Last month, a 46-year-old military veteran in Houston died of pancreatitis, an urgent but treatable condition, while waiting to be admitted to a hospital overwhelmed with unvaccinated Covid patients. Last week, the governor of Hawaii signed an executive order releasing the state’s hospitals from liability if they turn away sick patients because they have no room. On Monday, the Idaho state health department declared “crisis standards of care,” a triage system that allows hospitals with no spare beds to decide which patients they will accept.
Simultaneously, a Florida high school teacher went viral after describing how he took his 12-year-old to an emergency room that turned out to be overwhelmed with Covid patients. The child’s ruptured appendix, which could have been life-threatening, forced them to wait six hours. After five days at the hospital and a $5,000 initial bill, his son was able to survive.
Patients who couldn’t get to hospitals, stuck in waiting rooms or lingering on ambulances and life-flighted elsewhere where they might have an open bed, are all stories that this summer has been awful. Their health is at risk from overcrowding. Overcrowding poses an even more serious threat to patients already in hospital. It makes it difficult for staff to perform their duties and creates the conditions that enable dangerous infections to spread.
A new study based upon infection statistics in hospitals which faced the Covid outbreaks in 2020 has shown how serious that threat really is. The Centers for Disease Control and Prevention published a report last week in Infection Control and Hospital Epidemiology. It found that hospitals have lost years of their progress in controlling hospital infections. In 2020, according to a federal registry that collects data from thousands of hospitals, urgent care centers, and outpatient facilities, there were sharp, consistent increases in bloodstream and urinary tract infections related to catheters and pneumonias caused by being put on ventilators–including infections caused by drug-resistant staph, better known as MRSA.
Health-care-associated infections, as they’re known, arise from a collision of factors. When patients are exposed to infection due to severe illness, such as a serious illness that weakens the immune system or when they have to stay in ICUs with other people who are sick, it can make them more vulnerable. Unwittingly, health care workers can transmit pathogens between patients. Lifesaving equipment like breathing tubes and catheters can allow these pathogens into the body.
These infections can be fatal and they are a serious consequence of hospitalization, particularly in the intensive care unit. Citizen advocates discovered that nearly one-in-20 patients contracted one of these infections each year in the 2000s. This led to more than 1,000,000 unnecessary deaths and illnesses annually, and cost the federal reimbursement system and health care billions in excessive spending. Their pressure on state legislatures and Congress led to mandatory reporting laws and a national action plan, created in 2013, which forced health care providers to work on reducing the conditions–staff behavior, treatment algorithms, equipment types–that let infections occur. There was real progress. The rates of some of the most deadly and common ones have declined since 2015 including ventilator-related pneumonias and catheter-related infections.
Covid was the only thing that existed up to this point. Pandemic caused a flood of critically ill patients to seek lifesaving equipment in ICUs. These overworked healthcare workers were deprived of proper protective equipment, resulting in hospital infections that can rise. According to the CDC catheter-related bloodstream infection (CLABSIs) rose by 47 percent between the ends of 2019 and 2020. Ventilator-associated pneumonias and other infections rose 44.8 percent. The 18.8 percent increase in catheter-related infections of the urinary tract was a surprise.
This news is shocking, but it’s not unexpected to those who have watched patients flood hospitals. In 2020 there weren’t any vaccines or effective treatments. And in 2021 vaccines were being rejected. “We really had a perfect storm when it comes to health-care-associated infections and Covid,” says Arjun Srinivasan, a physician and associate director of the CDC’s program for preventing those infections.
During the first waves, he points out, the patients most likely to come into hospitals with severe Covid were older, with chronic illnesses, possibly immunocompromised–and as a result, more likely to end up in an ICU and need ventilation tubes to take over breathing and ports into their bloodstreams to deliver medications. Because there were so many patients, the health workers had to be stretched thinner, which meant they could not complete preventive tasks. With such a limited supply of PPE, it was more likely that patients would unknowingly carry pathogens. Srinivasan explains, “So while you have more patients that you ever have before, you also have less staff than would be normal to care for them.” The reason why normal systems of care delivery fail is because there’s too many people who need it and not enough providers.
