. (2020) and Mo et al. (2020) used an observational cohort study design that presented some methodological limitations. Carter et al. (2020) compared mortality rates between nosocomial and community-acquired COVID-19 infections. The main limitation presented by Carter et al. (2020) is that case-mix differences could not be allowed between the community-acquired and nosocomial infection groups . Carter et al. (2020) also failed to assess the exact cause of death for the COVID-19 patients but assumed that COVID-19 significantly contributed to their deaths. Other methodological limitations for observational cohort studies include susceptibility to selection bias and the need for a large number of subjects to effectively study hospital-acquired COVID-19. Melancon et al. (2022) used a single-center retrospective design which makes it difficult to prove causality and limited the generalizability of the data. Ridwan et al. (2021) used a single-center study design which presented several limitations including a small number of patients to sample from and poor generalizability of findings.

4.5 Sampling

The selected studies mainly sampled the participants based on their disease status during the enrollment period. Since the studies examined hospital-acquired COVID-19 infections,  patients who tested positive for COVID-19 within specific periods after admission were included in the studies. All studies only included patients who were clinically diagnosed with COVID-19.

4.6 Approaches to Analysis

The main analysis methods in the selected studies included descriptive statistics used to present patient demographic information and other characteristics, regression models, multivariate logistic models, and sensitivity analysis.

4.7 Outcomes/Findings

Factors Associated With COVID-19 Infections in Healthcare Facilities

The findings from the studies illustrate that the main factor linked to the spread of COVID-19 in healthcare facilities is contact with other infected patients. Rickman et al. (2020)  identified 66 cases of nosocomial COVID-19 and 69 percent of the cases were linked to contact with other infected patients. Mo et al. (2021) explained that for susceptible patients, spending one day in the same unit as another patient with COVID-19 significantly increased the risk of infection. Other factors such as hospital infrastructure were also determined to influence the spread of hospital-acquired COVID-19. Melancon et al. (2022) explained that in the healthcare facility where the study was conducted, the wards were not installed with mechanical ventilation and the rooms were only separated by curtains. The hospital design explained why patients who shared rooms with infected patients tested positive for COVID-19 within a few days in the wards.

Impact of Hospital-Acquired COVID-19 Infections on Patient Health and Outcomes

The findings illustrated that hospital-acquired COVID-19 has a significant impact on patient outcomes. In a sample of 579 patients, Ridwan et al. (2021) identified only 4 cases of hospital-acquired COVID-19 and two of the patients died from respiratory complications attributed to COVID-19. One patient recovered although he was admitted for 52 days in the healthcare facility and needed oxygen support. Only one patient was asymptomatic and was discharged after four days. Melancon et al. (2022) also determined that nosocomial COVID-19 infections increase the risk of poor outcomes, including mortality and increase the length of hospital stay. In a sample of 697 patients diagnosed with COVID-19, Melancon et al. (2022) determined that 36.3 percent of the cases were nosocomial and that the mortality rate was higher among these patients than community-acquired infections. Additionally, Melancon et al. (2022) also determined that nosocomial COVID-19 led to poor outcomes among younger patients. Carter et al. (2020) and Rickman et al. (2020) also determined that nosocomial COVID-19 increased the risk of mortality and the length of hospital stay among patients.

The findings also link severe nosocomial COVID-19 infections to comorbidities. Patients with chronic illnesses such as hypertension, reduced renal function, coronary artery disease, diabetes, hematologic malignancy, and myocardial infarctions exhibited poorer outcomes including higher mortality rates and longer length of hospital stay (Melancon et al., 2022; Carter et al., (2020).

Measures to Reduce Spread of Hospital-Acquired COVID-19

Recommendations for reducing COVID-19 infections in healthcare facilities include appropriate use of personal protective equipment (PPE) by both healthcare providers and visitors and thorough hand hygiene practices. Surveillance testing is also recommended for both patients and staff to facilitate early detection of COVID-19 cases and implementation of strategies such as isolation that will reduce the risk of transmission to other patients. All equipment used in healthcare facilities d all surfaces should also be regularly cleaned and disinfected.

4.8 Quality Assurance Issues

The studies demonstrated poor external validity since the study populations were not good representatives of the COVID-19 population or healthcare facilities. Therefore, the results cannot be generalized to patients and healthcare facilities on a larger scale. Concerning the methodology used, there was no bias in outcome assessment for the studies. All the patients were tested for COVID-19 using the same test and the criteria for hospital-acquired COVID-19 was applied similarly to all patients.

