A Reset for Infection Prevention Protocols

Infection prevention took a hit this past year, but rebuilding is already taking place

Is it fair for Medicare to penalize the bottom 25% of hospitals because of patient infections or other avoidable medical complications? Fair or not, in February, the Centers for Medicare & Medicaid Services did just that, announcing that 774 hospitals would lose 1% of their Medicare payments over the next 12 months (based on pre-COVID performance, from mid-2017 to 2019.) It’s part of Medicare’s Hospital Acquired Condition Reduction Program.

The American Hospital Association believes the six-year-old program is flawed, for a number of reasons: Some quality measures are inaccurate, and the program fails to take into account patient safety improvements that hospitals have made, says AHA. What’s more, it unfairly penalizes teaching hospitals, large hospitals and small hospitals.

Even the Medicare Payment Advisory Commission, which provides the U.S. Congress with analysis and policy advice on the Medicare program, has criticized the so-called “tournament model” penalty system, in which providers are scored relative to one another, “despite the potential availability of clear, absolute and prospectively set performance criteria.”

The HAC Reduction program is just one of several government programs that are intended to reduce healthcare-associated infections. Others include the National Action Plan to Prevent Health Care Associated Infections, the Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Antibiotic Use, and CDC’s U.S. National Action Plan for Combating Antibiotic-Resistant Bacteria.

Do we need so many programs to monitor and (it is hoped) reduce healthcare-acquired infections? Do they work? And even if they did, how has COVID-19 affected them?

“Each of these programs provides a framework for the infection control and epidemiology communities in hospitals and other settings,” says Lynne Batshon, director of policy and practice for the Society for Healthcare Epidemiology of America (SHEA). “Adoption of new measures is a key component toward progress, [but] the measures have to be the right measures, they must be reliable, and they must be properly risk-adjusted.”

Progress

The CDC’s 2019 National and State Healthcare-Associated Infections Progress Report offers some evidence of progress. At the national level, acute care hospitals achieved:

  • About 7% decrease in central-line-associated bloodstream infections (CLABSIs) between 2018 and 2019. (Largest decrease: 13% in NICUs.)
  • About 8% decrease in catheter-associated urinary tract infections (CAUTIs) between 2018 and 2019. (Largest decrease in ICUs: 12%.)
  • A 2% increase in ventilator-associated events (VAEs) between 2018 and 2019. (Increase observed in ICUs.)
  • No significant change in hospital onset Methicillin-resistant Staphylococcus aureus (MRSA) bacteremias between 2018 and 2019.
  • About 18% decrease in hospital onset C. difficile infections between 2018 and 2019.

In addition, a study published in February 2021 found that hospitals using the AHRQ Safety Program for Improving Antibiotic Use decreased usage of antibiotics and reduced C. difficile infections, a potentially deadly condition of the colon and digestive system. More than 150 million antibiotic prescriptions are written annually in the United States, according to AHRQ. If antibiotics are overused, they can become less powerful over time as some bacteria grow resistant. (The Centers for Disease Control and Prevention estimates that at least 2.8 million infections and 35,000 deaths a year are caused by antibiotic-resistant bacteria in the United States.)

The COVID impact

Perhaps not surprisingly, COVID has had a dramatic impact on providers’ ability to prevent healthcare-associated infections, says Batshon. Particularly in facilities and locales that experienced surges in the coronavirus, professionals who had been responsible for overseeing infection prevention protocols had to turn their attention to caring for COVID-19-positive patients. “We learned that without sustained infection prevention programs, even in places where programs had been effective, quite frankly, you’re going to see slippage,” she says. In addition:

  • Some hospitals had to staff provisional ICU units with people who weren’t familiar with the ICU or its infection prevention protocols.
  • Staff were overworked, exhausted, and forced to care for more patients than they normally would.
  • Many hospitals experienced shortages of personal protective equipment.

The COVID-19 pandemic has required hospitals to take unprecedented measures to maintain continuity of patient care and protect healthcare personnel from infection, the CDC noted in December. Yet “[t]his outbreak highlights that multidrug-resistant organisms can spread rapidly in hospitals experiencing surges in COVID-19 cases and cause serious infections in this setting.”

“What I’m hearing from experts is that a lot of ground was lost since 2020, when a lot of energy was directed toward patient safety,” says Batshon. “And this won’t be our last healthcare crisis. Healthcare systems need to be prepared to maintain and sustain their existing infection prevention programs and techniques.”

In December 2020, SHEA joined the Association for Professionals in Infection Control and Epidemiology and the Society for Infectious Diseases Pharmacists in requesting that CMS refrain from using 2020 quality data for the HAC Reduction Program for payment determination. In a letter to the deputy secretary of the Department of Health and Human Services, representatives from the three organizations wrote, “As the number of COVID-19 cases surge, hospitals are becoming overwhelmed with more patients than can be managed with typical care standards. Requiring reporting and enforcing penalties on hospitals related to quality measures during the pandemic will only shift critical resources to non-essential surveillance activities and result in reduction of resources and funding available to support necessary patient care and staffing.”

A CMS spokesperson told The Journal of Healthcare Contracting that CMS will make an announcement on the HAC Reduction Program for the fiscal year 2022 program year later this year.

COVID collides with safe protocols

In a case report, CDC researchers and the New Jersey Department of Health described an outbreak of carbapenem-resistant Acinetobacter baumannii (CRAB) at an unnamed New Jersey hospital, which affected 34 patients and was linked to 10 deaths. Investigation of the outbreak, which occurred during a COVID-19 surge that lasted from March through June 2020, found that pandemic-related resource challenges severely limited the hospital’s infection prevention and control policies:

  • To conserve equipment during the surge, the hospital’s respiratory therapy unit instituted a policy to extend the use of ventilator circuits and suctioning catheters for individual patients, replacing them only if they were visibly soiled or malfunctioning. (Prior to March 2020, ventilator circuits and suctioning catheters were changed at specified intervals of every 14 days and every three days, respectively, unless malfunctioning or visibly soiled.)
  • To conserve PPE, gown use was suspended for care of patients with vancomycin-resistant Enterococcus spp. and MRSA.
  • Anticipating shortages, the hospital adopted an extended-use PPE protocol for N95 respirators and face shields.
  • To prioritize personnel resources, activities of the multidrug-resistant-organisms (MDRO) workgroup were suspended, along with biweekly bedside central venous catheter and indwelling urinary catheter maintenance rounds.
  • Routine audits of appropriate PPE use, hand hygiene compliance, and environmental cleaning were temporarily discontinued.
  • Responding to COVID-19-related care needs also resulted in unintentional changes in standard practices, including less frequent patient bathing with chlorhexidine gluconate and a 43% reduction in ICU CRAB screening tests.

Counting the cost of infections

According to a CDC report, more than 2.8 million antibiotic-resistant infections occur in the U.S. each year, and more than 35,000 people die as a result. In addition, 223,900 cases of Clostridioides difficile occurred in 2017 and at least 12,800 people died.

Additionally, according to a collaborative CDC study, the estimated national cost to treat infections caused by six multidrug-resistant germs identified in the report and frequently found in health care can be substantial – more than $4.6 billion annually.

“Dedicated prevention and infection control efforts in the U.S. reduced deaths from antibiotic-resistant infections by 18% overall and by nearly 30% in hospitals. However, the number of people facing antibiotic resistance is still too high,” the CDC said. “More action is needed to fully protect people.”