Pandemic created ‘perfect storm’ for health care-associated infections
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COVID-19 placed a strain on infection prevention and control programs, highlighting vulnerabilities that existed before the pandemic, according to experts.
Guidance published earlier this year by the Association for Professionals in Infection Control and Epidemiology (APIC) could help ensure that facilities are better prepared to protect patients.
Source: Nate Langer/UPMC
“Health care facilities faced enormous challenges during the initial years of the COVID-19 pandemic,” Alexander J. Sundermann, DrPH, CIC, FAPIC, an assistant professor of infectious diseases at the University of Pittsburgh Center for Genomic Epidemiology, told Healio | Infectious Disease News.
“After years of a downward trend in health care-associated infections (HAIs), there was a continuous increase during 2020 and 2021,” said Sundermann, whose work focuses on the epidemiology and transmission of nosocomial pathogens.
Sundermann explained that many factors contributed to the increase in HAIs, including decreased time for infection preventionists (IPs) to focus on routine prevention efforts.
According to APIC President Linda Dickey, RN, MPH, CIC, FAPIC, the pandemic arrived suddenly with two new challenges: a fear of the unknown — how SARS-CoV-2 was transmitted and how severe COVID-19 would be — and a supply chain that struggled to deliver personal protective equipment, which “exacerbated a feeling of vulnerability,” she said.
“As we moved through the pandemic, that normalized, but it had its effect,” Dickey said.
Sundermann said addressing staffing shortages could help remove many of the obstacles faced by infection prevention and control (IPC) programs.
Infectious Disease News spoke with Dickey, Sundermann and other IPC experts about the impact that COVID-19 had on health care facilities, including hospitals and nursing homes, and what those facilities learned through the pandemic.
‘A perfect storm’
CDC researchers reported last year that the incidence of some HAIs increased significantly in 2020 because of pandemic-related disruptions.
The largest increases occurred in central line-associated bloodstream infections (CLABSIs), which were around 46% to 47% higher in the third and fourth quarters of 2020 compared with 2019. The study, published in Infection Control & Hospital Epidemiology, also showed dramatic increases in the frequency and duration of ventilator use and rates of ventilator-associated events (VAEs), which rose by around 45% in the fourth quarter of 2020 compared with 2019. Catheter-associated UTIs (CAUTIs) increased by around 19% in the fourth quarter in 2020 compared with 2019, and MRSA rates were 22% to 34% higher in the third and fourth quarters than the previous year, the researchers reported.
“COVID-19 created a perfect storm for antibiotic resistance and health care-associated infections in health care settings,” Arjun Srinivasan, MD, associate director for HAI prevention programs at the CDC, said in a press release at the time.
A more recent report published earlier this year — also in Infection Control & Hospital Epidemiology — showed that many increases in HAIs persisted during the second year of the pandemic.
Compared with 2019, rates of VAE and MRSA bacteremia were 51% and 39% higher, respectively, in the first quarter of 2021. During the second quarter, rates of CLABSI, VAE, and MRSA bacteremia were at their lowest since the start of the pandemic, but this changed in the third quarter, when rates of CLABSI, CAUTI, VAE and MRSA bacteremia were all significantly higher compared with prior quarters and pre-pandemic quarters.
Specifically, data showed that VAEs during the third quarter were 149% higher than in 2019 at the same hospitals.
The authors wrote that the data “underscore the continued challenges experienced in infection prevention.”
“Resilient approaches are needed to reduce HAIs in 2022 and beyond,” they said.
Protecting patients and staff
In March, APIC published recommendations in a paper titled Between a Rock and a Hard Place: Recommendations for Balancing Patient Safety and Pandemic Response that it said will ensure the United States is better prepared to protect patients during health emergencies like COVID-19.
According to APIC, IPC programs were already underfunded and understaffed when the pandemic hit. The added burden of responding to COVID-19 “exacerbated those patient safety weaknesses, leaving health care facilities with insufficient capacity to prevent common, often deadly health care-associated infections,” APIC said.
Thomas R. Talbot, MD, MPH, chief hospital epidemiologist at Vanderbilt University Medical Center, likened the early days of the pandemic to building an airplane while trying to fly it.
“One of the things we saw during the pandemic, when everybody shut down those first few months, was that there were people who needed health care for non-COVID conditions who didn’t seek or receive health care,” Talbot said. “They were scared to come to facilities. We saw the harm of that. So, how can you surge during a pandemic and still deliver health care in a safe way that protects patients and workers?”
APIC’s recommendations included:
- CMS should require that an IP be involved in developing the infectious disease surveillance program for the health care facility or agency, including decisions about surveillance testing plans for patients, employees and visitors.
- Congress should allocate funds for health care facilities to build IPC capacity to ensure the continuity of safe patient care during a pandemic and to have enough frontline IPs during an infectious disease emergency, such as a pandemic.
- CMS should require that additional nursing home staff be trained in the foundations of IPC to reinforce the facility’s plan for surge capacity in the event of an infectious disease outbreak.
- Congress must invest now in incentivizing the next generation of health care professionals to join the IPC pipeline. Legislation has been introduced to create a loan repayment program for infectious disease personnel, which can be crucial to attracting and retaining talent.
- Congress should fund the National Institute for Occupational Safety & Health to develop an off-the-shelf, one-size-fits-all respirator that can be used in health care facilities for infectious disease emergencies without the need for fit-testing.
