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COVID-19 and HAIs · The SHEA Podcast

• 0:08
  SPEAKER_02: Welcome to the Rapid Response Podcast brought to you by the Society for Healthcare Epidemiology of America, SHA, promoting the prevention of healthcare associative infections and antibiotic resistance and seeking to advance the field of healthcare epidemiology and antibiotic stewardship.
• 0:23
  SPEAKER_02: I'm Dr.
• 0:24
  SPEAKER_02: Jessica Howard Anderson, Assistant Professor of Medicine in the Division of Infectious Diseases at Emory University School of Medicine and the Associate Hospital Epidemiologist at Emory University Hospital Midtown, and I will serve as your moderator.
• 0:37
  SPEAKER_02: The discussion on the podcast does not reflect Shay's perspective, but facilitates communication of multiple perspectives and experiences as we go through this challenging time together.
• 0:46
  SPEAKER_02: Shay is excited to launch this episode of the podcast, COVID-19 updates what we know now.
• 0:52
  SPEAKER_02: Today's discussion will focus on COVID-19 and healthcare associated infections, or HAIs.
• 0:57
  SPEAKER_02: Our speakers today are Dr.
• 0:58
  SPEAKER_02: Mohamed Fakih, Chief Quality Officer at Ascension, and Lisa Sturm, Senior Director of Infection Prevention at Essencion.
• 1:06
  SPEAKER_02: Thank you both for joining us today.
• 1:08
  SPEAKER_02: Before we get started, I'd like to turn it over to Dr.
• 1:10
  SPEAKER_02: Chris Crinch for a brief news and guidance update for the week.
• 1:14
  SPEAKER_00: Thank you, Dr.
• 1:14
  SPEAKER_00: Howard Anderson.
• 1:15
  SPEAKER_00: As of September 29th, there were a total of 233 million cases of COVID-19 and 4.8 million COVID-19 related deaths reported worldwide.
• 1:26
  SPEAKER_00: In the United States, there have been 43.2 million cases and 693,000 COVID-19 related deaths reported to date.
• 1:34
  SPEAKER_00: On a more optimistic front, the CDC's COVID data tractor shows the seven-day average of COVID-19 cases, hospitalizations and deaths appear to be on the decline.
• 1:43
  SPEAKER_00: In the past week, daily COVID-19 cases have declined by 30% compared to a peak on September 1st, and COVID-19 related hospitalizations and deaths have dropped approximately 15 and 9%, respectively.
• 1:55
  SPEAKER_00: The big news since our last podcast episode was the FDA amended the emergency use authorization for the Pfizer Biointech vaccine on September 22nd to allow use of a single booster dose for persons who have previously received the Pfizer Biointect MRM Day vaccine are at least six months beyond completion of the initial two-dose vaccine series and either older than 65 or age 18 to 64 with certain medical conditions that elevate the risk of developing severe COVID-19 or are employed in an occupation that elevates the risk of being exposed to COVID-19.
• 2:28
  SPEAKER_00: Well, the vote by the CDC Advisory Committee on Immunization Practices to recommend a booster to 18 to 64 year olds with occupational exposures did not pass.
• 2:37
  SPEAKER_00: CDC Director Rochelle Wolinsky overruled the committee's vote, stating this was a decision about providing rather than withholding access.
• 2:44
  SPEAKER_00: And she further stated many of these workers are already living in communities hardest hit by COVID-19.
• 2:49
  SPEAKER_00: The most direct evidence supporting the benefits of a booster vaccine can be found in an Israeli study published in the New England Journal of Medicine on September 15th.
• 2:57
  SPEAKER_00: In this study of nearly 1 million persons over the age of 60, the risk of breakthrough infections was 11 times less likely, and the risk of developing a severe illness as a result of a breakthrough infection were nearly 20 times less likely among individuals who received a booster dose of the Pfizer Biointech mRNA vaccine as compared to previously vaccinated age-matched individuals who did not receive a booster vaccination.
• 3:20
  SPEAKER_00: In other news, a study published this week in the International Journal of Epidemiology by a research team at the University of Oxford found that life expectancy at birth dropped in 27 of 29 studied countries.
• 3:31
  SPEAKER_00: A loss of greater than one year of life expectancy among females was documented in eight countries and in males in 11 countries respectively.
• 3:39
  SPEAKER_00: The United States, Lithuania, Bulgaria, and Poland were the countries with the largest decline in life expectancy among females, and the United States and Spain were the countries with the largest decline in life expectancy among males.
• 3:51
  SPEAKER_00: The authors of this study noted that this magnitude of life expectancy decline has not been observed since World War II and has wiped out five years of progress in the countries included in the study.
• 4:01
  SPEAKER_00: More positively, a cohort study published in JAM on September 24th found that nearly one-third of persons who initially endorsed vaccine to hesitancy during a baseline period from August to December of 2020 reported receiving the vaccine during the follow-up period from March to April of 2021, and an additional third had transitioned from being vaccine hesitant to vaccine willing.
• 4:22
  SPEAKER_00: Consistent with other studies, higher levels of vaccine hesitancy and stability, in this opinion, were reported among those with lower levels of education.
• 4:30
  SPEAKER_00: While Hispanic participants demonstrated similar levels of vaccine hesitancy and changes over time as compared to non-Hispanics, these individuals were significantly less likely to be vaccinated at follow-up, suggesting that access inequalities may be at play here.
• 4:44
  SPEAKER_00: Findings from an open label, cluster randomized controlled trial, published in Lancet on September 14th demonstrates that using a test-to-stay approach was not inferior to a mandatory quarantine approach of close contacts in secondary schools in the United Kingdom.
