Introduction
The COVID-19 pandemic created many new barriers to providing high-quality care,1 resulting in increased healthcare-associated infection (HAI) rates across the US.2 Multiple articles focusing on central line-associated bloodstream infections (CLABSI)3 and catheter-associated urinary tract infections (CAUTI)4 rates and prevention activities in hospitals during the pandemic report that CLABSI and CAUTI rates increased as the COVID-19 burden in these facilities increased.5 6 The association between COVID-19 surges and elevated rates of most HAIs emphasise the need for careful balancing of pandemic-related demands with routine hospital infection prevention (IP).7
Common COVID-19-related challenges have been reported in high-acuity settings such as intensive care units (ICUs), and some of these challenges likely contributed to the increased HAI rates.8 Participants identified a number of challenges: a shortage of personal protective equipment (PPE), staffing shortages, high turnover, an influx of floating staff unfamiliar with the ICU, a decrease in frequency and number of clinical rounds, and reconciling rapidly changing and conflicting guidance on caring for COVID-19 patients.1 9 Furthermore, ‘pandemic fatigue’—a concept that people working in the midst of pandemic-related stressors became unmotivated to follow recommended protective behaviours—emerged over time, driven by various emotions, experiences and perceptions.10 Staffing challenges were notable as hospital leaders and staff were, out of necessity, extensively focused on the pandemic. Staffing shortages resulted in a reduction and relocation of staff and less time available to implement activities focused on quality improvement (QI), such as infection surveillance.11–13
Resource constraints such as limited PPE and staff time led to delays in the provision of other care such as elective surgeries, which compete with patients suffering from COVID-19 for acute and critical care resources.14 Fu et al reported on the dangers of neglecting or delaying elective surgery due to COVID-19, stating delayed care will result in sicker patients.15 This conforms with earlier studies. Vogel et al found that in-hospital delay of elective surgery was associated with a significant increase in infectious complications.16 McMullen et al predicted increased use of femoral lines in the US during the pandemic due to the higher-than-average degree of acuity of patients being admitted to hospitals.17 As reported by Palmore et al, staff in COVID-19 wards in 2020 across the US reported an increased workload caring for these higher-acuity patients, resulting in a more challenging work environment that exacerbated the staffing problems outlined above.18 Other healthcare personnel reported needing to be re-educated or provided with reminders on basic IP to prevent HAIs due to conflicting guidance and various practice changes implemented during the pandemic or inexperience of staff reallocated to the ICU setting.1 Furthermore, IP teams across the country reported changes to routine CLABSI and CAUTI prevention practices in ICUs, such as ‘less universal decolonisation, alterations in (central) line care due to intravenous pumps placed in hallways, line and dressing integrity gaps related to prone positioning of patients, opportunities in scrub-the-hub compliance, and increases in line draws for blood cultures.’19 These challenges only increased the burden on staff and made IP efforts more difficult.
Much of the published literature on CLABSI and CAUTI rates during the pandemic was concerned principally with the elevated rates of these infections and, to a lesser extent, the role QI programmes play in mitigating them.17 20 21 Yin et al conducted a broad-ranging literature review on the use of QI during the pandemic and found healthcare teams derived value from integrating QI into their pandemic response, specifically calling out benefits such as increased collaboration and learning from past emergencies.22 The value of a QI programme rests in units’ experiences and ability to tailor the usefulness of the programme to local circumstances and external pressures.
McMullen et al recommended that IP specialists refocus on core IP surveillance tasks to decrease HAIs during the pandemic. These include increased central line and urinary catheter monitoring, emphasis on the importance of handwashing, and overall, the existence and implementation of IP surveillance.17 These common strategies had been significantly hindered by the onset of the pandemic.
However, to be successful, QI programmes should be well integrated into health systems to allow for closer collaboration with public health officials and subject matter experts (SMEs).20 There is a strong need to develop effective tactics to support units to maintain the highest-quality IP and control activities while simultaneously promoting a strong response in the next pandemic. Basic IP practices must engage both IP specialists and bedside staff to integrate practices into routines. Training should be provided for all staff for the system to adapt when stressed.18 This paper seeks to elaborate on specific ways in which participating ICUs adapted an existing QI programme as well as their approaches to IP during the pandemic to meet their diverse and local needs.
Programme background
Launched in 2015 and running through 2021, the Agency for Healthcare Research and Quality (AHRQ) Safety Programme for ICUs: Preventing CLABSI and CAUTI, hereafter referred to as the AHRQ ICU Safety Programme, consisted of a series of six 12-month intervention periods aimed at helping ICUs with elevated CLABSI and/or CAUTI rates to reduce these rates using the AHRQ-developed Comprehensive Unit-based Safety Programme (CUSP). The CUSP model combines techniques to improve safety culture, teamwork and communications, together with clinical knowledge to provide a sustainable, actionable framework for teams to address quality issues.23 Key elements of CUSP include guidelines for establishing a QI team within the care unit, understanding the science of safety, engaging leadership, identifying process defects that lead to harm and improving teamwork and communication across unit staff. The programme’s implementation team consisted of state leads from state hospital associations working directly with participating units and a national programme team (NPT) designing programme materials, such as webinars and on-demand learning modules, and facilitating cross-unit interaction and access to SMEs. Participating units agreed to implement several elements of CUSP, including the formation of a CUSP team, performing an ICU assessment to ascertain process defects, developing an action plan to ameliorate those defects, and engaging senior leadership and staff in the effort, but were otherwise self-directed in their implementation. This manuscript focuses on the sixth and final cohort of the programme, whose participation (December 2019–April 2021) overlapped with the pandemic.
As with previous cohorts, the last cohort, cohort 6, began with each unit providing a self-assessment of its current CLABSI and CAUTI prevention and safety culture practices to help the state leads and the NPT understand each ICU’s unique needs. Using these ICU Assessments, units then worked to develop an action plan, which outlined the unit’s goals for participation, the specific steps it would take to achieve them, and likely barriers. Units could participate in the programme’s educational curriculum—a suite of webinars, on-demand learning modules and tools, coaching calls, training videos, and audio files—that emphasised both the technical and adaptive aspects of CLABSI and CAUTI prevention. Some units participated in site visits wherein state leads and, if requested by the state lead or unit, project-associated SMEs met with ICU staff to discuss the unit’s challenges and provide coaching. When COVID-19 began to have a significant impact on participating units in March 2020, the programme instituted a 5-month pause, restarting in August 2020 after units communicated to state leads that they were ready to resume programme activities. At that time, units were given the opportunity to reassess their needs and alter their action plans if appropriate.