Experts agreed that the recommendations were necessary and important for many reasons.
“Having facilities where the staff are put in garbage bags as gowns and bandanas as masks can’t ever happen again,” said Deborah Burdsall, PhD, RN-BC, CIC.
Talbot further addressed existing gaps in IPC, including lack of appropriate hand hygiene practices and insufficient data sharing between facilities.
“All these gaps can affect anyone seeking health care,” he said. “Just because you’re healthy and have a good immune system does not mean you’re not as at risk to acquire an infection as these other folks,” he said, noting that a lack of precautions negatively affects health care workers just as much as patients. “We want them to be protected in large part because they’re out there on the front lines caring for patients.”
Kara M. Jacobs Slifka, MD, MPH, who leads the long-term care team in the CDC’s Division of Healthcare Quality Promotion, and David T. Kuhar, MD, director of the CDC’s Office of Healthcare Worker Safety and team lead of the Hospital Infection Prevention team, said staffing, training and burnout “are factors that can affect a health care facility’s preparedness.”
“Employers need to be vigilant in ensuring adequate staffing numbers, providing needed infection prevention and control training and education, and identifying and addressing burnout in health care personnel before staff numbers dwindle,” Jacobs Slifka and Kuhar said in a joint email.
‘The one who steers the ship’
According to Jacobs Slifka and Kuhar, there is a shared responsibility between health care facilities and public health authorities to ensure that facilities are prepared for surges like the one that occurred during the COVID-19 pandemic. Additionally, CMS requires that facilities adhere to specific standards and periodically evaluates them to ensure they are appropriately prepared, Jacobs Slifka and Kuhar said.
According to Burdsall, IPs play a “huge role” in keeping facilities on the right course.
“The infection preventionist is the one who steers the ship,” said Burdsall, although she noted that infection prevention is not a well-known career path and that IPC duties often fall to a person who “has way more on their plate than they can handle anyway,” like nurses.
When Burdsall did infection control assessments at nursing homes, one of the first questions she would ask the person in charge of infection prevention is, “Do you like this?”
“Is it something you chose to do? Or want to do? Because nine times out of 10, they say ‘no,’” Burdsall continued.
Like many health care providers, IPs have been susceptible to burnout and high stress during COVID-19. A survey of nearly 1,000 IPs demonstrated how they struggled during the pandemic. Depression, anxiety and burnout were reported by 21.5%, 29.8% and 65% of respondents, respectively. Additionally, less than 34% of respondents met guidelines for sleep, physical activity and fruit and/or vegetable consumption.
The authors said IPs have played a critical role in preventing the spread of COVID-19 in acute and outpatient settings but that the resulting increases in stress have negatively impacted their mental and physical well-being.
“APIC must continue to promote and provide guidance on instituting and sustaining work cultures that promote IP’s well-being and fixing system issues known to cause burnout and other mental health problems as there is a growing body of evidence that poor mental and physical health in clinicians adversely impacts the quality and safety of health care,” they wrote.
Room for improvement
Sundermann said hospitals are much better prepared than they were 2 years ago but “there’s still room for a lot of improvement.”
“COVID-19 has taught our health care systems the successes and failures in managing surges and new diseases,” Sundermann said. “We can take what we’ve learned from the past couple years and try to prevent those issues from happening again.”
He said IPs “will be invaluable as we all face new, emerging challenges like mpox” — WHO’s updated name for monkeypox — “RSV, polio, etc.”
Bolstering the IPC workforce will take a lot of investment, he said.
“Such action has always been at the heart of the dilemma for infection prevention: How do we convince people to invest in something when, if it works, no one notices?” he said.
Professional organizations such as the Society for Healthcare Epidemiology of America and APIC also must continue to take action, Sundermann said, noting that they have both made health care staffing, preparedness, and COVID-19 response legislative priorities.
“We just have to keep the momentum going,” Burdsall said. “It’s critical.”
- References:
- HAI fast forward: Accelerating HAI prevention. https://apic.org/wp-content/uploads/2022/03/PandemicResponse_WhiteP-FINAL.pdf. Published March 8, 2022. Accessed Nov. 15, 2022.
- Lastinger LM, et al. Infect Control Hosp Epidemiol. 2022;doi:10.1017/ice.2022.116.
- Melnyk BM, et al. Am J Infect Control. 2022;doi:10.1016/j.ajic.2022.04.004.
- Shen K, et al. JAMA Netw Open. 2021;doi:10.1001/jamanetworkopen.2021.22885.
- Weiner-Lastinger LM, et al. Infect Control Hosp Epidemiol. 2021;doi:10.1017/ice.2021.362.
- For more information:
- Deborah Burdsall, PhD, RN-BC, CIC, can be reached at dburdsall@gmail.com.
- Linda Dickey, RN, MPH, CIC, FAPIC, can be reached at ldickey@hs.uci.edu.
- Kara M. Jacobs Slifka, MD, MPH, can be reached at media@cdc.gov.
- David T. Kuhar, MD, can be reached at media@cdc.gov.
- Alexander J. Sundermann, DrPH, CIC, FAPIC, can be reached at als412@pitt.edu.
- Thomas Talbot, MD, MPH, can be reached at tom.talbot@vumc.org.
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