4.9 Conclusion

The findings obtained from the selected studies reveal that nosocomial COVID-19 increases the risk of mortality among patients. Patients who survived were admitted for a longer period. However, issues such as the inability to generalize the findings limit the validity of the findings. Additionally, given that only 5 studies were appraised, the results cannot be used to provide valid conclusions. The next chapter will discuss the implications of the findings to nurses, healthcare facilities, and nursing literature.

 

CHAPTER FIVE – DISCUSSION

In this systematic appraisal that addressed hospital-acquired COVID-19 infections, the findings illustrate that patients who acquire COVID-19 in healthcare facilities are at a higher risk of poor outcomes including increased length of hospitalization and mortality. This chapter will discuss the findings obtained from the appraisal and also provide a critical discussion of the appraisal process and the findings in relation to the wider body of nursing literature. Additionally, the chapter will identify implications for nursing practice, identify evidence gaps, and describe implications for future research.

5.1. What are the main factors associated with COVID-19 infections in healthcare facilities?

The appraised studies sufficiently answered this research question by providing evidence that inpatient COVID-19 infections are mostly transmitted from one infected patient to others. In some cases, healthcare professionals may infect patients although this is less likely to happen because of proper hand hygiene practices and the use of personal protective equipment (PPE) among healthcare professionals. However, as per Oda et al. (2020), there is still a significant risk of transmission from patients to healthcare providers, especially nurses who spend the most time with patients. Another significant point highlighted by the appraised studies is that hospital visitors also contribute to hospital-acquired infections. This point is consistent with the information presented by Jaswaney et al. (2021) in a study that analyzed visitor restrictions in hospitals. Jaswaney et al. (2021) explained that many healthcare facilities imposed visitor restrictions to reduce the risk of the spread of COVID-19 among both patients and the healthcare staff.

Several issues regarding the research processes used in the appraised studies emerged. Some studies focused on symptomatic patients only and ignored asymptomatic patients. For instance, Rickman et al. (2021) did not include patients with undiagnosed COVID-19 or those who had been exposed but were still asymptomatic when they were discharged. It was also difficult to access data on when the patients first presented with COVID-19 symptoms. Mo et al. (2021) relied on patients to report the day when their symptoms began and this presented the issue of recall bias.

5.2. How do hospital-acquired COVID-19 infections impact patient health and outcomes?

The appraised studies addressed this research question by providing evidence that hospital-acquired infections have a negative impact on patient outcomes. The studies only focused on the length of hospitalization and mortality as the main outcomes. However, other aspects of patient outcomes, including the functional status of patients and readmission rates should also have been examined. As per Marques (2021), severe COVID-19 results in impairment in body structure and functioning including fatigue, dyspnea, myalgia, and muscle weakness which lead to limitations in daily activities such as lifting objects and walking. Contextual factors such as age and comorbid health conditions also increase the risk of functional limitations. As explained in the appraised studies, patients with other conditions such as hypertension and diabetes are more susceptible to poor outcomes associated with COVID-19 hence it is likely that hospital-acquired infections would have a negative impact on their body functioning.

A significant issue that emerged in the appraised research process is that two studies did not assess the cause of death for patients with COVID-19 to ascertain that the illness played a significant role in their death. Carter et al. (2020) did not examine the cause of death for both community-acquired and hospital-acquired infections. Mo et al. (2021) did not consider how admission pathology impacted patient outcomes. No study conducted a post-discharge follow-up to gather more information on patient outcomes.

5.3. What measures can healthcare facilities implement to reduce the spread of COVID-19 among patients?

The appraised studies addressed this research question by providing recommendations of steps that healthcare facilities could take to reduce the risk of inpatient COVID-19 transmission. The recommended measures include the screening of all patients before admission, continuous surveillance testing for both patients and staff, and thorough use of infection prevention and control (IPC) and PPE precautions. Ridwan et al. (2021) recommended that all patients undergoing surgery should be vaccinated to reduce the risk of infection. However, since these measures are recommendations, there is no evidence from the appraised studies that they are effective in preventing nosocomial COVID-19 infections. A study conducted by (Shitrit et al., 2021) after COVID-19 vaccines were rolled out revealed that nosocomial outbreaks were still a relevant issue even among highly vaccinated populations. The outbreaks were attributed to the COVID-19 Delta variant that resulted in severe illness or death among patients thus illustrating that vaccination may not be effective in preventing nosocomial COVID-19.

5.4. Critical Discussion of the Appraisal Process

The appraisal process facilitated the identification of literature that focused on nosocomial COVID-19. However, several limitations are presented in the appraisal process. There is a limited body of knowledge on nosocomial COVID-19 infections. Excluding articles that were not published in English or did not have full texts available online limited the number of articles that were appraised.

