Pandemic Collateral Damage and the CLABSI Toll

Author: Deva Rea, MPH, BSN, BS, RN, CIC

Over the course of the COVID-19 pandemic, we’ve managed to learn quite a bit about the SARS-CoV-2 virus through a massive focus on data and research. Even though we’ve learned a substantial amount about the virus, there’s still so much we don’t understand about the tangential effects of pandemics. Only now are we starting to see some of the peripheral complications of dealing with a pandemic over a long period of time. One such negative outcome, an increase in healthcare associated infections (HAIs), was predicted early in the course of the pandemic. This forecast is now proving to be accurate.

An increase in CLABSIs:

Of all the HAIs, new evidence has shown that the pandemic has negatively impacted central line associated bloodstream infections (CLABSIs), quite considerably. One recent study looked at CLABSI & CAUTI outcomes reported into the Center for Disease Control’s (CDC) National Healthcare Safety Network (NHSN) from 78 hospitals of a large multi-state healthcare system. They found their CLABSI rates increased 51% (0.56 to 0.85 per 1,000 line-days; p<0.001).¹ The most substantial increase was in the intensive care units, where they observed a 71% increase in the CLABSI rate (0.68 to 1.16 per 1,000 line days; p<0.001).¹ Another study predicted CLABSI to be the most affected HAI due to the pandemic. They reported a 420% and 327% increase in CLABSI rates at hospitals located in New York City & St. Louis when compared to pre-pandemic CLABSI rates.² Another study out of Detroit found an overall 325% increase in their CLABSI rate during the pandemic.³ Even if they removed patients with COVID-19 from their analysis, they still saw an alarming 194% increase in CLABSI rates.³

Digging into the Why:

The glaring question of “why” there has been an uptick of CLABSIs during the COVID-19 pandemic has some interesting potential explanations. Let’s explore some of these details.

1. COVID-19 patients were very ill and more inclined to develop CLABSIs. As noted in one study, COVID-19 patients had a five times greater likelihood of developing a CLABSI vs. non-COVID-19 patients during the pandemic period.¹
2. COVID-19 patients required longer hospitalizations. The average CLABSI developed in patients approximately 18 days after their COVID-19 diagnosis.¹ Prolonged hospitalizations can increase the risk of CLABSI.
3. Many COVID-19 patients needed to be in the prone position for better oxygenation. This can lead to inadequate central line maintenance. A patient in the prone position is subjected to more “pulling, tugging and friction at central line insertion sites” along with “decreased visualization of the insertion site and other fluid buildup to compromise dressing integrity.”²
4. Overall, there was an increase in patient acuity. Along with seriously ill COVID-19 patients, there was an increase in the seriousness of general acutely ill patients due to lack of care sought due to the pandemic. These patients would also have increased lengths of stay.²
5. Critically ill patients also have an increased use of central venous access lines overall. Practitioners may have been more inclined to place central lines in the femoral vs. subclavian or internal jugular veins out of sense of safety, because the femoral site is away from the mouth and respiratory tract.²
6. Nursing and provider-related practice changes due to COVID-19 patients potentially led to an increase in CLABSI. To reduce exposure potential, more bundling of tasks was done and changes to routine care were made. These changes that affected traditional CLABSI prevention efforts included:
   1. Moving medication pumps and dialysis machines out of patient’s rooms into hallways. This could lead to tubing being on the floor, increasing contamination risk, and other infection prevention risks.¹ ²
   2. A reduction of time in patient’s rooms could cause more “cutting corners” and less adherence to good infection prevention standards, such as appropriate hand hygiene, tubing and vascular access site maintenance, and disinfection of needless access connectors (scrubbing the hub) prior to access of vascular devices.¹ ²
   3. There were reported increases in blood cultures being drawn from central lines. The increase also led to higher blood culture contamination rates with commensal organisms in patients with COVID-19. ¹ Additionally, gram-positive associated CLABSIs increased more than 80%, with coagulase-negative Staphylococcus associated CLABSIs leading the way and doubling in their number of CLABSIs.¹ An increase in blood culture contamination may also represent breaches in aseptic technique when obtaining the blood cultures.¹
   4. Broad spectrum antimicrobials were used in an increasing amount during the COVID-19 pandemic. A caveat to overuse of these antimicrobials and prolonged use of central lines was an increase in Candida species associated CLABSIs. ¹
   5. Universal decolonization including nasal and skin decolonization practices likely were not performed as frequently due to priorities shifting and the decreased amount of time in patients’ rooms. ¹
7. Staffing issues have also been a potential influencer on increases in CLABSIs. When there were patient surges and subsequent increases in patients needing critical care, staffing had to be adjusted to meet the demanding needs of these patients. Staff may have been pulled from a variety of areas with different levels of experience with central line care and maintenance. Some staff may have had minimal experience with central line practices which could have led to more lapses in proper maintenance. ²
8. Compliance with CLABSI prevention efforts by using “line rounds” suffered during the COVID-19 pandemic. Line rounds are essential to ensure things like proper device maintenance, selection, and utilization are being followed. Competing priorities depleted resources for line rounds as many staff members were pulled to focus on COVID-19 pandemic related duties. ¹
9. The Centers for Medicare & Medicaid Services (CMS) waived reporting requirements for HAIs through June 2020.² The Interim Final Rule made in August 2020 revealed that CMS would not use data submitted from January-June 2020 for performance calculations in their hospital quality reporting penalty and incentive programs.¹ With reporting being delayed or not required, it would be difficult for facilities to recognize if they were having CLABSI issues. This could have inadvertently taken a lack of focus off of CLABSIs, leading to diminishing prioritization and an unintentional increase in CLABSIs.
10. Investigating and “ruling out” CLABSIs also changed during the pandemic. “Ruling out” CLABSIs may have been hindered due to the inability to perform diagnostic testing (i.e. imaging) if it wasn’t deemed critical. The movements of COVID-19 patients were reduced to minimize exposures to COVID-19. However, diagnostic imaging would be important in supporting alternative HAI definitions and in ruling a CLABSI out as a secondary process.²
11. An overall increase in demands placed on the healthcare system in general, regardless of COVID-19 patients, led to an increase in CLABSIs.³

