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Cambridge University Press - PMC COVID-19 Collection logoLink to Cambridge University Press - PMC COVID-19 Collection
. 2021 Mar 15:1–4. doi: 10.1017/ice.2021.108

Impact of COVID-19 pandemic on central-line–associated bloodstream infections during the early months of 2020, National Healthcare Safety Network

Prachi R Patel 1,2,, Lindsey M Weiner-Lastinger 1, Margaret A Dudeck 1, Lucy V Fike 1, David T Kuhar 1, Jonathan R Edwards 1, Daniel Pollock 1, Andrea Benin 1
PMCID: PMC8047389  PMID: 33719981

Abstract

Data reported to the Centers for Disease Control and Prevention’s National Healthcare Safety Network (CDC NHSN) were analyzed to understand the potential impact of the COVID-19 pandemic on central-line–associated bloodstream infections (CLABSIs) in acute-care hospitals. Descriptive analysis of the standardized infection ratio (SIR) was conducted by location, location type, geographic area, and bed size.


The US Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN) is the nation’s surveillance system for healthcare-associated infections (HAIs). Hospitals and public health organizations track HAIs using the standardized infection ratio (SIR), and the Centers for Medicare and Medicaid Services (CMS) require submission of data on HAIs to the NHSN for payment programs such as the Hospital-Acquired Conditions Reporting Program (HACRP).1 From 2015 to 2019, there was a 31% decline in the national SIR for central-line–associated bloodstream infections (CLABSIs).2 However, in the face of the coronavirus disease 19 (COVID-19) pandemic, HAIs in hospitals may have increased.3,4 To understand the impact of the early months of the COVID-19 pandemic on CLABSIs nationally, SIRs for the second quarter of 2020 (2020 Q2: April, May, June) were compared to those from 2019 Q2.

Methods

Reporting on CLABSIs to the NHSN should occur in any inpatient location where data on central lines can be collected, including intensive care units (ICUs), specialty care areas (SCAs), neonatal intensive care units (NICUs), and wards.5 In this analysis, we included data as of January 1, 2021, from acute-care hospitals (ACHs) for 2019 Q2 and 2020 Q2. Only locations that had continuous and consistent reporting, defined as ACHs reporting all 3 months of CLABSI data for the same location in both 2019 Q2 and 2020 Q2, were included. SIRs were calculated by dividing the number of observed infections by the predicted number determined from the logistic regression model generated from national data during a baseline period.6 A mid-P exact test was preformed to compare the 2020 Q2 SIRs to the baseline of 1 and to the 2019 Q2 SIRs. Device utilization ratios were calculated by dividing central-line days by patient days. Regions were defined by the US Department of Health and Human Services (HHS).7

Our analysis was restricted to the units included in the CMS HACRP and location types that had at least 20 reporting locations nationwide.1 Because CMS suspended the HACRP reporting requirement for HAIs during 2020 Q2, the number of reporting hospitals in 2020 Q2 was compared to 2019 Q2.

The percentage change in the SIR was calculated as follows: [(SIR for 2020 Q2 – SIR for 2019 Q2)/SIR for 2019 Q2 × 100]. A mid-P exact test was performed to estimate the 95% confidence intervals around SIR percentage change values. The percentile distribution of 2020 Q2 SIRs included those facilities that had a denominator of the SIR (ie, number predicted CLABSI) >1. Percentile distributions are shown for strata with >20 facility-level SIRs.

Results

Our analysis included 13,136 inpatient units from 2,986 ACHs; 936 facilities had at least 1 predicted CLABSI and an SIR calculated. A 28% increase (95% CI, 20.0–33.6) was observed in the national SIR, from 0.68 in 2019 Q2 to 0.87 in 2020 Q2 (Table 1). Device utilization increased nationally from 0.21 in 2019 Q2 to 0.23 in 2020 Q2 (data not shown).

Table 1.