5.5. Critical Discussion of the Findings about the wider body of Nursing / Health literature

The findings illustrate that nosocomial COVID-19 is a significant issue in healthcare due to its negative implications to patient health. Since there are very few studies that examined the impact of nosocomial COVID-19, this appraisal enhances the existing body of knowledge by making available evidence more accessible to nurses and other healthcare professionals.

5.6 Implications for Nursing / Health practice / education / management        

The findings present several implications for nurses. During the peak of COVID-19 pandemic, nurses were at the frontline providing care to patients and risking their lives as they exposed themselves to infected people. Therefore, nurses understand the impacts of COVID-19 on both mental and physical health. The findings illustrate that nurses should always implement infection control measures, including hand hygiene and the use of personal protective equipment when engaging with patients. Nurses should always be on the lookout for COVID-related symptoms among admitted patients and ensure that they are constantly tested. Additionally, nurses must remain aware of asymptomatic COVID-19 cases and ensure that all patients are tested upon admission.

Healthcare practice should implement policies that reduce the risk of nosocomial COVID-19. These policies should include COVID-19 testing for all patients as soon as they are admitted and continuous tests during the hospitalization period, availing protective equipment for all healthcare professionals and availing tests for healthcare professionals. Additionally, all visitors in healthcare facilities must adhere to infection control practices including hand hygiene, wearing masks, and social distancing. Vulnerable patients such as the elderly and those suffering from severe chronic illnesses should be isolated to reduce the risk of poor outcomes in case of a nosocomial COVID-19 outbreak. Healthcare institutions should ensure that proper hygiene measures are adhered to including cleaning and sterilizing all equipment and surfaces constantly and ensuring proper ventilation and air circulation in the facilities.

Education is also a critical component of effective COVID-19 management. All healthcare professionals in all facilities should be educated on proper infection control practices including hand hygiene and the use of protective equipment. They should also be educated on what symptoms to watch out for when engaging with patients. Patients should also be educated on infection control practices and encouraged to maintain a safe distance when engaging with their families and friends who visit them.

5.7 Identified Gaps in the Evidence

           The main gap in the evidence was that four out of five selected articles did not describe the interventions provided to patients who tested positive for COVID-19 and whether the interventions made any difference in the patient outcomes. Additionally, the studies were conducted before the COVID-19 vaccines were introduced hence it is difficult to determine if ensuring that all patients are vaccinated would have reduced the risk of poor outcomes and mortality. All the studies did not conduct a follow-up to determine whether the discharged patients who had tested positive for COVID-19 had different outcomes. Additionally, there was no evidence on the health status of the patients who survived nosocomial COVID-19 to further provide more insight on patient outcomes. For the patients who died, the studies did not establish whether COVID-19 was the cause of death which may not always have been the case.

5.8 Implications for future research

Future research studies should include follow-up for patients diagnosed with inpatient nosocomial COVID-19 to ascertain the exact impacts of the illness on patient outcomes. Additionally, in nosocomial cases that result in mortality, the cause of death should be established to determine whether COVID-19 contributed to death. To gather more accurate information on the time of infection for patients, future studies should focus on capturing patient symptoms and testing for COVID-19 as soon as the symptoms occur. Another limitation presented by the appraised studies is that two of them, Ridwan et al. (2021), Rickman et al. (2021), and Melancon et al. (2022) used a single-center design and this limited the generalizability of their findings. Future studies should cover more healthcare facilities and a larger patient population to improve the validity and reliability of the findings.

5.9 Critical discussion about the problematic nature of ‘evidence’ and its collection, collation, and interpretation

People require adequate skills to search for available evidence, process it, and make sense of it. However, by nature, evidence is iterative, emerging, and undergoes constant changes based on the changes that occur in the modern world. Accurate evidence is, therefore, temporary regardless of its source and the individuals making sense of it. Evidence requires constant updates. Based on the ever-evolving landscape, it is difficult to make accurate interpretations of data. In many cases, it is difficult to find high-quality evidence hence large volumes of poor quality evidence are often put together and conclusions drawn from them. When collecting evidence, other challenges that may be incurred include missing research evidence which makes it impossible to make important decisions. Interpretation of evidence varies from one person to another based on their understanding of the evidence, their career path, and what they intend to use the evidence for. For instance, when interpreting evidence on nosocomial COVID-19, non-clinical managers would view it from a multidimensional perspective to determine how it can be applied to improve outcomes and performance. On the other hand, nurses would consider it from the perspective of gathering knowledge that would help them improve the care they provide to patients (Madjar and Walton, 2001). For the current appraisal, most of the studies were conducted in 2020 or 2021. Given that COVID-19 has mutated and several vaccines introduced to the market, it is important to seek more recent evidence.

