Despite Modest Progress on Lowering HAI Rates Since the Pandemic, IP&C Challenges Persist

By Kelly M. Pyrek

In the subsequent years since the COVID-19 pandemic first began, the rates of healthcare-acquired infections (HAIs) have fluctuated, due in part to the singular focus on SARS-CoV-2, but also because of waning complications of supply chain shortages that impacted personal protective equipment (PPE) and other supplies, compounded by staffing challenges, and then a resumed re-dedication to evidence-based infection prevention and control (IP&C) practices.

The year 2022 (for which the latest data is available) showed progress in preventing several important HAIs in U.S. acute-care hospitals (ACHs). This progress is the first of its kind since the emergence of the COVID-19 global pandemic in 2020 and reverses a trend of spiking HAIs documented by Lastinger, et al. (2023).

Late last year, the Centers for Disease Control and Prevention (CDC) released the 2022 National and State Healthcare-Associated Infections Progress Report showing that some healthcare settings saw no change or increases in infections, ACHs reported decreases in some HAIs between 2021 and 2022:
• Central line-associated bloodstream infections (CLABSI) decreased by 9 percent
- The largest decrease was in ICUs (21 percent)
- The largest increase was in NICUs (11 percent)
• Catheter-associated urinary tract infections (CAUTI) decreased by 12 percent
- The largest decrease was in ICUs (27 percent)
• Ventilator-associated events (VAE) decreased 19 percent
- There was about an 18-percent decrease observed in ICUs
- There was about an about a 37-percent decrease observed in non-ICUs
• Hospital-onset methicillin-resistant Staphylococcus aureus (MRSA) bacteremia decreased 16 percent
• Hospital-onset Clostridioides difficile (CDI) decreased 3 percent
• Surgical site infections (SSI) following abdominal hysterectomy and colon surgery had no significant changes

While these are relatively modest decreases, they represent progress compared to recent years when Lastinger, et al. (2023) examined NHSN data to assess the impact of COVID-19 on the incidence of HAI during 2021. They found that standardized infection ratios (SIRs) in ACHs were significantly higher than those during the pre-pandemic period, particularly during 2021-Q1 and 2021-Q3. As the researchers acknowledged, “During 2021-Q1, all-time highs of COVID-19–associated hospitalizations were recorded throughout the country. Although large increases were noted in CLABSI, VAE, and MRSA bacteremia in 2021-Q1, the increase in the CAUTI SIR was modest. Improvements in CLABSI, CAUTI, VAE, and MRSA bacteremia SIRs were observed in 2021-Q2, coincident with the dramatic reduction in nationwide COVID-19 hospitalizations. However, as the severe acute respiratory coronavirus virus 2 (SARS-CoV-2) δ (delta) variant emerged in 2021-Q3, dramatic increases in SIRs were observed again.”

Lastinger, et al. (2023) continue, “Changes in most SIRs were driven by changes in the number of reported HAIs, with several factors contributing to such changes. First, device-associated HAIs were likely affected by the continued alteration of hospital practices that occurred throughout the pandemic. Modifications of CLABSI prevention practices during 2020 are well documented, and prevention practices likely continued to be altered during 2021. By contrast, the modest increase in CAUTI SIRs may be related to the fact that catheter removal, a primary approach to CAUTI prevention, was still possible even during times of stress on the healthcare system. Conversely, pandemic-related improvements in hand hygiene, PPE practices, and environmental cleaning may have contributed to the decreases observed in the CDI SIR. Colon surgeries and abdominal hysterectomies were not typically performed as part of COVID-19 care, and process flows in the operating room remained relatively unchanged during this time. This finding may explain the lack of significant changes observed in SSI SIRs.”

They add further, “Different patients may have been admitted to healthcare settings in 2021 compared to the pre-pandemic period, and the increases in SIRs may be explained by changes in the proportion of patients with different characteristics (race or ethnicity and comorbidities). Although some characteristics (patient location) were controlled for in the device-associated HAI SIRs, the risk-adjustment models may not have adjusted for all relevant characteristics. In addition, increases in SIRs could have been due to increased patient morbidity from COVID-19.”