• 4:59
  SPEAKER_00: In this study, close contacts of individuals diagnosed with COVID-19 and intervention schools underwent daily testing using a lateral flow device, and individuals with negative results were allowed to remain in school.
• 5:10
  SPEAKER_00: Close contacts and control schools underwent a mandatory 10-day home quarantine before being allowed to return to school.
• 5:16
  SPEAKER_00: Despite a rather meager participation rate in intervention schools of only 42%, rates of post-exposure PCR-positive cases were similar in intervention and control schools.
• 5:26
  SPEAKER_00: While the frequency of COVID-19 absences were not significantly different between the two study arms, there was a trend towards reduced absences in the intervention arm of the study.
• 5:35
  SPEAKER_00: These data, coupled with findings from previously published modeling studies, suggest that test to state protocols may play an important role in minimizing post-exposure absences in other settings, including healthcare facilities.
• 5:47
  SPEAKER_00: Finally, Pfizer and BioNTech have submitted data from their phase three studies in children ages 5 to 11 as part of an emergency youth authorization application in this age group.
• 5:57
  SPEAKER_00: Studies using a reduced mRNA concentration as compared to the product authorized for persons over the age of 12 and 2,200 children appear to demonstrate favorable safety and efficacy.
• 6:07
  SPEAKER_00: It is expected the FDA will take up review of the application in the coming weeks.
• 6:11
  SPEAKER_00: And this concludes our weekly news updates.
• 6:14
  SPEAKER_00: Back to you, Dr.
• 6:15
  SPEAKER_00: Howard Anderson.
• 6:16
  SPEAKER_02: Thank you so much for those news updates.
• 6:18
  SPEAKER_02: I will now move into the discussion with our speakers.
• 6:21
  SPEAKER_02: So first, I'd like to ask both of you if you can briefly provide our listeners with your background in infection prevention and work in HAIs.
• 6:29
  SPEAKER_02: Dr.
• 6:29
  SPEAKER_02: Fakih, we'll start with you.
• 6:30
  SPEAKER_01: Thank you, Dr.
• 6:31
  SPEAKER_01: Howard Anderson.
• 6:32
  SPEAKER_01: My name is Mohammed Fakih.
• 6:34
  SPEAKER_01: I serve as Chief Quality Officer at Discension, which is a nonprofit health system with more than 100 hospitals.
• 6:41
  SPEAKER_01: My background is hospital epidemiology, building processes to mitigate the risk for healthcare associated infections.
• 6:48
  SPEAKER_01: Particularly, I focus on reducing device associated infections, whether it's central lines or catheter-associated UTIs.
• 6:54
  SPEAKER_01: The other facet of my work includes diagnostic stewardship, an important element, you know, as far as antimicrobial stewardship and its impact on catheter-associated UTI.
• 7:02
  SPEAKER_01: Lisa?
• 7:03
  SPEAKER_03: Hi, my name is Lisa Sturm, and I'm currently the senior director of infection prevention at Ascension.
• 7:09
  SPEAKER_03: I have been in infection prevention for 28 years, working in different types of health system settings.
• 7:14
  SPEAKER_03: At Ascension, I lead the infection prevention community, which consists of about 150 infection prevention across our market.
• 7:21
  SPEAKER_03: I am active with APIC nationally, serving on the APIC Public Policy Committee, and I'm active at the chapter level as well.
• 7:29
  SPEAKER_03: I like to think of myself as a strong advocate for the IP community.
• 7:33
  SPEAKER_03: Thank you both for being here.
• 7:35
  SPEAKER_02: So as I'm sure you're both aware, the CDC recently published a report using NHSN data about the impact of COVID-19 on HAIs in 2020, which observed significant increases for central line associated bloodstream infections, catheter associated UTIs, ventilator-associated events, and MRSA bacteremias.
• 7:54
  SPEAKER_02: I know your group earlier this year also published data showing an increased rate of collabs associated with the COVID-19 pandemic.
• 8:01
  SPEAKER_02: So, Dr.
• 8:02
  SPEAKER_02: Feki, could you start with telling us a little bit more about your study and how it compares to the recently published CDC data?
• 8:08
  SPEAKER_01: Oh, absolutely.
• 8:09
  SPEAKER_01: And you know, the CDC study is, you know, the largest study we've ever had so far.
• 8:15
  SPEAKER_01: It's the whole country over a year.
• 8:16
  SPEAKER_01: And they compared 2019 different quarters to 2020.
• 8:20
  SPEAKER_01: I'm just going to summarize a couple of words about it.
• 8:23
  SPEAKER_01: I think a key element is that each quarter was a little bit different from the other when you compare it.
• 8:29
  SPEAKER_01: For example, when you look at the fourth quarter, they had 47% increase in CLABSI, 34% increase in lab ID, hospital onset, MRSA bacteremia, and 45% increase in ventilator-associated events, whereas CASA-associated UTI was about 19%.
• 8:45
  SPEAKER_01: And in the quarters before, it was much lower.
• 8:48
  SPEAKER_01: On the other hand, they did not see much of an increase in SSI or CDI or clostroydioid infection.
• 8:55
  SPEAKER_01: Now, what we have done in our study, we focused on two device infections, central line infection in addition to CACR-associated UTI.
• 9:03
  SPEAKER_01: And we looked at 78 hospitals, and that was in 12 states.
• 9:07
  SPEAKER_01: Our study focused on the first six months of the pandemic.
• 9:11
  SPEAKER_01: So some of our markets had early pandemic impact, and that's how we were able to show this very early on.
