is a priority , nothing is a priority . Those competing priorities come into play . As we move forward , COVID-19 will continue to take a toll on our healthcare system and on the priorities and goals that we bring forward into stewardship and infection control . This is not a sprint , this is a marathon .” Cawcutt offered several practice improvement suggestions . “ First , ensure that you have a liaison or a battle buddy that sits between infection control and stewardship programs so that you can align efforts and develop programs and projects that are additive or synergistic . Second , engage your hospital leadership to ensure they understand the value of stewardship and infection control working together on priorities , so you have the support , but also so that they understand the value of setting aligned priorities . Third , remember that not everything can be a priority , so choose wisely . Fourth , consider the impact of burnout and implementing projects that help improve the workload burden of your frontline staff while also achieving your outcomes . Finally , make sure you get feedback from the frontline on how to collaborate , innovate , and achieve your goals . Allow team feedback and diversity of thought as you plan these programs . I think it is important to align by design , meaning to intentionally design your programs and projects to be synergistic or additive , to combine stewardship and infection control , and to engage collaboratively with the frontline to help them also succeed in achieving desired patient outcomes .”
In his 2021 IDWeek presentation , “ Moving Forward and Back to Normal ,” Arjun Srinivasan , MD , assessed the elements of the former status quo of healthcare epidemiology and the ‘ new normal ” going forward after the pandemic .
“ When discussing the issue of moving back to normal , it ’ s important to consider what was normal before COVID . There is no doubt that we were seeing successes in our efforts to reduce healthcare-associated infections ( HAIs ), reduce antibiotic resistance , and reduce inappropriate antibiotic use ; however , those successes were not uniform in distribution . The U . S . has done extremely well at reducing HAIs ; however , in 2019 , 9 percent of hospitals had a standardized infection ratio that was significantly higher than the national standardized infection ratio , so not every hospital was seeing the same success in reducing central line-associated bloodstream infections . In 2015 , we were doing reasonably well in making progress toward implementing antibiotic stewardship programs , but again , that progress was not uniform .”
Srinivasan pointed to a graph depicting the percentage of U . S . acute-care hospitals ( n = 4,569 ) responding to the NHSN survey that met all seven of the CDC ’ s Core Elements for Hospital Antibiotic Stewardship Programs ( ASPs ). “ Twenty-six percent of critical-access hospitals had an antibiotic stewardship program that had all seven of the CDC ’ s core elements for hospital ASPs , compared to 66 percent of hospitals with more than 200 beds . So , clearly , we were not doing well across the board with stewardship programs .”
Srinivasan continued , “ The same holds true for community antibiotic prescription rates from outpatient pharmacies . There is 100 percent difference between the lowest state and the highest state , so not all of that low prescribing is necessarily good , and maybe not all that high prescribing is necessarily bad , but major variations argue for the fact that our success in improving antibiotic use in the community was not uniform across all geographic areas .”
It is important to align by design , meaning to intentionally design your programs and projects to be synergistic or additive , to combine stewardship and infection control , and to engage collaboratively with the frontline to help them also succeed in achieving desired patient outcomes .”
Srinivasan addressed disparities in the impacts of antibiotic resistance . “ Our successes in preventing resistance were not uniform ,” he said . “ We saw significant disparities based on socioeconomic factors , gender and race in several of the major resistant pathogens such as MRSA , ESBLs , C . difficile and Candida . We also saw that from 2005 to 2014 there were decreases in invasive hospital-onset healthcare-associated MRSA , however the rates in Black populations remain significantly higher than those in White populations , so normal success was not uniform success . We also saw that play out during the COVID-19 pandemic .”
Srinivasan pointed to studies demonstrating that nursing homes were operating in resource-constrained settings that have a very high percentage of Medicaid residents . “ Those nursing homes have lower quality and poorer scores on financial performance . During the pandemic those nursing homes that were disproportionately resource-constrained also suffered disproportionately among COVID-19 illness . The five-star nursing homes had lower rates of COVID across the board , so again we see that there were successes , but they were not uniform in distribution .”
He addressed workforce-related issues , noting that “ Nursing homes were understaffed even before COVID . A national survey of the registered nurse workforce from 2018 showed significant shortages , so these shortages in healthcare workforce were part of our ‘ normal ’ before COVID . Of course , those shortages exist when it comes to infection control and antibiotic stewardship as well . What happens when you don ’ t have enough healthcare staff , don ’ t have enough infection preventionists , don ’ t have enough healthcare epidemiologists ? They end up getting pulled away from all of the good work that they ’ re doing day-to-day . One survey showed almost 80 percent of respondents indicated that they were spending more than 75 percent of their time on COVID response . So , all the prevention work that they were doing previously had to be crammed into that remaining 25 percent of their time . A lot of that work simply ground to a halt . We saw the same thing happen in antibiotic stewardship programs . Data from the Michigan Hospital Medicine Collaborative showed the Impact of COVID on antibiotic stewardship efforts in 51 hospitals ; without exception , those stewardship efforts either somewhat decreased or strongly decreased during the pandemic .”
Srinivasan said that what was “ normal ” was not to the liking of most clinicians , in that infection and antibiotic stewardship surveillance data “ was not what we would like ,” and that most hospital HAI data required manual entry . Additionally , there was no information source for data on hospital capacity and resources , as well as limited data on hospital antibiotic use . “ Additionally , even before COVID under the normal circumstances , our infection prevention and stewardship gains were largely based on educational and behavioral interventions that were completely dependent on people remembering to do the right thing every time . Checklists have been a powerful tool for us , but they ’ re not