Last year, there was a skeptic that such a thing might occur. In the American Journal of Infection Control, New York-based researchers and St. Louis scientists predicted that Covid would lead to fewer people needing hospitalizations. The team predicted that this would result in an increase of patients suffering from severe illnesses who will need to have hospital infections treated. They based that prediction on early signals from their own institutions: In the first three months of the US pandemic, central-line-associated bloodstream infections rose by 420 percent in one hospital and 327 percent in another, compared to the previous 15 months.
Kathleen McMullen is the senior manager for infection prevention at Northwest Healthcare and Christian Hospital in St. Louis, as well as the first author of the study. We heard from colleagues across the country that they had also been affected by it and decided to share our findings.
They also predicted that certain types of infection, like those that can be caught in incisions during surgery, would decrease as elective procedures were delayed. They were right. According to the CDC, only surgical-site infections after colon surgery (or hysterectomy) saw a decline in hospital infection rates last year. This is not true for laparoscopy or open incisions. The pernicious and dangerous intestinal infection, difficile.
McMullen said that all of this made sense given the circumstances hospitals faced in the first wave. “There was so many patients and not many health workers and so much fear–of being uncomfortable, of wanting in and out quickly of patient’s rooms.
McMullen, her coworkers and McMullen predicted that the CDC data they uncovered was consistent with what McMullen had observed. But she says it may actually underrepresent hospital infections across the country, because the labor of caring for patients in that first wave was so intense that the federal Center for Medicare and Medicaid Services allowed hospitals to suspend mandatory reporting between April and June.
The CDC data contains a particularly alarming sign. One of the infections that spiked, rising by a third between the end of 2019 and the end of last year, was bacteremia–dissemination of infectious bacteria throughout the bloodstream, which can lead to sepsis and septic shock–caused by MRSA. Because it was one of the CMS-required infections, this was the only drug resistant infection that they had. MRSA, and other staph bacteria can live on skin so incisions or catheters are possible to inject the bacteria into the body.
MRSA isn’t just a drug-resistant disease that healthcare workers are concerned about. At the start of the pandemic, researchers worried that empiric use of antibiotics–given on a presumption of what’s wrong, rather than a lab test–was increasing, a hedge against the possibility that Covid patients might develop bacterial pneumonias while on ventilators or in ICUs. Although antibiotics are not used to treat Covid, their presence might make it more difficult for other bacteria to grow resistance.
Those concerns have now been backed up by data. The Pew Charitable Trusts reported in March, based on a database of 6,000 admission records, that more than half of patients hospitalized in the first months of the pandemic received at least one antibiotic; a third received multiple prescriptions. Nearly all, 96%, of those hospitalized in the first months experienced their first antibiotic quicker than any lab tests could complete. This reinforces concerns about whether prescriptions are unnecessary and empiric. Simultaneously, the rise in telehealth, which can also enable empiric prescribing, led to higher numbers of outpatient prescriptions.
In hospitals, however, there was an increase in drug-resistant infections. Srinivasan presented to a federal panel that winter. He stated that 20 cases of Covid-related outbreaks were investigated by the CDC between February 2020 and February 2021. These included the New Jersey outbreak of Acinetobacter Baumanii and Florida’s Candida auris, both of which had developed resistance to last-resort medications.
These investigations and data reported by the CDC last week predate the rise in the Delta variant. The case rate in some areas of the US is higher than at any time during the pandemic. Even with the replenishment of protective PPE, there is still intense pressure on the healthcare system. The crowding at ICUs combined with the emotional trauma from the fourth wave has created conditions that allow for hospital infections to continue spreading.
Cornelius J. Clancy is a University of Pittsburgh hospital doctor and an associate professor of medicine. “The strain has been insidious.” For 18 months, health care workers have worked full-time. The staffing situation is dire. The people are tired. We’re now moving to what is normally the busiest season in a hospital.
It may be that the panacea for hospital infections and the burgeoning resistance to antibiotics is the same thing as it was to combat the pandemic. There will be fewer seriously ill patients in intensive care and a lower number of staff members who are overworked.
Srinivasan states that “we have to concentrate on getting people vaccinated” because this will prevent them from going to the hospital. Although we wouldn’t normally think of the Covid vaccine being a preventative measure against infection, it is one of our most valuable tools right now.
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Publited Fri, 10 Sep 2021 at 11:23:51 +0000