• 9:19
  SPEAKER_01: When we looked at our hospitals, we found out that collapsy rates significantly increased the first six months of the pandemic compared to the 12 months before the pandemic, up to about 50% when you look at device days as far as the denominator.
• 9:34
  SPEAKER_01: That was even higher when you looked at the whole population.
• 9:37
  SPEAKER_01: Because what we found is that there was an increase in also utilization of devices.
• 9:41
  SPEAKER_01: Now, when we dug a little bit deeper into the data, the vast majority of the change was in the intensive care unit.
• 9:48
  SPEAKER_01: So the impact was really in the ICU rather than on the floor.
• 9:52
  SPEAKER_01: Peeling off the onion a little bit more, you see that in fact the population that was hit the most was really those patients that had COVID-19 infection.
• 10:02
  SPEAKER_01: That's probably what's a little bit different from our study versus CDC.
• 10:06
  SPEAKER_01: We're able to differentiate who got the infections, whether it's COVID-19 versus non-COVID-19.
• 10:12
  SPEAKER_01: And when we looked at the prevalence of COVID-19 within the hospital at the same time when they had the infection, we found out that if if you have less than 5% of your patients that are COVID compared to 10%, there was a huge difference, or 10% or more, there was a huge difference.
• 10:28
  SPEAKER_01: For those hospitals that had more than 10% COVID-19 infected patients, they had 2.4 times higher CLABsy event than those that had very low prevalence.
• 10:37
  SPEAKER_01: Now, proportionately, when you looked at COVID patients, they were five times higher in number as far as CLABSI events compared to non-infected COVID patients with CLABSI.
• 10:48
  SPEAKER_01: So when they have CLABSI.
• 10:49
  SPEAKER_01: On the other hand, you know, when you look at catheter social UTI, we did not see these findings.
• 10:54
  SPEAKER_01: So CDC reports, in fact, on different quarters that they had a slight increase in catheter social UTI, and then it went up to 19% when the pandemic became much more prevalent in the country.
• 11:06
  SPEAKER_01: We have not seen the decrease in catheter social UTI in our hospitals.
• 11:11
  SPEAKER_01: And we believe that the two diseases are very different.
• 11:15
  SPEAKER_01: So CLAPSI is very sensitive to big events such as what happened with the pandemic when changes in practice happened, versus catheter associated UDI is very sensitive to another thing, which is culturing practices.
• 11:29
  SPEAKER_01: So if I don't do a lot of urine cultures, the impact of the pandemic may not be as strong.
• 11:36
  SPEAKER_01: And that's, I think, what we've seen in our system.
• 11:39
  SPEAKER_01: We have worked for quite a few years on diagnostic stewardship and antimicrobial stewardship within our system and focusing on Cast Resource GTI.
• 11:47
  SPEAKER_01: So we've not seen that impact.
• 11:50
  SPEAKER_02: Thank you.
• 11:50
  SPEAKER_02: Those insights are really useful, especially comparing your experience with the national data.
• 11:56
  SPEAKER_02: And Ms.
• 11:56
  SPEAKER_02: Sturm, I know you've been on the front line of monitoring and obviously working to prevent these HAIs.
• 12:02
  SPEAKER_02: So what do you think have been some of the key reasons behind the increases seen in HAIs, both at your institutions and nationally?
• 12:10
  SPEAKER_03: So our experiences with our HAIs did mirror what has been published, with the exception of CODI, as Dr.
• 12:15
  SPEAKER_03: Faket just pointed out.
• 12:17
  SPEAKER_03: I think that HAIs and in particular bloodstream infections were impacted due to many factors that collided together, resulting in the infection.
• 12:26
  SPEAKER_03: Most of these things we had very little control over, such as the high acuity and the COVID patients, the fact that these patients were in COVID isolation and we were limiting the number of people going to the bedside and other factors.
• 12:39
  SPEAKER_03: We recognized that these patients also had extensive and unique care needs, such as ECMO, advanced respiratory care, proning, et cetera.
• 12:49
  SPEAKER_03: Unfortunately, we also had little control over the other variables as well, such as shortages in the PPEs and supplies, clinicians being reassigned to unfamiliar care environments, staffing shortages, and of course, sometimes a very frightened, stressed-out workhorse working in a very high pressure, stressful environment.
• 13:10
  SPEAKER_03: For a healthcare worker, applying and optimizing our infection prevention strategies to prevent HAIs maybe was not at top of mind for them as a priority with so many other competing priorities.
• 13:23
  SPEAKER_03: We understand that.
• 13:24
  SPEAKER_03: So even where we were hardwired and where we thought we had, you know, multi-years of success with HAIs, we still saw breakdowns in some of those hardwired practices.
• 13:36
  SPEAKER_03: Meantime, the standard infection preventionist workflow was dramatically changed, as all other healthcare workers in the hospital experienced as well.
• 13:45
  SPEAKER_03: So they had to shift their focus to emergency preparedness and pandemic preparedness instead of their usual work, which might have been rounding, device rounding, educating, and working on the process improvement projects.
• 13:59
  SPEAKER_03: So we know that happened.
• 14:01
  SPEAKER_03: And I guess in conclusion, I, you know, I don't think we can just point to any one or even two or three things.
• 14:07
  SPEAKER_03: I think it was just a collision of all these factors that brought about the increases.
• 14:11
  SPEAKER_03: And like everything in infection prevention, there's never just one thing and there's never just one solution either.
• 14:17
  SPEAKER_02: Thanks.