The 2022 data indicate that 3,951 acute-care hospitals reported to NHSN, accounting for 36,448,691 hospital admissions. The average number of beds at these facilities was 129, and the average number of ICU beds was 14. The average number of full-time epidemiologists at these facilities was 0.44. General hospitals (3,396/85.95 percent) comprised the greatest number of facilities reporting to the NHSN.

As we know, SIR is a summary statistic that can be used to track HAI prevention progress over time; lower SIRs are better. Here’s a look at the number of events (infections) and SIRs for all hospitals reporting on three main HAIs:
• Observed CLABSIs: 23,389; 0.836
• Observed CAUTIs: 20,237; 0.697
• Observed VAE: 32,631; 1.188
According to the data, on the state level compared to itself from 2021 and 2022:
• 31 states performed better on at least two infection types
- 17 states performed better on at least three infection types
- 6 states performed better on at least four infection types
• 3 states performed worse on two or more infection types
- 1 state performed worse on at least three infection types

Deborah Yokoe, MD, MPH, FSHEA, immediate past-president of the Society for Healthcare Epidemiology of America (SHEA) recognizes the hard work that acute-care facilities – under the leadership of healthcare epidemiologists and infection preventionists -- have undertaken to shift attention that was focused on responding to the COVID-19 pandemic back to broader infection prevention initiatives that protect patients – and healthcare personnel -- from a wide range of infections.

Yokoe says the multi-factorial nature of the COVID-19 pandemic presented the perfect storm that challenged all healthcare facilities when it came to maintaining their equilibrium regarding HAI prevention.

“We saw worsened patient outcomes and HAI rates starting with the onset of the COVID-19 pandemic,” Yokoe affirms. “Patients with COVID-19 infection were at higher risk for some of these HAIs, including central line-associated infections, catheter-associated urinary tract infections, and certainly for ventilator-associated events. Because they were often so sick, they required invasive medical devices, and were complicated patients to take care of. So, just having many patients with COVID-19 in the hospital increased HAI rates, and in addition, all the pressures and consequences of dealing with the pandemic on the massive level that we did starting in 2020 and into 2021 impacted HAI risks for all patients. There were times where we had limited access to supplies, including PPE, hand hygiene products, and surface cleaners and disinfectants, which challenged our ability to care for our patients and their environment. This was compounded by the number of patients that we had in our hospitals, limited hospital beds, and limited staffing, as well as illness, losses, and burnout among some of our workforce; all those issues placed immense stress on the whole healthcare system. So, in addition to taking care of very sick patients, we were also dealing with some limitations in resources and redirecting some of the energy, time and effort that we had previously been focusing on HAI prevention to deal with all the consequences of COVID-19.”

Yokoe continues, “In 2021, when it became clear that our outcomes and HAI rates had suffered during that time period, there was a great deal of attention re-focused back on HAI prevention and at the same time we were experiencing some relief from the initial onslaught of the COVID-19 pandemic. I think that 2021 report made very clear the impacts of diverting resources away from fundamental, foundational HAI prevention, on patient safety and HAI prevention, and emphasized the importance of having resources and looking to the expertise of groups like healthcare epidemiologists, infection preventionists and antimicrobial stewards to guide the way in using evidence-based best practices. Following the recommendations in the Compendium, and then getting the many stakeholders that are necessary to optimize our HAI prevention efforts together to work in a coordinated way around HAI prevention, have been two of the major reasons that we've seen improvements in outcomes in the 2022 data.”

Thomas R. Talbot, MD, MPH, FSHEA, president of SHEA and chief hospital epidemiologist at Vanderbilt University Medical Center, points out that many of the infections most impacted during the worst of the pandemic were related to indwelling medical devices.

