Study shows outsized COVID impact on community hospitals

Intubation equipment and hospital patient
Intubation equipment and hospital patient

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A new analysis of healthcare-associated infections (HAIs) at hospitals in the southeastern United States highlights some of the downstream healthcare impacts of COVID-19.

The study, published this week in Clinical Infectious Diseases by a team of researchers from Duke University and the University of North Carolina, found that rates of central line-associated bloodstream infections (CLABSIs), ventilator-associated events (VAEs), and Clostridioides difficile infection (CDI) at hospitals in six southeastern states rose significantly during the pandemic compared with previous years. But the impact was most keenly felt in smaller community hospitals.

"During the pandemic, the volume and acuity of COVID-19 cases quickly overwhelmed the very limited resources in community hospitals in these areas," the study authors wrote.

The findings aren't surprising, since previous studies have documented the uptick in HAIs seen in US hospitals during the first year of the pandemic. Those increases, which followed years of HAI declines at US hospitals, were mainly the result of overwhelmed, short-staffed hospitals dealing with a crush of severely ill patients and having fewer resources to devote to infection prevention and control and patient safety.

This is the first study, however, to address how small, rural hospitals with fewer resources were affected by the pandemic.

Community hospitals struggled

To evaluate the impact of COVID-19 on HAI incidence and trends in different-size hospitals, the researchers analyzed data on hospital-level incidence rates (IR) from two large academic medical centers—Duke University Hospital and the University of North Carolina Medical Center—and 51 community hospitals belonging to the Duke Infection Control Outreach Network (DICON), which includes hospitals in North Carolina, South Carolina, Virginia, West Virginia, Georgia, and Florida.

In addition to CLABSIs, VAEs, and CDI, the researchers also looked at catheter-associated urinary tract infections (CAUTIs). The study included a baseline period from January 2018 through February 2020, and the pandemic period was divided into three phases to match COVID-19 surge patterns: Pandemic Phase 1 (March through June 2020), Pandemic Phase 2 (July through October 2020), and Pandemic Phase 3 (November 2020 through March 2021).

Thirty-nine of the community hospitals were considered small (fewer than 250 beds) and 12 were medium (250 to 424 beds) and large (more than 425 beds).

Compared with the baseline period, CLABSI and VAE IRs increased by 24% (95% confidence interval [CI], 1.2% to 54.1%) and 34% (95% CI, 7% to 67.8%), respectively, across all 53 hospitals at the start of the pandemic period. CDI IR increased by 4.2% per month compared with the baseline, but CAUTI IR did not change.

When the researchers stratified the analysis by hospital type, the results showed that CLABSI and VAE IRs rose by 48% and 41.1%, respectively, in the community hospitals at the start of the pandemic period but did not change significantly at the academic medical centers. CDI rates at the community hospitals rose by 4.5% per month at the start of the pandemic period, while dropping 43% at the academic medical centers.

Further analysis stratified by hospital size showed that CLABSI IR increased by 82.1% across small hospitals at the start of the pandemic and 6.3% per month at medium hospitals, and VAE IR increased by 48.7% and 104% at small and medium hospitals, respectively. At large hospitals, CLABSI and VAE rates remained relatively stable. CDI increased by 4.5% per month at small hospitals and 12.5% per month at medium hospitals, but declined by 27% at large hospitals.

These disparities were likely the result of a combination of factors, the authors say. Most small community hospitals don't have an infectious disease (ID) specialist on staff. Changes in workflow during the pandemic, and higher levels of care required for COVID-19 patients, may have led to lapses in protocols for insertion, maintenance, and removal of central lines, ventilators, and other invasive devices. Repeated COVID-19 surges led to staff resignations. And to cover for staff shortages, hospitals had to reassign infection prevention and antibiotic stewardship staff to cover other critical areas.

"Despite access to remote infection prevention expertise through DICON, these community hospitals struggled to manage complex COVID-19 patients, to advocate for resources, staff, and infrastructure, and retain focus on patient safety in the absence of an onsite ID physician champion," the authors wrote.

In addition, they noted, smaller community hospitals tend to be located in rural areas and primarily serve an uninsured older population that includes patients with several comorbidities who may be more prone to infections. And many of these hospitals were struggling with limited resources and staffing shortages long before the pandemic hit.        

Strengthening the ID workforce

The authors say that future efforts should focus on better understanding the staffing and resource shortages faced by community hospitals, which serve nearly two thirds of all Americans, and exploring potential partnerships with larger healthcare systems and government entities.

One possibility that has shown promise in previous studies is using telehealth to provide remote ID services and expertise to community hospitals that lack an ID specialist on staff.

But ultimately, the nation's ID workforce needs to be reinforced, they argue.

"A national plan is needed to strengthen ID workforce in community hospitals to cope with increased complexity of patients," they wrote. "In order to prevent ongoing HAI escalations, health care facilities must invest resources in staff retention and wellbeing, and focus on 'recruiting, training, and retaining' our ID workforce."

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