• 14:18
  SPEAKER_02: Yeah, I think all of us in infection prevention and hospital FB around the country can relate to a lot of those factors you pointed out.
• 14:24
  SPEAKER_02: So the CDC report revealed that the largest increases, as you touched on, were observed from CLABC with also big increases in ventilator-associated event incidents and ventilator utilization across all four quarters of 2020.
• 14:38
  SPEAKER_02: Do you have ideas about why these HAIs in particular were the most affected?
• 14:42
  SPEAKER_02: And Dr.
• 14:42
  SPEAKER_02: Pakie, we'll start with you first.
• 14:44
  SPEAKER_01: So as we shared in relation to CLABC, a large proportion of those who developed CLABC are COVID-19 affected patients.
• 14:50
  SPEAKER_01: In addition, the main increases occurred in the intensive care units.
• 14:54
  SPEAKER_01: COVID-19 is a disease that is associated with much higher morbidity and mortality when you look at the other groups at medical hospital.
• 15:02
  SPEAKER_01: It has a longer length of stay, and a much larger proportion of these patients end up being in the ICU.
• 15:07
  SPEAKER_01: So that makes a huge difference as far as the device days, you know, per patient and the risk factors that these patients with COVID have.
• 15:16
  SPEAKER_01: So if we if we look at the risk factors for CLABsy in COVID-19 patients, you have patient factors such as prolonged lengths of stay and need of ICU and other extrinsic factors such as steroid and immunomodulator use.
• 15:30
  SPEAKER_01: These are much higher risk individuals compared to others.
• 15:32
  SPEAKER_01: And then you add what Lisa talked about as far as gaps and infection prevention practices associated with their care.
• 15:38
  SPEAKER_01: In our experience, when we looked at our system, we had about 40% of our COVID-19 patients admitted to the ICU at one point during their stay.
• 15:46
  SPEAKER_01: And about 30% of those that are admitted end up being on mechanical ventilation at one point.
• 15:52
  SPEAKER_01: So this is a very sick population.
• 15:54
  SPEAKER_01: As far as this, you know, ventilator associated events, I think the COVID-19 disease as a disease is predominantly a restroom disease.
• 16:01
  SPEAKER_01: So people decompensate, they end up being on the van, decompensate more, they get the VAE.
• 16:06
  SPEAKER_01: So it's it's, I mean, for all of us, I think it's clear why we haven't increased.
• 16:10
  SPEAKER_01: Lisa, what do you think?
• 16:12
  SPEAKER_03: Well, I completely agree.
• 16:13
  SPEAKER_03: We did know all these experiences with changes related to line care.
• 16:18
  SPEAKER_03: And we were told anecdotally by our infection preventionists across our markets, they saw more femoral lines going in in the emergency department, some under emergency conditions, that maybe they didn't get changed out as per normal.
• 16:30
  SPEAKER_03: And then also increased use of dialysis lines.
• 16:33
  SPEAKER_03: Those, of course, in addition to the ECMO lines, which are in a completely different league of vascular access.
• 16:40
  SPEAKER_03: I think increases in VAE here would be expected, as Dr.
• 16:43
  SPEAKER_03: Fiki indicated, it's a respiratory disease with a proportion deteriorating and having respiratory failure.
• 16:49
  SPEAKER_03: Some of the increases were potentially definitional related, though we were picking up them through our definitions due to the adjustments in ventilator settings and oxygen requirements.
• 16:58
  SPEAKER_03: So I think the increases there were a little bit more expected.
• 17:02
  SPEAKER_03: I don't think we were prepared for the increases, though, in the vascular access devices.
• 17:07
  SPEAKER_02: So on the flip side, the CDC study also revealed that certain HAIs like SLEC surgical site infections and C diffacetal did not show any increase with the pandemic.
• 17:17
  SPEAKER_02: So why do you think this might be the case?
• 17:19
  SPEAKER_02: And Ms.
• 17:20
  SPEAKER_02: Stern, we'll start with you this time.
• 17:22
  SPEAKER_03: Yeah, to be quite honest, I was really surprised that we didn't see spikes in our C diff SAR.
• 17:27
  SPEAKER_03: We were fully expecting that as we were being told of increasing antibiotic use across the country within the hospitals.
• 17:34
  SPEAKER_03: What would be interesting to know that I have not seen published in the recent CDC study or elsewhere is what has happened to the community onset C diff rates.
• 17:44
  SPEAKER_03: And were those also correspondingly lower or stable?
• 17:48
  SPEAKER_03: And that's something we're going to take a closer look at at ascension.
• 17:51
  SPEAKER_03: It is also possible with the cessation of ambulatory services and outpatient care in 2020, with the few exceptions made for emergency procedures, that there could have been less overall utilization of antibiotics in the outpatient setting, whether it's prophylaxis for dental procedures or other minor procedures, or indiscriminate use for other viral infections that we were not seeing.
• 18:14
  SPEAKER_03: I think that this is an area that definitely warrants further study and probably something we'll definitely dive deeper on.
• 18:20
  SPEAKER_03: I also believe with the increased attention on the environment and cleaning and disinfection, sometimes with more harsh agents than we would normally use, some people going for straight up sporositals, we likely eliminated most causes of horizontal transmission of C.
• 18:35
  SPEAKER_03: diff, not to mention all the patients and contact precautions.
• 18:38
  SPEAKER_03: So fortunately, we've been able to maintain those higher standards of housekeeping, which is probably one of the silver linings to that.
• 18:45
  SPEAKER_03: As to surgical site infections, I thought a lot about that because we didn't see increases either in colon or hysterectomy.
