As COVID-19 spread, the feds relaxed rules, and hospitals tried to contain the outbreak. Other infections may have risen
Jumps in infections at two hospitals in New York and St. Louis – up to five times higher – suggest they may have been right.
"Many facilities will take advantage of those waivers" because their infection prevention staff haven't been able to properly monitor patients for serious infections, Kathleen McMullen and her co-authors wrote in a commentary in the American Journal of Infection Control.
Controlling the spread of COVID-19 within hospitals, the authors wrote, took up most of infection prevention staffers' time.
Marian Hollingsworth, a San Diego-based patient safety advocate, said it's dangerous to relax regulatory oversight, especially during a pandemic. "I think they will know to get away with all kinds of things," Hollingsworth said.
The Centers for Medicare and Medicaid Services put a long list of hospital safety requirements, including nonemergency inspections, on hold during the public health emergency declared in March. The state of emergency was extended July 25, but hospitals had to start reporting infections as of June 30 unless they got waivers.
Some of the tactics used to control the spread of COVID-19, and staffing shortages exacerbated by the disease, may have played a role in the spread of infections, nurses and researchers said.
About 99,000 people die each year of infections they contract while hospitalized. Infection is one of the leading causes of preventable hospital deaths.
COVID-19 patients who already had weakened immune systems or developed them because of the virus can be more susceptible to bacterial infections, including deadly superbug infections that can't be treated with antibiotics, said infection control expert Lawrence Muscarella.
"Continuing to exercise proper infection control practices that prevent superbug infections in today’s health care settings is essential to public health," said Muscarella, who runs the blog Discussions in Infection Control and owns a Pennsylvania consulting company focused on health care safety.
Spikes in two types of infections at hospitals in New York, St. Louis
Hollingsworth has personal experience with patient safety. In 2018, her husband developed sepsis after surgery. Hollingsworth had seen a nurse put her unwashed hand on an incision after taking off her glove.
This week, her husband is having cancer surgery. She won't be allowed to be with him before surgery.
"I am told I can have 10 minutes with him after he gets out of surgery, so I hope it's in the room, so I can clean it," she said. "The first thing I'll do is put on gloves and get those super-duper industrial wipes and wipe the bed railings, the call buttons, anything he would touch in there."
The authors of the journal article compared infection rates of two hospitals during the COVID-19 pandemic with the previous 15 months.
Both facilities had increases in what are known as central line-associated bloodstream infections and catheter-associated urinary tract infections. Central lines are placed in veins to deliver medications; they're known to be paths for organisms that cause infections.
The hospitals – Mount Sinai Morningside in Manhattan and Christian Hospital and Northwest Healthcare in St. Louis – were identified in the article but not connected by name to the infection numbers.
Bloodstream infections increased by 420% at the facility identified as "Hospital A" and 327% at "Hospital B." Urinary tract infections rose by 179% at Hospital A and 57% at Hospital B.
Surgical site infections were expected to drop because of the cutback in elective surgeries, the article said. Both hospitals had decreases in infections of drug-resistant organisms such as C. difficile, which attacks the intestinal system.
The increases could be due to the fact that only the sickest patients went to hospitals when most of the country was ordered to stay home, the authors wrote. They could also be tied to the difficulty of keeping catheters in place when flipping intubated COVID-19 patients onto their stomachs, which is done to get more oxygen to the lungs.
Or, they wrote, the blame may lie with infection control personnel being diverted to prevent the spread of the coronavirus within hospitals.
The lack of regulatory oversight could play a role, Muscarella said.
The suspension of "certain nonemergency state survey inspections to focus more on COVID caused me to ask whether other safety issues, particularly the spread of superbugs, might not receive the needed attention, which could possibly contribute to an increased risk of infections," he said.
Patient says she wasn't bathed
In Asheville, North Carolina, Karen Ball was rushed to Mission Hospital on May 2 after a heart attack. She wound up having four surgeries and two heart catheterizations.
After she came home the second time, Ball developed a 103.8-degree fever and a swollen leg that the hospital said was probably gout. When milky white fluid was removed from her knee and tested, the diagnosis was "systemic infection post-catheterization."
Ball said that wasn't a surprise because she was never bathed or wiped down during her last stay from May 28 to June 4 – until she finally asked for soap and water and got wipes.
"I believe my infection was caused by the unsanitary conditions," Ball said. "I was not offered a bath … nor did I see anyone come in to mop the floors during any of my admissions.
"It really upsets me," she said, "to think a hospital doesn't take the precautions to keep their patients from getting infections after surgery."
Mission Health spokeswoman Nancy Tindell said bathing with antiseptic wipes is "typically done daily," but she couldn't comment on specific patients. She noted the hospital has a five-star rating from the Centers for Medicare and Medicaid Services.