Preliminary National Central-Line–Associated Bloodstream Infection (CLABSI) Standardized Infection Ratios (SIRs) in US Acute-Care Hospitals During the Early Months of the COVID-19 Pandemic, April 2020–June 2020

Characteristic Reporting Hospitals in 2020 Q2a Total Reporting Hospitals in 2019 Q2b Observed CLABSI Predicted CLABSI Central- Line Days 2020 Q2 SIR 2019 Q2 SIR SIR % Changec 95% Confidence Interval for the SIR % Change Facility-Level Distribution of the Standardized Infection Ratio (SIR) for 2020 Q2d
10% 25% 50% 75% 90% 100%
All Hospitals 2,986 3,594 2,887 3,334.17 3,302,324 0.87e 0.68e 28.0f (20.0 to 33.6) 0.00 0.00 0.68 1.17 1.96 6.72
Location type
CC 2,513 3,070 1,911 1,836.02 1,707,981 1.04 0.75e 38.7f (29.2 to 48.5) 0.00 0.00 0.78 1.51 2.31 6.49
CC_ONC 19 21 10 10.93 10,706 0.91 1.08 −15.7 (−63.2 to 89.6)
NICU 812 1,035 162 305.93 219,115 0.53e 0.65e −18.5 (−33.4 to 0.5) 0.00 0.00 0.00 0.80 1.26 2.56
Wardg 2,852 3,478 804 1,181.29 1,364,522 0.68e 0.60e 13.3f (2.3 to 23.9) 0.00 0.00 0.51 0.99 1.81 7.89
Bed size
<100 beds 1,117 1,341 114 124.46 180,626 0.92 0.66e 39.4f (4.2 to 82.7)
100–199 beds 774 921 418 429.09 520,542 0.97 0.74e 31.1f (14.2 to 52.7) 0.00 0.00 0.77 1.56 2.42 6.24
200–299 beds 474 553 505 594.21 612,958 0.85 0.66e 28.8f (13.0 to 46.7) 0.00 0.00 0.62 1.08 2.01 6.72
300– 499 beds 426 536 820 1,030.37 956,115 0.80e 0.62e 29.0f (15.6 to 41.5) 0.00 0.00 0.64 1.20 1.99 4.76
500–699 beds 123 156 549 620.14 557,211 0.89 0.68e 30.9f (15.7 to 48.3) 0.14 0.39 0.73 1.11 1.74 4.31
>700 beds 72 88 481 535.91 474,872 0.90 0.80e 12.5 (−0.8 to 27.9) 0.30 0.50 0.85 1.14 1.70 2.17
HHS Region
1 - Upper Northeast 116 147 137 128.45 133,833 1.07 0.74e 44.6f (11.3 to 88.4) 0.00 0.00 0.92 1.19 2.72 4.48
2 - Middle Northeast 131 254 111 159.39 162,136 0.70e 0.67e 4.5 (−20.0 to 36.6) 0.00 0.00 0.42 1.31 1.86 3.46
3 - Lower Northeast 286 336 357 379.91 368,526 0.94 0.70e 34.3f (14.4 to 56.3) 0.00 0.00 0.70 1.14 1.99 3.83
4 - Southeast 694 786 660 802.99 786,484 0.82e 0.72e 13.9f (2.0 to 26.9) 0.00 0.12 0.65 1.07 1.89 6.72
5 - Great Lakes 460 576 498 525.58 514,927 0.95 0.71e 33.8f (16.7 to 51.7) 0.00 0.00 0.67 1.40 1.97 4.82
6 - South Central 494 597 366 442.18 442,148 0.83e 0.76e 9.2 (−6.2 to 25.4) 0.00 0.31 0.71 1.16 1.83 2.90
7 - Middle Plains 163 188 134 160.40 157,863 0.84e 0.68e 23.5 (−4.1 to 56.1) 0.00 0.00 0.75 1.11 1.91 2.62
8 - Northern Plains 135 143 107 107.02 106,249 1.00 0.62e 61.3f (19.9 to 121.2) 0.00 0.45 0.81 1.54 2.18 2.83
9 - West 400 454 434 508.19 505,247 0.85e 0.57e 49.1f (30.2 to 74.7) 0.00 0.00 0.63 1.20 2.28 4.64
10 - Northwest 105 112 82 119.25 123,656 0.69e 0.45e 53.3f (10.3 to 114.6) 0.00 0.00 0.61 1.17 1.90 2.70

Note. CC, critical care; CC_ONC, oncology critical care; NICU, neonatal intensive care units; HHS, Department of Health and Human Services.

a

Includes hospitals reporting three months of complete CLABSI surveillance data for the same location in both 2019 Q2 and 2020 Q2.

b

Includes all hospitals reporting 3 months of complete CLABSI surveillance data for 2019 Q2 (will be greater than consistent and continuous reporters).

c

Calculated as follows: [(SIR for 2020 Q2 – SIR for 2019 Q2)/SIR for 2019 Q2 × 100].

d

If there were <20 SIRs nationally, the distribution is displayed as missing.

e

Significantly different from 1; P < .05.

f

Significant difference between 2020 Q2 and 2019 Q2 SIRs; P < .05.

g

Includes the following location types: medical ward, medical surgical ward, pediatric medical surgical ward, pediatric medical ward, surgical ward, and pediatric surgical ward.

