Major Research Report Finds Healthcare-Associated Infections Surging During Pandemic | Healthcare Innovation

A new research report is shedding light on a troubling problem emerging in hospitals, as the COVID-19 pandemic re-surges. As the text of a press release published on September 2 to the website of The Society for Healthcare Epidemiology in America (SHEA) began, “After years of steady reductions in healthcare-associated infections, significantly higher rates of four out of six routinely tracked infections were observed in U.S. hospitals, according to a Centers for Disease Control and Prevention analysis of data from the National Healthcare Safety Network (NHSN) published today in Infection Control & Hospital Epidemiology, the journal of the Society for Healthcare Epidemiology of America. Increases were attributed to factors related to the COVID-19 pandemic, including more and sicker patients requiring more frequent and longer use of catheters and ventilators as well as staffing and supply challenges.

“COVID-19 created a perfect storm for antibiotic resistance and healthcare-associated infections in healthcare settings. Prior to the pandemic, public health — in partnership with hospitals — successfully drove down these infections for several years across U.S. hospitals,” said Arjun Srinivasan, M.D., Associate Director of Healthcare Associated Infection Prevention Programs at the Centers for Disease Control and Prevention (CDC). “Strengthening infection prevention and control capacities works. This information emphasizes the importance of building stronger, deeper and broader infection control resources throughout healthcare that will not only improve our ability to protect patients in future pandemics but will also improve patient care every day.”

Arjun Srinivasan, M.D.CDC

As the press release noted, “For this analysis, researchers used data collected through NHSN, the nation’s largest healthcare-associated infection surveillance system, which is used by nearly all U.S. hospitals to fulfill local, state, or federal infection reporting requirements. Major increases were found in 2020 compared to 2019 in four serious infection types: central line-associated bloodstream infections, catheter-associated urinary tract infections, ventilator-associated events, and antibiotic resistant staph infections. The largest increases were bloodstream infections associated with central line catheters that are inserted into large blood vessels to provide medication and other fluids over long periods. Rates of central line infections were 46 percent to 47 percent higher in the third and fourth quarters of 2020 compared to 2019.”

Further, the press release noted, “With dramatic increases in the frequency and duration of ventilator use, rates of ventilator-associated infections increased by 45 percent in the fourth quarter of 2020 compared to 2019. The CDC analysis found sharp increases in standardized infection rates, indicating that the increases were not simply a reflection of more devices being used.

“Infection control practices in COVID-19 wards often adapted to shortages of personal protective equipment, responded to fear of healthcare personnel, and did not always lend themselves to better infection prevention,” said Tara N. Palmore, M.D., and David K. Henderson, M.D., of the National Institutes of Health, in an editorial that accompanied the study. “The success of the previous several years, with steady declines in rates of these (healthcare-associated) and device-related infections, further accentuated the upswings that occurred in 2020.”

One passage from the article, entitled “The Impact of Coronavirus Disease 2019 (COVID-19) on Healthcare-Associated infections in 2020: A Summary of Data reported to the National Healthcare Safety Network,” speaks to the challenges involved. “This report is the first to present national and select state-level quarterly SIRs [state-level standardized infection ratios] for each HAI [healthcare-associated infection] type in 2020, along with a comparison to 2019 SIRs. Due to reporting requirements for the CMS HACRP, NHSN data are representative of largely all ACHs [acute-care hospitals] in the country and provide a national picture of how patient safety, in particular HAI incidence, may have been affected by the COVID-19 pandemic. Prior to the pandemic, widespread decrease in HAI incidence had been observed across US hospitals. Except for VAE, the national 2020-Q1 SIR for each HAI was below 1 and significantly lower than that from 2019-Q1, indicating a continual decline in HAI incidence at the beginning of 2020. As hospitals began to respond to the COVID-19 pandemic in 2020-Q2, increases in national SIRs became apparent. Initial increases in the SIRs were observed early in the year for CLABSI [central–line–associated bloodstream infections] and MRSA bacteremia (starting in 2020-Q2) and for VAE (starting in 2020-Q1). However, compared to 2019, 2020-Q3 and 2020-Q4 saw large and significant increases in the CLABSI, CAUTI [catheter-associated urinary tract infection], VAE [ventilator-associated event] and MRSA bacteremia SIRs. The CLABSI SIR experienced the greatest increase among all HAI types; the heightened CLABSI incidence during the pandemic and the likely impacts of hospital COVID-19 prevention activities on central line insertion and maintenance practices have been previously documented. CAUTIs and VAEs were also reported more frequently in 2020 than 2019.”