“When you look at the infections that were most affected by COVID-19, it's those that are related to devices that require proper day-to-day handling and care,” he says, “compared to surgical site infections which are a bit more controlled or regimented in the operating room. And when you consider those day-to-day practices and the challenges around COVID-19 when people were exhausted, busy and stretched, compounded by a shortage of the proper supplies, those were sort of the proverbial canaries-in-the-coal-mine -- those infections got worse because we couldn't deliver the same attention to detail that we had to for COVID-19 infections. Other factors that we've seen in play include turnover in staffing. We've seen nationally during the pandemic and beyond a lot of nursing personnel who left their institutions to either become traveling nurses, or they went to other areas in healthcare, or they left the occupation completely. So, hospitals experienced a great deal of turnover of more seasoned nurses who are traditionally the ones to teach new nurses in the field. That kind of training during COVID was either spread thin or disappeared altogether, and so that called into question the infrastructure for how to onboard and train healthcare personnel.”

Talbot continues, “To Dr. Yokoe’s point, the infection prevention control programs of our healthcare systems underwent a huge stress test with COVID-19. In some ways, hospitals did some remarkable things during the pandemic, but it also drew attention away from that basic infrastructure of HAI prevention practices. Going forward, hospitals must examine their existing levels of resourcing, staffing, and components of an infection prevention and control program to ensure they are strong enough to withstand the next pandemic, whatever that is, and continue to move forward to reduce patient and healthcare personnel harm.”

As COVID-19 transitions to more of an endemic and possibly seasonal illness, clinicians will need to include SARS-CoV-2 among the pathogens of concern that hospitals address as standard operating procedure. As the threat of what is being called a “tripledemic” caused by the confluence of COVID-19, influenza and RSV illnesses emerges, healthcare facilities face a scenario that could potentially trigger utilization and pose similar challenges that the pandemic did.
“I think there is that risk,” Talbot says. “I don't know if that would be as extreme as the first year of the COVID-19 pandemic which distracted from other basic infection prevention strategies, but any time that you have any unexpected strain on the healthcare system coupled with a weaker infection prevention and control program, you could be jeopardizing patient and healthcare personnel safety. However, if you are onboarding new healthcare workers and regularly educating existing workers in proper infection prevention and control practices, you're making it easy to do the right thing regardless of how much of a strain that an RSV or flu outbreak causes. There's always the risk that you could have lapses in infection control practices during outbreaks, and if you don’t keep your eye on those interventions that are proven to fight infections, you could risk experiencing escalating HAI rates.”

Yokoe emphasizes that the heart of the ongoing challenge is around sustainability of HAI prevention practices.

“HAI rates look better in 2022, but it's clear that if we take our eyes off the ball, we could be back in the same place we were before, so we should take this opportunity to think about what we need for sustainable HAI prevention efforts,” she says. “As Dr. Talbot mentioned, we need to build resilience into our infection prevention and control programs. They must be adequately staffed. They must be adequately funded and resourced to be able to withstand ongoing challenges by emerging pathogens in the future. We will face a continuing series of infectious disease crises, so we must be prepared to contend with issues similar to what we experienced with COVID-19. I agree with Dr. Talbot that we are in a much better position now than we were early in the COVID-19 pandemic, even with the possibility of increased influenza and RSV cases, but we should take this opportunity to learn from our experiences and build and reinforce an IP&C foundation that is able to sustain basic infection prevention practices, even in the face of competing demands.”
Maintaining consistency in the application of evidence-based HAI prevention practices is key, but as studies demonstrate, compliance by healthcare personnel is often subpar. (See a related article on IP&C compliance in this issue on page XX.) Many studies indicate that embracing a multi-faceted approach toward improving IP&C intervention strategies can drive improvements. Lack of knowledge of guidelines for infection prevention and control, combined with an unawareness of preventive indications during daily patient care and the potential risks of transmission of microorganisms to patients, constitute barriers to infection prevention and control compliance.

Talbot encourages hospitals to revisit the foundational, pragmatic basics of infection prevention and control to ensure they have been mastered by healthcare personnel.