Critical care units had the greatest percentage increase (39%) in SIR, from 0.75 in 2019 to 1.04 in 2020. Ward locations experienced the second highest increase (13%). Critical care locations had the highest number of CLABSIs in 2020 Q2, with 1,911 events. Hospitals in all bed-size categories exhibited an increase in SIR.

In 2020 Q2, reporting of CLABSI surveillance dropped by 17% nationally, in contrast with 2019 Q2. The greatest decrease in reporting (48%) occurred in the Middle Northeast. Regional analysis showed significant percentage changes in the SIR from 2019 to 2020 in 7 regions: Upper Northeast, Lower Northeast, Southeast, Great Lakes, Northern Plains, West, and Northwest. The highest regional 2020 Q2 SIR was 1.07 and occurred in the Upper Northeast, representing a 45% increase compared to 2019 Q2.

Evaluating by ward type, pediatric medical-surgical wards contributed 4% of the national central-line days from ward locations in 2020 Q2 and had the greatest change in their SIR (118% increase) (Table 2). Statistically significant increases in the SIR also occurred in medical critical care (60%), medical-surgical critical care (59%), and neurosurgical critical care (108%). In addition, the device utilization ratio increased in pediatric medical-surgical wards from 0.14 (2019) to 0.18 (2020) (data not shown).

Table 2.

Preliminary National Central-Line–Associated Bloodstream Infection (CLABSI) Standardized Infection Ratios (SIRs) During the Early Months of the COVID-19 Pandemic, by Location Type, April 2020–June 2020

Location Type No. of Locations Observed CLABSI Predicted CLABSI Central-Line Days 2020 Q2 SIR 2019 Q2 SIR SIR % Changea 95% Confidence Interval for the SIR % Change Location Type distribution of the Standardized Infection Ratio (SIR) for 2020 Q2b
10% 25% 50% 75% 90% 100%
Critical care locations
Burn critical care 51 29 52.58 15,819 0.55c 0.44c 25.3 (−28.1 to 120.6) 0.00 0.00 0.10 0.96 1.42 2.44
Medical cardiac critical care 211 91 87.17 81,439 1.04 1.06 −1.1 (−26.0 to 32.3)
Surgical cardiothoracic critical care 341 116 193.66 180,522 0.60c 0.64c −6.3 (−26.9 to 20.0) 0.00 0.00 0.57 0.96 1.60 2.92
Pediatric surgical cardiothoracic critical care 44 40 68.48 43,248 0.58c 0.50c 16.0 (−26.7 to 84.20) 0.00 0.00 0.51 0.88 1.25 2.10
Medical critical care 584 397 274.19 263,176 1.45c 0.91 59.6d (35.9 to 87.7) 0.00 0.00 1.21 2.35 2.78 7.39
Medical-surgical critical care 2,076 885 727.37 774,905 1.22c 0.77c 58.9d (42.6 to 77.3) 0.00 0.00 0.93 1.80 3.35 5.21
Pediatric medical-surgical critical care 237 76 106.36 70,845 0.71c 0.66c 8.3 (−20.8 to 47.7) 0.00 0.19 0.78 1.06 1.87 2.96
Pediatric medical critical care 27 8 5.73 3,944 1.40 1.50 −6.9 (−66.3 to 156.8)
Neurologic critical care 73 21 28.58 26,628 0.73 0.73 0.4 (−46.4 to 88.7)
Neurosurgical critical care 157 62 67.29 61,448 0.92 0.44c 107.9d (34.5 to 226.8)
Surgical critical care 260 136 135.29 125,839 1.01 0.93 8.6 (−14.8 to 38.3) 0.00 0.00 0.81 1.20 1.96 3.56
Trauma critical care 126 48 85.99 57,473 0.56c 0.56c −0.5 (33.2 to 48.1) 0.00 0.00 0.35 0.93 1.74 2.84
NICU
Neonatal critical care (level II/III) 514 68 118.07 84,535 0.58c 0.66c −13.0 (−37.1 to 20.0) 0.00 0.00 0.00 0.94 1.45 2.56
Neonatal critical care (level III) 330 94 187.39 134,080 0.50c 0.63c −20.9 (−39.6 to 3.3) 0.00 0.00 0.00 0.80 1.13 1.96
Wards
Medical ward 2134 251 381.28 435,198 0.66c 0.64c 2.8 (−13.1 to 21.4)
Medical-surgical ward 3,985 346 512.83 619,386 0.67c 0.59c 14.3 (−1.3 to 32.5)
Pediatric medical-surgical ward 564 49 54.65 53,821 0.90 0.41c 117.6d (37.1 to 249.5)
Pediatric medical ward 180 19 22.89 21,839 0.83 0.75 10.2 (−40.4 to 101.9)
Surgical ward 1,168 134 202.84 228,044 0.66c 0.60c 10.6 (−12.6 to 40.1)
Pediatric surgical ward 30 5 6.80 6,234 0.74 0.76 −3.4 (−71.3 to 198.5)