CHAPTER 6 – CONCLUSION

There are several limitations of the systematic appraisal. First, two out of five of the identified studies were conducted in the U.K., and one was conducted in both the U.K. and Italy. The remaining two studies were conducted in Canada. Although all these studies met the inclusion and quality criteria, the restricted geographical locations do not provide room for generalization. Secondly, the extent to which confounding variables such as comorbidities impacted the patient outcomes were not considered in the studies. Thirdly, the available studies were either single-center or multiple-center studies. The patient population involved in each study was not large enough to generalize the findings to other healthcare facilities in the world. Fourthly, none of the appraised studies followed a specific theoretical framework or model.

Patient-to-patient transmission was identified as the main factor leading to nosocomial infections. Patients admitted with COVID-19 infected others and in some cases, these patients were admitted while asymptomatic. Transmission between healthcare providers and patients was also mentioned although such cases were rare. Nosocomial COVID-19 can deteriorate the health condition of patients leading to an increase in their length of hospital stay and in some cases, death. Patients with comorbidities such as diabetes, cancer, and hypertension experience a higher risk of poor outcomes when infected. Measures such as social distancing, isolation of critically-ill patients and those infected with COVID-19, use of personal protective equipment, and thorough hand hygiene practices can limit the spread of COVID-19. The identified gaps in evidence include lack of information on whether treatments provided to patients for nosocomial COVID-19 were effective and lack of follow-ups after patient discharge. These gaps illustrate the need for comprehensive patient follow-up in future research studies and analysis of the types of treatment that can help improve patient outcomes.

This appraisal has expanded the body of knowledge on hospital-acquired COVID-19 transmission by synthesizing available evidence. The appraisal is beneficial to healthcare professionals including nurses and physicians since it facilitates easy access to information regarding hospital-acquired COVID-19 infections. The information obtained from the appraisal can be used by healthcare workers to ensure that they adhere to infection prevention and control protocols. Additionally, health administrators can use the findings to implement policies such as continuous COVID-19 testing for patients and staff, measures that encourage hand hygiene such as easy availability of water, soap, and sanitizers, and continuous availability of proper protective equipment. Both staff and patient education is also necessary to ensure that everyone adheres to infection prevention protocols. Patient education should also include the significance of social distancing when engaging with visitors and encouraging them to wear their masks properly. Given the ever-evolving nature of evidence, more research should be carried out to determine the current status of nosocomial COVID-19 infections, especially after the introduction of the vaccines and the development of COVID-19 variants.

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APPENDIX 1: GLOSSARY OF TERMS

Hospital-acquired infections or nosocomial infections: Infections that patients acquire in the treatment process. They are also referred to as nosocomial or healthcare-associated infections and usually appear after 48 hours of admission or within 30 days after visiting a healthcare institution for treatment.

COVID-19: A respiratory illness attributed to a new coronavirus called SARS-CoV-2 that was first detected in 2019. The illness is communicable since the virus is transmitted from an infected person to others via respiratory droplets when talking, sneezing, or coughing. The severity of illness ranges from one person to another although the elderly and chronically ill patients are at high risk of severe illness.

Personal protective equipment: Protective gloves, face masks, clothing, and respirators worn by healthcare professionals and during the pandemic, everyone else, to protect themselves from illness or infection.

APPENDIX 2: ALL EXCLUDED STUDIES

Author and Year, country	Aim of the Study
(Behzadifar et al., 2022), Italy	To investigate impacts of COVID-19 on hospital revenue.
(Birkmeyer et al., 2020), USA	To examine the rates of hospital admissions during the COVID-19 pandemic
(Connolly et al., 2021), a scoping review of multiple studies from multiple geographical locations	To examine palliative and end-of-life care during the pandemic.
(De Kock et al., 2021) Rapid review, no specific country	To establish risk factors for poor mental health among healthcare workers during the COVID-19 pandemic.
(Khera et al., 2021) USA	To evaluate healthcare utilization during COVID-19 and patient outcomes.
(Magnavita et al., 2021) Italy	To assess COVID-19 management in healthcare facilities
(Razu et al., 2021) Bangladesh	To explore challenges encountered by healthcare professionals in Bangladesh.
(Silvera et al., 2021),  USA	To examine the impacts of hospital visitation restrictions in USA
(Van Loon et al., 2020) Belgium	To assess COVID-19 infections among healthcare professionals
(Wambua et al., 2021), Kenya	To quantify the impact of COVID-19 on inpatient services in Kenya