• 18:53
  SPEAKER_03: But you know, it's been my long-standing belief that those are surgical procedures that are in general harder to impact with infection prevention practices.
• 19:01
  SPEAKER_03: They are clean contaminated procedures and they're less sensitive, probably, to extrinsic factors such as screening and decolonization, crap, aseptic technique, operating room traffic, instruments, et cetera.
• 19:14
  SPEAKER_03: Therefore, if these infection prevention practices were impacted or changed in the ORs because of the pandemic, those metrics may have been less likely to show those changes.
• 19:24
  SPEAKER_03: Conversely, our experience with our clean surgical procedures, such as our orthopedic joint surgeries that were impacted during the pandemic with subsequent drops in numbers as well.
• 19:36
  SPEAKER_03: And those are clean surgeries indicating they might likely be more sensitive to changes in infection prevention practices that were going on.
• 19:43
  SPEAKER_03: And as the OR shut down during the pandemic across the country, resulting in the cancellation and deferral of elective procedures, this ultimately did leave behind a smaller proportion of higher risk patients for colon and hysterectomy.
• 19:57
  SPEAKER_03: So we were fully bracing to see an increase in our SIR, but we were pleasantly surprised that we did not see increases in SSIs there.
• 20:05
  SPEAKER_02: That's really interesting.
• 20:06
  SPEAKER_02: Dr.
• 20:06
  SPEAKER_02: Faki, anything to add on this?
• 20:08
  SPEAKER_01: Oh, I agree with Lisa.
• 20:10
  SPEAKER_01: However, if we think about this, I think the attrition issue is very important.
• 20:15
  SPEAKER_01: So for surgical side infection, there was attrition seen and reporting, and by about 25% for colon surgery and by about a third for abdominal sterectomy of the US hospitals that were reported.
• 20:26
  SPEAKER_01: In fact, in certain areas, it was up to 60% of the state, you know, like certain states had about 60% drop in reporting.
• 20:35
  SPEAKER_01: So when you have that for certain quarter, this tells you that there's quite a bit of a bias, selection bias.
• 20:41
  SPEAKER_01: And I would assume the underperformers decided not to submit.
• 20:44
  SPEAKER_01: And hopefully it's not the case, but you know, the other side of the story is that surgical SSI surveillance is quite labor intensive.
• 20:51
  SPEAKER_01: So potentially under-reporting may have occurred even if you are reporting.
• 20:55
  SPEAKER_01: It takes quite a bit of time to look at all these cases.
• 20:58
  SPEAKER_01: And that's another potential thing to consider by the CDC in the future, how to make the surveillance much easier.
• 21:06
  SPEAKER_01: Because, you know, when you're stressed, I think you're going to have much more shortcuts.
• 21:09
  SPEAKER_01: For CDF, I love what Lisa was thinking about as far as the community onset.
• 21:13
  SPEAKER_01: You know, I think there are a couple of things we need to consider.
• 21:16
  SPEAKER_01: One, the population is changed.
• 21:18
  SPEAKER_01: The population that is admitted is not the same as the one we had in 2019.
• 21:22
  SPEAKER_01: Could it be that this population has a lower colonization rate of close radioides difficile?
• 21:28
  SPEAKER_01: And then if you have a lower colonization rate, even with high antimicrobial pressure, you may not have the same numbers of patients with CDI.
• 21:35
  SPEAKER_01: So that's one thing to think about.
• 21:37
  SPEAKER_01: The other thing, the antimicrobial pressure varied honestly, by hospital practice.
• 21:41
  SPEAKER_01: So we can't say that in every single hospital we went and used way more antibiotics than the other.
• 21:47
  SPEAKER_01: It really depends on their stewardship in each hospital.
• 21:50
  SPEAKER_01: More to come on this, I think it needs to be more examined.
• 21:53
  SPEAKER_02: Thanks.
• 21:53
  SPEAKER_02: Those are really important points.
• 21:54
  SPEAKER_02: So switching gears a little bit, this was not touched on in the CDC study, but there have been many.
• 22:00
  SPEAKER_02: Many reports about increased rates of fungal infections, particularly aspergillosis in patients with COVID-19, which may occur later in the hospital course.
• 22:08
  SPEAKER_02: Dr.
• 22:08
  SPEAKER_02: Vicky, do you have any additional insights into this?
• 22:11
  SPEAKER_02: And is this something you've seen at your institution at all?
• 22:14
  SPEAKER_01: So, what I can share with you is that we have received some reports of a few COVID-19 infected patients in the ICU ending up being colonized with Espergillus species.
• 22:25
  SPEAKER_01: As you know, having Espergillus nysputum does not mean it's an invasive disease.
• 22:29
  SPEAKER_01: And it's much harder to prove it is invasive versus just being colonized.
• 22:33
  SPEAKER_01: We don't have really good data on whether we have much of Aspergillus invasive disease, at least in our hospitals.
• 22:39
  SPEAKER_01: On the other hand, I really want to share something very interesting we've seen, and hopefully it'll be out in print soon.
• 22:46
  SPEAKER_01: We have been looking at hospital onset bloodstream infection, and we've been tracking this for a few years in a large number of our hospitals.
• 22:54
  SPEAKER_01: What we found out is that we have had an increase in hospital onset, staphylococcus aureus, so the monoseriginosa and candida species bloodstream infections.
• 23:03
  SPEAKER_01: Why am I sharing this?
• 23:04
  SPEAKER_01: We have seen more infections related to stephylococcus aureus pneumonia, you know, in these patients, or so the moncerinosa.
