The researchers emphasize that while their analysis highlights hospital burden during the pandemic , “ Important work remains to quantify the impact of the pandemic on routine hospital operations , especially on healthcare-associated infections ( HAIs ) that are routinely tracked by the NHSN .”
To that end , Fakih , et al . ( 2021 ) emphasize that the pandemic has had “ a considerable impact on U . S . hospitalizations , affecting processes and patient population ,” and in their analysis , sought to evaluate the impact of COVID-19 pandemic on central line-associated bloodstream infections ( CLABSIs ) and catheter associated urinary tract infections ( CAUTIs ) in hospitals .
The researchers performed a retrospective study of CLABSIs and CAUTIs in 78 U . S . facilities 12 months before COVID-19 and six months during the pandemic . During the two study periods , there were 795,022 central-line days and 817,267 urinary catheter days . Compared to the period before the COVID-19 pandemic , the researchers found that CLABSI rates increased by 51.0 percent during the pandemic period from 0.56 to 0.85 per 1,000 line-days and by 62.9 percent from 1.00 to 1.64 per 10,000 patient days . Hospitals with monthly COVID-19 patients representing more than 10 percent of admissions had an NHSN device standardized infection ratio ( SIR ) for CLABSI that was 2.38 times higher than hospitals with less than 5 percent prevalence during the pandemic period . Coagulase-negative Staphylococcus CLABSIs increased by 130 percent from 0.07 to 0.17 events per 1,000 line-days , and Candida spp by 56.9 percent from 0.14 to 0.21 per 1,000 line-days . In contrast , no significant changes were identified for CAUTI ( 0.86 vs 0.77 per 1,000 catheter days ).
Regarding correlations between COVID-19 hospital prevalence , CLABSI and CAUTI events , Fakih , et al . ( 2021 ) report that during the months when patients with active COVID-19 represented more than 10 percent of admissions , the CLABSI dSIR was 2.38 times higher ( dSIR , 1.58 ) than in months when COVID-19 prevalence among hospitalized patients was less than 5 percent ( dSIR , 0.67 ; P = . 004 ).
Fakih , et al . ( 2021 ) emphasize the importance of hardwiring processes for optimal line care and regular feedback on performance to maintain a safe environment . They observe , “ An integral risk reduction strategy for CLABSI is anchored in the optimal maintenance of the device … The pandemic likely affected both the care of the line for COVID-19 and non – COVID-19 hospitalized patients . Qualitative feedback from infection prevention teams reported changes to routine CLABSI prevention practices in ICUs , such as less universal decolonization ( e . g ., mupirocin administration and chlorhexidine bathing ), alterations in line care due to intravenous pumps placed in hallways ( e . g ., extension tubing used and less bedside checks on lines ), line and dressing integrity gaps related to prone positioning of patients , opportunities in scrub-the-hub compliance , and increases in line draws for blood cultures . Another variable potentially impacting CLABSI outcomes includes staffing changes responding to increased patient volume on the units , such as the help of traveling clinicians not as familiar with standard unit prevention practices . Lastly , during the pre-COVID-19 period , ‘ line rounds ’ were a routine practice , ensuring that proper device selection , utilization , and bedside practices were being followed . The teams reported that many of those rounds stopped during the COVID-19 pandemic period due to competing priorities . On the other hand , with the less intense needs for indwelling urinary catheter device care , nominal changes in practice were reported , with the exception of some reports of increases in pan-culturing for febrile patients .”
Of note , in addition to the increases in the occurrence of CLABSI during the pandemic , the researchers say they observed changes in the microbiology associated with these events : “ Gram-positive-associated CLABSIs increased by more than 80 percent during the pandemic period , and coagulase-negative Staphylococcus-associated CLABSIs more than doubled . This change may indicate the increased risk for line infection and contamination due to suboptimal aseptic practices while obtaining blood cultures in a stressful environment .”
As they emphasize , “ Our results underscore the importance of ensuring close monitoring of processes and outcomes related to device use during the pandemic and providing regular feedback on performance to the frontline staff and clinical leaders to ensure a safe environment to care for all our hospitalized patients . These results also highlight the importance of avoiding any disruption of public reporting of healthcare-associated infections . We must learn from the COVID-19 pandemic and design processes resilient to any unpredictable event .”
COVID & CLABSIs As we have seen , CLABSIs provide a glimpse into how HAI rates fared during the pandemic .
Midway into the pandemic , McMullen , et al . ( 2020 ) had offered commentary on the potential infection prevention impact of crisis care for COVID-19 and anticipated resulting impact on HAI rates , including CLABSIs . As they observed , “ The highest impact to HAI from COVID-19 is expected to be CLABSI rates , and two of our facilities have seen rates increases ( comparing several months of COVID to rates the prior 15 months , Hospital A saw a 420 percent increase to rate = 5.38 cases per 1,000 central line days , while Hospital B saw a 327 percent increase to rate = 3.79 cases per 1,000 central line days ). Several factors are expected to increase the number of CLABSI cases , while decreasing low-risk central line denominators , resulting in overall increases in rates and standardized infection rates . As stay-at-home orders proliferated around the country , many hospitals saw major decreases in overall census . Patients not coming to receive care are those that are lower acuity , such as those seeking elective procedures , and likely have a lower risk of developing bacteremia . This will result in a decrease of the central line denominator , and a shifting of the denominator toward high-risk patients . Similar impact will likely be seen in the hospital-onset methicillin-resistant Staphylococcus aureus bacteremia rates .”
As McMullen , et al . ( 2020 ) explain , “ COVID-19 patients are at higher risk of CLABSI for many reasons , including several related to the disease process and medical staff decision-making . The patients who require hospitalization have increased acuity and longer lengths of stay . There may be increased use of femoral lines for central access , as the insertion process is easier in patients presenting with overwhelming critical illness . Additionally , practitioners may believe it is safer than an insertion in the subclavian or internal jugular veins since the femoral site is away from the mouth and respiratory tract . COVID-19 also leads to an increased incidence of acute kidney injury , requiring high numbers of patients to have central access for dialysis . There will be decreased provider focus on removing central lines , and likely