Next steps: What is important for us to do in order to get back on track in CLABSI prevention?

1. Get back to the basics— including good hand hygiene, line maintenance and care, selection of least risky line type, and discontinuation of the central line when no longer needed.
2. Monitor infections and perform root cause analysis on the CLABSIs as they occur.
3. Know your numbers! Monitor blood cultures and early signs of CLABSIs when feasible. Have processes in place that alert of potential CLABSIs.
4. Monitor compliance! Bring back routine line rounding and CLABSI prevention/ bundle compliance. Reevaluate processes, and give routine, real-time feedback to clinicians.
5. Utilize your vendors. Many vendors offer free services including assessments, education, and guidance to help facilities succeed in CLABSI reduction.

While many practices and processes changed due to COVID-19, there was a reported decrease in CLABSI in one study out of Singapore. They found their CLABSI rates decreased “substantially” during the pandemic.⁴ Their CLABSI rate pre-pandemic was 0.83 incidents per-1,000 device days, and it fell to 0.20 incidents per-1,000 device-days during the COVID-19 pandemic (statistically significant difference IRR = 0.24, 95% CI = 0.07-0.57, P < .05).⁴ How did they manage to see a decrease in their CLABSIs? They attributed the decrease to improved compliance to their CLABSI bundle, and associated consistent monitoring of bundle compliance.⁴ Additionally, they felt their increased compliance to hand hygiene, Standard Precautions, and use of personal protective equipment (PPE) also facilitated better CLABSI outcomes.⁴

The COVID-19 pandemic, while still ongoing, is far from a distant memory. And just as we deal with the aftermath of a natural disaster, we may spend months or years getting back to our pre-pandemic status once it finally subsides. Indeed it may take a great deal of time and resources to see CLABSI rates improve. But, with reprioritization and focus, we can decrease CLABSIs, and once again considerately improve patient outcomes.