Further, the article’s authors wrote, “A longer patient length-of-stay, additional comorbidities and higher patient acuity levels, and a longer duration of device use in 2020 could have contributed to an overall increased risk of a device-associated infection during the pandemic. In addition, some studies identified an increased risk of ventilator-associated conditions in critically ill COVID-19 patients.5,20 The characteristic worsening of respiratory status in some patients with COVID-19 resulted in an increase in the number of hospitalized patients in 2020 that required ventilation, and an increase in patients’ average duration of ventilation, both of which could have contributed to an increased risk of VAE. Almost all states previously identified by CDC with a high COVID-19 hospital admission burden observed increases in their 2020-Q2 CLABSI and VAE SIRs compared to 2019, most of which were statistically significant.” The authors are as follows: Lindsey M. Weiner-Lastinger M.P.H., Vaishnavi Pattabiraman, MSc, M.S., M.P.H., Rebecca Y. Konnor M.P.H., R. Patel, M.P.H., Emily Wong, M.P.H., Sunny Y. Xu, M.P.H., Brittany Smith, M.P.H., Jonathan R. Edwards, MStat, and Margaret A. Dudeck, M.P.H.

Healthcare Innovation interviewed Dr. Srinivasan at the time of the release of the study. Asked what he considered to be the most important themes and revelations from the study, Srinivasan told Editor-in-Chief Mark Hagland that “It’s important to know that these increases in HC-associated infections are occurring. It is definitely a situation that’s enormously challenging. The last thing we want is to lose someone we’re treating for COVID, to a healthcare-associated infection. At the same time, the healthcare system is enormously challenged right now, and a lot of these patients are very sick. So people need to know that this challenge exists, and to think about what that means” for how to optimize processes during a moment of crisis for care delivery.

Asked about whether what’s happening is the inevitable result of ICUs and hospital wards being overwhelmed right now with floods of patients ill with COVID-19, and with the inevitability that nurses in particular simply lack the time and energy to be able to pay full attention to potential infections of the types uncovered in the study, Srinivasan said that “I think it’s a yes-and. Hospitals are full and over-full, in the ICUs and the wards. And we hear all the time about global staffing shortages. And then some providers themselves become sick. And all of those come to bear on this. And—you hear about COVID—who are the patients who are becoming sick with COVID? Often, they have significant preexisting risk factors, and are therefore also predisposed to these infections. So we see the data reflected here.”

Meanwhile, Hagland also interviewed a practicing infectious diseases specialist, David P. Calfee, M.D., who is a professor of medicine at Weil-Cornell Medical Center in New York City. Dr. Calfee was not an author of the study. Asked what elements leaped out at him from the study’s results, Calfee said that “This is data from an unprecedented time in modern healthcare here in the United States, during a period of time in which the HC system has been stressed in ways we’ve never been stressed before. That’s the background that makes this particularly relevant and important. And in interpreting the data, there were increases in a number of healthcare-associated infections.”

Asked the significance of the study, Calfee said that, “In thinking about what that means, it’s probably representative of a couple of things. During the second, third, and fourth quarters of 2020, hospitals were seeing an influx of very sick patients, and in patients who were on medical devices involving risk. So these were patients who required ventilators, central venous catheters, urinary tract catheters, for long periods of time, and that weren’t as common in pre-pandemic settings—and so these were very sick patients, who were infectious, and there were large numbers of them. And there had to be a space to take care of these patients, and hospitals were creating areas that had not been ICUs previously. There was crowding of patients; there were challenges of staffing.”

Could the fact of clinicians being overwhelmed be a major factor in the rise of these infections, particularly the catheter-related ones? Calfee said that, “This paper doesn’t explain the ‘why,’ but yes, that’s certainly possible. The ability to perform some of the basic care practices was reduced or inhibited, or unable to be done as routinely as under normal conditions.”

Hagland also asked Gary Stuck, M.D., chief medical officer of the 26-hospital, Downers Grove, Ill.- and Milwaukee, Wis.-based Advocate Aurora Health, about the implications of the study for clinical operations at a time of extreme stress on the healthcare delivery system. Dr. Stuck said that, “For health care providers across the country, infections remain the biggest challenge to providing a safe environment for patients. It’s concerning but not surprising that the data showed 2020 was a difficult year for infections nationwide, and that’s why our teams have doubled down on infection prevention in our hospitals during the pandemic, enforcing universal masking, distancing rules, enhanced cleaning and other measures to put the safety of our patients first.”

With regard to the question of what can be done during the current moment of crisis and stress, the CDC’s Srinivasan said, “That’s the key thing: we all have so much respect, and frankly, admiration, for what our healthcare providers are doing day in and day out, for patients and families. So this is not a message about failure, about people failing. What this is, is a system that wasn’t strong enough to survive a blow like this [pandemic], to the system. So we’re working to explore whether there are things that we can do. One element might be fixing the PPE [personal protective equipment] shortage, which would be of huge benefit. And right now,” he concluded, “the most important strategy we could implement would be COVID vaccination: making sure that people get vaccinated, and keep people out of the hospital. So there may be some individual strategies that we will learn, but right now, the most important thing we can do is to vaccinate, vaccinate, vaccinate.”