• 23:13
  SPEAKER_01: So it's not just the Espergillus to worry about, but there are other organisms that you may have, you know, healthcare acquired or or or associated that may have taken advantage of the COVID pandemic.
• 23:25
  SPEAKER_01: For example, our staph or bacterinia that's hospital onset is you know was four times more in COVID patients compared to non-infected.
• 23:32
  SPEAKER_01: So the monoserginosa five times more, candidate species three and a half times more.
• 23:36
  SPEAKER_01: And these are invasive, these are these are BSIs.
• 23:39
  SPEAKER_01: So more to come on this, uh Lisa has been leading this effort at our system.
• 23:43
  SPEAKER_01: I think we caution quite a bit, and this is an important probably comment to share.
• 23:47
  SPEAKER_01: You know, a lot of patients, rightfully so, are started on steroids for COVID-19 treatment.
• 23:52
  SPEAKER_01: Is when do we stop the steroids?
• 23:54
  SPEAKER_01: Do we keep it forever and ever or just for the course?
• 23:58
  SPEAKER_01: And that's, you know, immunosuppression for patients may lead to potentially higher risk for other adverse outcomes.
• 24:05
  SPEAKER_02: Thanks.
• 24:05
  SPEAKER_02: Yeah, I know our listeners will be excited to see the data when it comes out, hopefully soon, that you're working on.
• 24:11
  SPEAKER_02: So I'd like to focus now on thinking about ways for improvement.
• 24:14
  SPEAKER_02: We are now more than 18 months into the pandemic, and many organizations are having challenges with caregiver burnout and lack of staffing with so many competing priorities.
• 24:24
  SPEAKER_02: What do you think is the most valuable area to focus the efforts of our infection prevention teams and our frontline caregivers?
• 24:30
  SPEAKER_02: And Dr.
• 24:30
  SPEAKER_02: Fake, I'll start with you again.
• 24:32
  SPEAKER_01: So, this is a great question.
• 24:34
  SPEAKER_01: With the COVID-19 pandemic, healthcare associated infections mainly they reflect the canary in the coal mine.
• 24:41
  SPEAKER_01: So CLABSI or MRC bacteria are just a reflection of the impact on the standard processes we have in the acute care setting.
• 24:49
  SPEAKER_01: For example, you know, we can talk about the competencies for infection prevention practices, such as maintenance of the line, scrubbing of the hub, checking off the IV sites.
• 24:58
  SPEAKER_01: All of these have suffered with high healthcare worker turnover.
• 25:02
  SPEAKER_01: If I may just share one thing that's I think is important here, I was going to talk about at the end of the podcast, but I think it's very important here because it sticks to the story.
• 25:12
  SPEAKER_01: Competencies.
• 25:13
  SPEAKER_01: Shea has done a great job creating a module on preventing infection, whether it's device infection, whether it's pneumonia, whether it's reducing transmission.
• 25:23
  SPEAKER_01: And that prevention module, I think, has been created with quite a bit of attention to the frontline folks, whether it's a nurse, whether it's a physician, whether it's someone who touches the patient.
• 25:34
  SPEAKER_01: And I really think it's a it's a great tool to help all those that are frontline workers to improve their skills and know what to do and not to do and how to reduce the risk for our patients.
• 25:45
  SPEAKER_01: So I really encourage people to take that module.
• 25:47
  SPEAKER_01: It's and hopefully at the end you can talk a little bit about it.
• 25:50
  SPEAKER_01: So going back as far as high healthcare worker turnover and you know, doing the right thing every single time when we touch patients.
• 25:58
  SPEAKER_01: So that's one issue with the competency.
• 26:00
  SPEAKER_01: The other thing is auditing of processes also has dropped.
• 26:03
  SPEAKER_01: And these usually help.
• 26:04
  SPEAKER_01: So you have an audit and then you give feedback on performance.
• 26:07
  SPEAKER_01: All of these have really dropped quite a bit during the pandemic.
• 26:10
  SPEAKER_01: The third thing is the large patient load with searches will affect both nursing and physician care.
• 26:15
  SPEAKER_01: You know, we talk so much about nurses and nurses' burnout and the staffing.
• 26:20
  SPEAKER_01: We never ask, for example, is Dr.
• 26:22
  SPEAKER_01: Fiki or Dr.
• 26:24
  SPEAKER_01: Cernich or Dr.
• 26:25
  SPEAKER_01: Howard Anderson, can they see 40 consults a day versus 20 or 30 versus 15?
• 26:31
  SPEAKER_01: No one talked about it.
• 26:32
  SPEAKER_01: And I think the care changes quite a bit when you have that huge patient load.
• 26:37
  SPEAKER_01: What we have done as a system, we started an initiative and we call it recognize and rescue.
• 26:42
  SPEAKER_01: And the reason why we did it, we knew that it cannot be just infection prevention alone.
• 26:47
  SPEAKER_01: There are multiple things happening.
• 26:49
  SPEAKER_01: Under recognize, we said, let's address the situations where patients may be at risk of decompensation.
• 26:56
  SPEAKER_01: So, for example, if they have invasive devices, they are at risk of having an HAI.
• 27:01
  SPEAKER_01: Okay, it's not just the devices that are high risk, but what if they are on insulin or what if they are on opiates?
• 27:08
  SPEAKER_01: These are high risk situations.
• 27:10
  SPEAKER_01: So looking in a patient-centered way, and another example, there are some conditions where a patient comes in, for example, they have respiratory compromise.
• 27:18
  SPEAKER_01: You know, they come in with shortness of breasts, they are hypoxic, they did not crash yet.
• 27:22
  SPEAKER_01: These are patients that are much higher risk for crashing.
