• Impacts on Hospital Acquired Infection Rates due to the SARS-COV-2 Pandemic

    Charles Griffis, PhD, CRNA
    Chair, AANA Infection Control Advisory Panel

    The coronavirus pandemic has deeply affected the US healthcare system.1 This has included challenges with insurance coverage for COVID-19 care; deep racial and ethnic disparities in the effects of COVID-19 on populations; and tremendous financial losses to individuals and health care facilities.  One unexpected, and in some ways paradoxical effect, has been anecdotal reports of a potential rebound in the numbers of non-COVID-19 infections during the pandemic.2  The pandemic highlighted the importance of infection control and prevention measures and the increased focus on appropriate, albeit in low supply at times, personal protective equipment (PPE) for healthcare workers.  Therefore, one might expect that going forward, all infection rates would fall, and indeed, in some settings, this has been true, as reported by a team from Singapore.3 However, this has not proven to be universal.  Preliminary anecdotal data from several institutions for hospital-acquired infections (HAIs) such as central line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI) report opposite findings.2 

    Factors impacting the potential rise in HAIs:

    • The Centers for Medicare and Medicaid Services (CMS) waived reporting requirements and extended the recent submission deadline to allow focus on COVID-19 response and the reporting lag may play a role in HAI incidence.3,4
    • With the decrease in elective surgeries during pandemic surges, patients who are sicker will be the ones seeking care. Therefore, CLABSI cases will increase as these patients are more predisposed to infection. During surge periods, the infection rate likely increased, as the number of healthier, elective patients tended to decrease overall (e.g., the denominator in the equation).
      • Expect a similar effect (e.g., a census consisting of sicker patients who are more susceptible to infection) influencing the MRSA infection rate.
    • COVID-19 patients are more at risk for CLABSIs and CAUTIs than non-COVID-19 patients.5-7
    • Critically ill patients, such as those with COVID-19, are immunosuppressed, therefore may be more susceptible to infections.
      • Increased use of femoral vs. other central venous catheters may be used to avoid close proximity to airway secretions.
      • Increased insertion of temporary central venous access catheters for dialysis for COVID-related acute renal failure.
      • Reduced pressure to remove central lines in critically ill patients.
      • Increased desire to maintain central access for long periods to treat critical care needs.
      • Frequent prone positioning for pulmonary toilet may increase the risk of line contamination.
      • Care staff is encouraged to “batch” their care duties to avoid additional donning of short supply personal protective equipment (PPE), causing hurried and incomplete care measures.
        • Hand hygiene needs to be performed multiple times during “batched” care periods of limited patient contact.
      • Medication pumps and dialysis units placed out of patient care rooms to avoid contact with SARS-COV-2, necessitating long extension tubing which may wind up on the floor or be breached.
      • Inexperienced non-critical care float staff may be unfamiliar with best practice central line care measures.
    • CAUTI rates may increase due to hurried and incomplete preventive care, as well as the pulling and tugging of the urinary catheter during repeated prone positioning.
    • The pandemic also impacted surgical site infection (SSI) rates both positively and negatively due to:
      • Fewer elective surgical procedures during critical care admission surges, which may falsely depress actual SSI rates during pandemic surges.
      • Lower case volumes and reduced production pressure, which allows more time for SSI prevention measures and lowers risk overall.
      • Precautions such as the patient and care provider wearing surgical masks and the restriction of visitors also may have led to SSI risk reduction.8
    • Effect of a pandemic on other bacterial infections:
      • A decrease of diff and other multi-drug resistant organism infections may be noted due to emphasis on environmental cleaning and wearing of PPE including gowns and gloves at all times.2,9

    What can CRNAs do to keep HAI rates low during the pandemic?

    • Review and adhere to the recommendations in the AANA Infection Prevention and Control Guidelines for Anesthesia Care and Safe Injection Guidelines for Needle and Syringe Use.
    • Be mindful of commonly encountered situations in anesthesia care, many unrelated to the pandemic, which is associated with increased risk of disease transmission.
    • In addition to COVID-19-related infection prevention control measures, continue to practice hand hygiene and safe injection practices in all situations to prevent transmission of blood-borne pathogens.
    • Consult with infection preventionists in your work setting to review data to identify emerging risk factors and contribute to ongoing quality improvement activities and education.
    • Continue to monitor and report your own and the team’s infection control practices that may not meet facility or infection control expert-recommended infection control policy to develop and implement a plan for improvement.

    1. Blumenthal D, Fowler EJ, Abrams M, Collins SR. Covid-19 – Implications for the Health Care System. N Engl J Med. 2020;383(15):1483-1488.
    2. McMullen KM, Smith BA, Rebmann T. Impact of SARS-CoV-2 on hospital-acquired infection rates in the United States: Predictions and early results. Am J Infect Control. 2020;48(11):1409-1411.
    3. COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers Published 2020. Accessed Feb 15, 2021.
    4. Q3 2020 Data Submission Deadline Extension for Certain Medicare Quality Reporting and Value-Based Purchasing Programs. Published Dec 17, 2020. Accessed Feb 16, 2021.
    5. Diamond F. Study: CLABSI, CAUTI Rates Higher for COVID Patients. Infection Control Today. Published Oct 21, 2020. Accessed Feb 16, 2021.
    6. Knepper BC, Wallace K, Young H. CAUTI and CLABSI in Hospitalized COVID-19 Patients. Open Forum Infectious Diseases. 2020;7(Supplement_1):S178-S178.
    7. Buetti N, Ruckly S, de Montmollin E, et al. COVID-19 increased the risk of ICU-acquired bloodstream infections: a case-cohort study from the multicentric OUTCOMEREA network. Intensive Care Med. 2021;47(2):180-187.
    8. Losurdo P, Paiano L, Samardzic N, et al. Impact of lockdown for SARS-CoV-2 (COVID-19) on surgical site infection rates: a monocentric observational cohort study. Updates Surg. 2020;72(4):1263-1271.
    9. Wee LEI, Conceicao EP, Tan JY, et al. Unintended consequences of infection prevention and control measures during COVID-19 pandemic. Am J Infect Control. 2020.