Note. NICU, neonatal intensive care units.

a

Calculated as follows: [(SIR for 2020 Q2 – SIR for 2019 Q2)/SIR for 2019 Q2 × 100].

b

If there were <20 SIRs nationally, the distribution is displayed as missing.

c

Significantly different from 1; P < .05.

d

Significant difference between 2020 Q2 and 2019 Q2 SIRs; P < .05.

Discussion

The national SIR for CLABSIs increased significantly by 28% in 2020 Q2 versus 2019 Q2. During that same time, hospitals were faced with managing the emerging pandemic of COVID-19, which may have played a role in the increase. Infection control practices changed in many healthcare settings during the pandemic to accommodate increasing numbers of patients and to mitigate shortages of personal protective equipment, supplies, and staffing.4 Reducing the frequency of contacts with patients and of maintenance activities for central venous catheters (eg, chlorhexidine bathing, scrubbing the hub, site examinations) as well as alterations to processes of care (eg, risking disrupting catheter dressings when placing patients in a prone position) all have the potential to contribute to an increase in CLABSIs.4

Consistent with the concern that high-acuity care for patients with COVID-19 posed heightened challenges for preventing device-associated infections; CLABSIs in critical care locations occurred relatively frequently in the 2020 data. The number of CLABSIs in those locations exceeded CLABSIs in ward locations by 1,100 events for the quarter. In prior years, the number of CLABSIs identified in ward locations would typically exceed the number reported from ICUs.2 NHSN data do not enumerate the specific type of ICU location of patients with COVID-19, but among all ICUs, increases CLABSIs were highest in the medical-surgical critical care units. The significant 59% increase in the 2020 SIR highlights the likely burden that was placed on these units.

The reporting of data on CLABSIs decreased across all regions, with 609 fewer hospitals reporting in 2020 Q2. This drop in reporting may have affected the regional-level analyses because alterations in reporting may have occurred disproportionally in regions with more COVID-19 patients. In particular, even though New York and New Jersey experienced increased hospitalizations during this period, the Middle Northeast region did not demonstrate a significant increase in SIR, and this region had the largest decline in reporting of CLABSIs by 48%.8 In contrast, the Southeast region had only a 12% drop in reporting of data on CLABSIs to NHSN, and the analyses were able to discern an increase in CLABSI SIR against the backdrop of an increase in hospitalizations due to COVID-19 during June 2020.8

The analysis had several limitations. Results were restricted to locations for which data were consistently reported in both 2019 and 2020 Q2. New locations that may have been created in 2020 in response to patient surge due to the pandemic were not included because they were not present in 2019 for comparison analysis. Restricting the analyses to those units required by CMS HACRP may have excluded other units that were used by hospitals for COVID-19 patients (eg, pulmonary wards).

These findings highlight a substantial increase in CLABSIs in hospitals throughout the United States coinciding with the COVID-19 pandemic. The results of this analysis can be used to understand the increase in HAI burden being placed on the nation’s healthcare system and to prioritize ongoing efforts to prevent infections and to drive patient safety.

Acknowledgments

The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the US Centers for Disease Control and Prevention.

Financial support

No financial support was provided relevant to this article.

Conflicts of interest

All authors report no conflicts of interest relevant to this article.

References


Articles from Infection Control and Hospital Epidemiology are provided here courtesy of Cambridge University Press

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