• 27:25
  SPEAKER_01: So this is a population that's a higher risk, we have to look at it much more closely.
• 27:29
  SPEAKER_01: So that's the recognized function.
• 27:31
  SPEAKER_01: And then the other, the other side is rescue.
• 27:34
  SPEAKER_01: And rescue is very close to what we talk about in the literature as far as failure to rescue and how to address it.
• 27:39
  SPEAKER_01: So two components, one is a preventive, one is action to help.
• 27:43
  SPEAKER_01: And that helps us to get all these disciplines together.
• 27:46
  SPEAKER_01: So instead of the infection preventionist going to look for the line, it's going to be the nurse, it's going to be the physician, it's going to be any support person.
• 27:53
  SPEAKER_01: We're working together.
• 27:54
  SPEAKER_01: I think if we do it this way, we may have a better chance with limited resources to get better outcomes.
• 28:00
  SPEAKER_02: Thank you.
• 28:01
  SPEAKER_02: Mr.
• 28:02
  SPEAKER_02: What do you think we should be focusing on?
• 28:04
  SPEAKER_02: And can you give us any additional examples about what Ascension is doing to improve rates of HAIs?
• 28:09
  SPEAKER_03: Absolutely.
• 28:10
  SPEAKER_03: So I think we have to recognize the collateral impact to our workforce and our staffing numbers, both at the bedside and in quality and in infection prevention.
• 28:19
  SPEAKER_03: This is our new norm with no telling when things are going to stabilize.
• 28:23
  SPEAKER_03: So that being said, instead of being the victims of this, I've been trying to encourage us to rethink how we approach infection prevention in general.
• 28:32
  SPEAKER_03: Pre-pandemic, we would always launch or initiate these kind of single subject campaigns, right?
• 28:38
  SPEAKER_03: So we're going to reduce CADI, March is CADI reduction month, April is hand hygiene month, et cetera, et cetera.
• 28:46
  SPEAKER_03: But I don't think we have that luxury any longer.
• 28:49
  SPEAKER_03: So there just isn't enough staff, plus the clinicians are being taxed with too many other things right now.
• 28:55
  SPEAKER_03: That being said, we have to think outside the box of how we can still get our initiatives launched, but in a different way without investing so much at either end of the spectrum.
• 29:06
  SPEAKER_03: So what I am in favor of, and it's something that we're working on right now in quality under Dr.
• 29:12
  SPEAKER_03: P's leadership is we're hitching our wagon, if you will, to the larger scale initiative.
• 29:17
  SPEAKER_03: And that is the recognize and rescue campaign.
• 29:20
  SPEAKER_03: So this is nice because you know you only have these limited opportunities to get leadership and bedside clinicians' attention.
• 29:27
  SPEAKER_03: So this way we're kind of bundled in a more holistic approach versus just hitting one subject at a time.
• 29:35
  SPEAKER_03: And then the other thing that we're working on with our infection prevention departments is staying laser focused.
• 29:42
  SPEAKER_03: So if you're seeing an increase in CLABZ, now is not the time for you to go update your CGIF module, right?
• 29:48
  SPEAKER_03: You have to stay in that really specific swim lane.
• 29:52
  SPEAKER_03: Otherwise, you're just going to get pulled into a million different directions and you're not going to really solve, you know, where the big problem is.
• 29:59
  SPEAKER_03: So we are telling them that while they still have to continue to monitor everything as far as targeted interventions, we're really redirecting them to stay laser focused.
• 30:08
  SPEAKER_03: And this might involve having to say no to some people because you're going to get a lot of requests and pulled in a lot of different directions.
• 30:14
  SPEAKER_03: So you do have to kind of have that backbone to be able to say no.
• 30:18
  SPEAKER_03: And then you also need to be prepared to pivot quickly as something starts to increase.
• 30:22
  SPEAKER_03: So you have to be able to drop those efforts over here and come over and maybe put out another fire.
• 30:28
  SPEAKER_03: I guess my key advice is to be more focused than ever on where your problems are and where you're going to get the most bang for your buck, so to speak.
• 30:35
  SPEAKER_03: I always also encourage the IP community to use their infection control committee for these difficult decisions because then you're going to have the committee support and backing and institutional support.
• 30:47
  SPEAKER_03: Should you get pushback if you do have to defer on some activities or say no to others.
• 30:53
  SPEAKER_03: And the best way to do this, in my opinion, is to revisit your annual risk assessment and modify it or put an addendum to it.
• 31:01
  SPEAKER_03: So then you have your rationale and your thought process in writing, and you're able to point to something specific that was agreed upon by your committee.
• 31:09
  SPEAKER_03: And I can give you a specific example about focus that I acted on during the pandemic.
• 31:16
  SPEAKER_03: So we were moving our ascension nurses across the country to serve in some of our markets where they had staffing shortages, whereas some of our other markets, because it was regionally impacted, didn't have staffing shortages.
• 31:28
  SPEAKER_03: So our nurse educators came to me because they were preparing these giant educational packets for the nurses that were traveling around the country within Ascension.
• 31:36
  SPEAKER_03: And they wanted me to populate an infection prevention section with, you know, key bullet points about preventing CODI, preventing CLABSD.
• 31:45
  SPEAKER_03: And I didn't do that.
• 31:46
  SPEAKER_03: And I had a conversation with them about instead of giving them these bullet points, which would maybe be looked at or glazed over or even maybe ignored, I said instead we should be directing those traveling nurses when they land in that hospital or they land in that unit to have that discussion, even if it's a five-minute discussion with the local people working in that unit based on that unit's culture.
