Hospital-acquired infection (HAI) rates decreased dramatically in recent years, thanks to concentrated attention and intensive infection control efforts. Central line-associated bloodstream infections (CLABSI) decreased 50% between 2008 and 2014, catheter-associated urinary tract infections (CAUTI) decreased 24% on acute-care hospital units over approximately the same period, and hospital-associated invasive methicillin-resistant staph aureus (MRSA) infections decreased 36%, according to the U.S. Centers for Disease Control and Prevention (CDC).
And then, the COVID-19 pandemic hit.
Healthcare providers and health system executives went into survival mode. Their attention turned to meeting immediate (and ever-shifting) challenges. Regulatory systems also pivoted to help health systems manage the crisis. The Centers for Medicare and Medicaid Services (CMS) temporarily suspended HAI reporting requirements, and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and CMS halted on-site inspections and surveys.
Picture legions of healthcare workers, laboring inside a storm-proofed structure as a humongous hurricane rages outside. The winds of the hurricane have died down; now, it’s time to venture outside and get a clear-eyed picture of the storm’s impact.
The good news: Most health systems survived the storm.
The bad news: Almost all health systems sustained significant damage. Providers are burnt out and mentally distressed. Finances are strained. And some evidence suggests that HAIs may have increased during the pandemic.
It will be a while until federal data on HAIs for 2020 is available (and even then, the information is likely to be incomplete, as hospital reporting of HAIs was optional for the first two quarters of the year). However, there’s reason to be concerned: An article published in the November 2020 issue of the American Journal of Infection Control reported that one hospital in New York noted a 420% increase in CLABSIs and 179% increase in CAUTIs, while a hospital in St. Louis experienced a 324% increase in CLABSIs and a 57% increase in CAUTIs.
Given that COVID-19 increased global awareness of the importance of hand hygiene and infection control to levels never before seen in history, why are infections going up? Such outcomes may seem counter-intuitive, yet the pandemic created a perfect storm that battered hospitals’ infection control infrastructure.
According to an article published on Advisory.com, the majority of infectious disease programs were “under-resourced” and under-staffed pre-pandemic. The limited resources of hospitals and healthcare systems were diverted to fend off and treat potentially life-threatening, life-altering illnesses caused by a novel virus. This required an incredible amount of effort from the hospital’s infection control teams that were already stretched too thin. Nearly 80% of infection control specialists who responded to an informal survey in April 2020 said they were spending more than 75% of their time on COVID-19 mitigation strategies. Which, of course, was the correct response to a pressing health challenge, but left little to no time for them to focus on the existing infection prevention initiatives.
To further exacerbate the staffing challenges, localized lockdowns and the cancelation of elective medical procedures dramatically decreased patient and procedure volume, reducing income and necessitating layoffs and furloughs. This resulted in both fewer staff available to help care for the patients and the staff that were fortunate enough to continue working had to work in different roles. This combination of exhausted staff working in roles or areas that they were not used to created many opportunities where patient safety could be compromised.
Increased demand for personal protective equipment (PPE) caused supply shortages, and staff, pressed for time and working with the knowledge and supplies they had at the time, did their best to protect themselves and patients. At one point, the CDC recommended that hospitals with gown shortages “stop using isolation gowns for endemic pathogens such as MRSA and vancomycin-resistant Enterococci,” according to an article in Infection Control Today. Similar systemic strains during the 2003 Severe Acute Respiratory Syndrome (SARS) outbreak led to a notable increase in MRSA infection rates and ventilator-associated pneumonia.
The limited supply of PPE also created a situation where staff were not removing gloves and were re-using them. While it is understandable that this happened, this creates an opportunity to spread HAIs. One of the most common misconceptions we see is that gloves are an appropriate substitute for hand hygiene. The reality is that most pathogens can live better on the surface of gloves than they can on your hands.
Perhaps the biggest factor is that hand hygiene likely declined dramatically in most hospitals. Despite the surge of hand sanitizer use in our everyday lives, within hospitals walls hand hygiene declined dramatically. This was counterintuitive to what nearly all of the hospital leaders we spoke with expected. Our own data demonstrated that without real-time feedback hand hygiene rates fell dramatically as COVID hit the hospitals.
As the storm passes, it’s important to assess the damage. Don’t be surprised if your HAI rates are up; most facilities’ probably are. Instead of focusing on your statistics, though, turn your attention to your infection control infrastructure. How can you repair and restore it?
It will likely take months, if not years, for healthcare systems to recover financially from the impact of COVID-19, so smart utilization of available resources will be crucial moving forward. You may not be able to add staff, but you can invest in technology that allows current staff to efficiently and consistently implement hand hygiene practices. You can also use technology to support just-in-time staffing models, like the Real-Time Intervention Blueprints provided by Clean Hands-Safe Hands automated hand hygiene monitoring systems.
Immediate action is necessary, as JCAHO and CMS have both resumed on-site inspections and investigations. Hospitals and healthcare systems financially stressed by the pandemic cannot afford to pay unnecessary penalties for poor infection control and patient safety metrics.
The nation’s healthcare providers did an admirable job of stepping up to an unprecedented challenge. Now, it’s time for us all to regroup and rebuild our infection control practices and infrastructure.