The Leapfrog Group, which is more specific about infections, gave the hospital a B grade but ranked it below average for bloodstream, clostridium difficile (or c. diff.) and surgical site infections. It was ranked above average for urinary tract infections and antibiotic-resistant staph.
Were relaxed rules a 'godsend'?
In March, when Seema Verma, administrator of the Centers for Medicare and Medicaid Services, announced "regulatory flexibilities" during COVID-19, she said they "will be a godsend for those on the front lines of the fight against this new virus.”
Infections have to be reported every quarter. Hospitals that accept Medicare patients have to be inspected every three years.
Almost 157,000 people in the USA have died of COVID-19, many at hospitals.
Sorting out which may have had infections, including sepsis or other antibiotic-resistant superbugs, is difficult because COVID-19 is considered the cause of death for many people who die after testing positive for the disease, Muscarella said.
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Researchers at the hospital infection program at Virginia Commonwealth University Health System did an informal Twitter poll of people in the infection prevention and epidemiology communities in April and published the results in the journal Infection Control and Hospital Epidemiology.
Of 220 respondents, 79% said they spent more than three-quarters of their time on COVID-19. The impact on traditional infection surveillance and prevention is "concerning," the authors wrote.
Experts said stepped-up safety precautions for COVID-19, such as face shields, multiple masks, gowns and other protective clothing, may have reduced the spread of other infections.
There are downsides, too. Given the amount of protective equipment staff must wear to go into patients' rooms, nurses may enter less frequently to monitor patients, said Cindy Barnard, vice president of quality for Northwestern Memorial HealthCare, which has 10 hospitals in and around Chicago.
The authors of the Infection Control article raised that issue as well, saying nurses are asked to do several tasks on each visit to patients' rooms, so they can conserve protective equipment. That could cause nurses to rush through important tasks, they wrote.
"If an infection is not found early enough, it can lead to sepsis and even death," said Barbara Murray, a former nurse at St. Petersburg General Hospital in Florida. "That’s why you want to be around them, in case they are becoming lethargic, you can find what are sometimes subtle signs earlier."
Murray said she was fired in July after she raised concerns about what she thought was an unsafe nurse-to-patient ratio on her shift – seven patients to one nurse – and because of her support for a nurses union.
Tammy Robiconti, a spokeswoman for parent company HCA Healthcare, said St. Petersburg General Hospital brought in additional staff from outside the area, including nurses from the state and the Federal Emergency Management Agency. She did not comment on Murray's departure.
"We are grateful for our caregivers and the outstanding job they are doing as we continue to keep our hospitals open and safe," Robiconti said.
At the Northwestern hospital system, Barnard said all identified infections are investigated. Controlling infections for COVID-19 patients is harder, she said, because they're hospitalized for much longer than other patients. They are often too sick to be mobile, so catheters and other lines are in place longer.
"There is certainly a possibility people are being inattentive to basic infection control, but it's also possible we're seeing a lot of unknowns at once. … Just like with COVID-19, we are still learning," Barnard said. "It's possible we may need to integrate the basics with treatment in new ways."
How to prevent hospital infections
Will Overfelt's father died of cancer at Mission Hospital in February, before the coronavirus was a known threat in the USA. He said his father wasn't bathed at all during a two-week stay.
Overfelt started a Facebook group called Mission Maladies in March to see if others had similar experiences. He said he expected about 10 people to join; he's attracted 9,300.
Patients need to be repositioned every two hours to prevent ulcers on the skin, said physician Kevin Kavanagh, founder of patient advocacy group Health Watch USA. Doing so will show staff when patients have soiled their beds, he said.
Daily bathing is necessary to prevent hospital infections, given "the dangerous pathogens and compromised patients," Kavanagh said, but bathing takes so many workers that short-staffed facilities too often don't do it.
At Northside Hospital, another HCA hospital in St. Petersburg, nurse Tania Lamb said only one nurse was scheduled to work the entire 28-bed emergency department the night of July 27. Lamb, the National Nurses United representative for the hospital, worked Sunday night and said she saw the staffing sheets.
Debra Armstrong, the nurse on duty the night of July 27, said she had about six COVID-19 patients and three alerts of likely sepsis within an hour.
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"A lot of these patients are very susceptible to becoming septic," Armstrong said. "You're trying to keep these patients from becoming more ill and going into septic shock. With resources as thin as they are, how do you prioritize?"
Robiconti said Northside brought in additional staff.
Overfelt said his father's treatment would have been worse if he had been hospitalized a few weeks later, at the height of the first wave of COVID-19 cases.
His family was at the hospital nearly around the clock trying to make sure his father was bathed and got pain medication. Overfelt said he doesn't blame the nurses: "They can't do what they're being asked to do."