• 32:13
  SPEAKER_03: What are your problems right now?
• 32:15
  SPEAKER_03: And what are your strategies to target those problems instead of this shotgun approach, where most of it would probably have been forgotten by the time they got there, anyways, because of the stressful environment.
• 32:25
  SPEAKER_03: So that is one example of how I was redirecting how we think about infection prevention, kind of right in the throes of the pandemic.
• 32:34
  SPEAKER_02: Thank you for sharing that.
• 32:35
  SPEAKER_02: I think that's a really useful example.
• 32:37
  SPEAKER_02: And you provide a lot of practical tips for our listeners.
• 32:41
  SPEAKER_02: So thank you both so much for your time.
• 32:43
  SPEAKER_02: I think this has been incredibly informative.
• 32:45
  SPEAKER_02: And I'll just close by asking if each of you have any final thoughts that you'd like to share with our listeners.
• 32:51
  SPEAKER_02: And Ms.
• 32:52
  SPEAKER_02: Stern, we'll start with you.
• 32:53
  SPEAKER_03: I guess my final message to the community is to stick with it, to hang in there and stay positive.
• 32:59
  SPEAKER_03: We have seen a loss in our staffing, just like all the other healthcare disciplines, due to burnout, exhaustion, and fatigue, going other places to make more money, consulting.
• 33:09
  SPEAKER_03: And then also the frustration and negativity that they're being bombarded with, especially because of the impact of social media and misinformation that they're reading, it can get so frustrating when you see some of this stuff swirling around.
• 33:22
  SPEAKER_03: And even people that you know are smart are buying into it.
• 33:26
  SPEAKER_03: So we're trying to really, really ensure that our infection preventionists and other quality team members are taking care of themselves, kind of like under the Maslow's hard care of needs.
• 33:36
  SPEAKER_03: So if you're not well, then you can't take care of others, right?
• 33:39
  SPEAKER_03: So whether at home or at work, and we need you.
• 33:42
  SPEAKER_03: We really, really need you.
• 33:44
  SPEAKER_03: So that's one thing.
• 33:45
  SPEAKER_03: And then the other thing is the power of community and just like things like this today, right?
• 33:50
  SPEAKER_03: Sharing our collective wisdom.
• 33:52
  SPEAKER_03: So we're stronger together.
• 33:55
  SPEAKER_03: We really have banded together during the pandemic and we've support each other.
• 33:59
  SPEAKER_03: And not a minute has gone by during the pandemic or even still now, where I can't reach out to a peer or a colleague and ask that crazy question or that stupid scenario that nobody would ever think would happen, but it's happening.
• 34:11
  SPEAKER_03: So we all have that comfort to kind of just put it out there and see what our others are.
• 34:16
  SPEAKER_03: So that's been really helpful.
• 34:18
  SPEAKER_03: And, you know, organizations like Shea, like APIC and other community groups really become our strength really through all of this.
• 34:26
  SPEAKER_03: And, you know, the bottom line is we're not solo artists, we're part of a bigger band.
• 34:30
  SPEAKER_03: So I think it's important we all play together.
• 34:32
  SPEAKER_03: And we're a family.
• 34:33
  SPEAKER_03: So thank you for inviting me today and sharing my thoughts.
• 34:36
  SPEAKER_03: I really appreciate it.
• 34:37
  SPEAKER_02: Thank you.
• 34:37
  SPEAKER_02: I love those thoughts.
• 34:38
  SPEAKER_02: Community is obviously so important.
• 34:40
  SPEAKER_02: So, Dr.
• 34:41
  SPEAKER_02: Faki, any final thoughts as well?
• 34:43
  SPEAKER_01: I think with all the difficulties that we have encountered during the pandemic, we've learned so much.
• 34:48
  SPEAKER_01: First, everyone has a better understanding of infection prevention and its value, keeping our patients and our healthcare workers safe.
• 34:56
  SPEAKER_01: So we have seen how important the competencies are to healthcare workers in order to optimize their practice and prevent harm.
• 35:03
  SPEAKER_01: And again, I'm I want to repeat the same thing.
• 35:06
  SPEAKER_01: The SHA course is a great course.
• 35:08
  SPEAKER_01: It's called the Prevention Course in Healthcare Associated Infection Knowledge and Control.
• 35:12
  SPEAKER_01: It has multiple modules that address HAIs, measures to reduce infection.
• 35:17
  SPEAKER_01: I highly recommend it.
• 35:19
  SPEAKER_01: The second thing I want to share is that we understand how essential is the hardwiring of standard infection prevention practices into the care and their impact on protecting our patients.
• 35:29
  SPEAKER_01: And finally, we should always value the patient-centric collaborative efforts between disciplines to be able to win and reduce the risk.
• 35:37
  SPEAKER_01: And thank you for having us.
• 35:38
  SPEAKER_02: Thank you so much for joining.
• 35:40
  SPEAKER_02: So thank you very much to our speakers for sharing their perspectives and experiences.
• 35:44
  SPEAKER_02: If you'd like to take the prevention CHKC course, Dr.
• 35:48
  SPEAKER_02: Fakee referenced in this podcast, please visit www.preventionch.org and use coupon code podcast, all capitalized letters at checkout.
• 35:59
  SPEAKER_02: This podcast can be accessed at SHAY's online education center, learning CE under the Rapid Response Program, where you will also find resources such as the SHA COVID 19 town halls.
• 36:10
  SPEAKER_02: This concludes today's episode of the Rapid Response Podcast.
• 36:13
  SPEAKER_02: Thank you for tuning in.