“In the real-world healthcare system, no intervention is perfect, so that’s why we have different layers of control to implement,” he says. “The key is to adhere to sustainable, hard-wired infection prevention practices. We need to be transparent and educate people around why we take these precautions and make it exceptionally easy for them to do them during the delivery of care. For instance, hospitals should make it so that healthcare personnel don't need to stop to wonder if the supplies are there, the resources are there, whether it's PPE or hand hygiene products. It's also about understanding the workflow in healthcare.”
Yokoe adds that hospitals must continue to try to make it as easy as possible for healthcare personnel to do the right thing, making interventions effortlessly implementable. “Especially in the busy healthcare environment that we all work in,” she emphasizes. “And continuing to remind healthcare personnel that everyone is accountable for infection prevention. Infection prevention practices must be built into everyday standard work practices for all healthcare professionals. I think that's the only way we're going to make any improvements that we achieve sustainable over time.”

The 2022 HAI Progress Report showed little progress in reducing HAIs in other healthcare settings. For example, among long-term acute-care hospitals (LTACHs), there were no significant changes in the 2022 SIRs compared with 2021. In Inpatient rehabilitation facilities (IRFs), only IRF-onset CDI observed a 9 percent decrease in 2022 compared to 2021.

“I'm very concerned about the harms that are occurring in these other healthcare settings,” Talbot says. “These are settings in which the infection prevention and control programs are likely even less resourced and possibly more elementary than in acute-care settings. There are nuances to any practice setting, of course. If you think about long-term care residents, you might have different approaches to HAI prevention interventions. Currently, there's some particularly good work being done to examine those strategies. No matter the setting, the resiliency and the resourcing of the infection prevention and control program is critical, so that it can be proactive and effective. It is an area to continue to push for more attention.”

“As Dr. Talbot mentioned, I think the basic infection prevention principles and practices are similar, but there are real challenges in terms of resourcing and staffing in these non-acute-care settings,” Yokoe says. “The CDC has been focused on long-term care settings, and SHEA is developing a guidance document focused on long-term care that will be issued sometime this year. So, I agree that it’s an area interest and priority for SHEA.” Yokoe adds that, “Hospitals should continue to prioritize HAI-prevention work and invest in the resources needed to implement and sustain effective infection prevention strategies, including those highlighted in the SHEA's Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals. This is essential for safe, high-quality healthcare.”

HAI prevention efforts are only as successful as their degree of resourcing and funding allows them to be. Talbot and Yokoe share their thoughts on how to make the business case of infection prevention and appealing to the C-Suite for HAI prevention leadership and support.

“SHEA is in the process of developing a whitepaper around the resources of an infection prevention and control program, and we hope to make this guidance available in the spring,” Talbot says. “All stakeholders, from the leaders of the healthcare facility to regulatory partners, need to see these programs as foundational infrastructure to the effective running of the healthcare institution. We've got so much data about not just reduction of harms, but reduction in length of stay, enhanced throughput, reduced costs, reduced waste, etc. You wouldn't have a hospital without a lab and a lab director, and so you must have that foundational infection prevention and control program appropriately resourced, with input and participation from all the individuals in the hospital who partner with that program to set expectations around the mission and the goal for the coming year. Infection prevention and control programs are foundational infrastructure programs for hospitals, not just something that allows you to say to Joint Commission, ‘I've checked these boxes.’ To be truly effective and reduce harm, it's got to be foundational.”

Yokoe adds that it's vitally important to get the message across to hospital executives and others about the importance of the work that is led by healthcare epidemiologist infection preventionists and antimicrobial stewards. “I'm not sure if all hospital executives truly understand the role of a healthcare epidemiologist. So, some of the work that Dr. Talbot is leading during the coming year will be to highlight the critical role that we play and the fact that we are the subject matter experts around HAI prevention and prevention of the spread of antimicrobial resistance.”

References:
Centers for Disease Control and Prevention (CDC). 2022 National and State Healthcare-Associated Infections Progress Report. Accessible at: https://www.cdc.gov/hai/data/portal/progress-report.html
Lastinger LM, Alvarez CR, et al. Continued increases in the incidence of healthcare-associated infection (HAI) during the second year of the coronavirus disease 2019 (COVID-19) pandemic. Infect Control Hosp Epidemiol. 2023 Jun;44(6):997-1001. doi: 10.1017/ice.2022.116. Epub 2022 May 20.