Hospital-acquired infections may be rising as COVID-19 strains workforce

Once relegated to the background, infection control specialists are now at the center of hospitals’ biggest challenge: responding to the COVID-19 pandemic.

But there are concerns among physicians and nurses in the field that the workforce is being stretched thin and hospital-acquired infections may be rising as a result.

Infection preventionists and infectious disease physicians play major roles in hospitals’ efforts to acquire and  appropriately use personal protective equipment; set up COVID-19 units and testing sites; and redesign patient units to accommodate for distancing and isolation practices. That’s on top of their everyday duties, such as surveillance of infections across the organization and oversight of best practices related to infection control such as hand hygiene.

All those responsibilities may mean less attention is being devoted to the usual infection control priorities, experts warn, especially since infection control programs were stretched thin before the pandemic because they don’t generate revenue.

“There has been a tremendous strain placed on infection preventionists during this pandemic,” said Connie Steed, president of the Association for Professionals in Infection Control and Epidemiology, known as APIC, which represents about 15,000 infection control professionals. “Many infectious disease programs are already under-resourced and really don’t have enough staff to be able to adequately monitor infection rates at all times.”

Although the data isn’t available yet, the combination of more strain on infection control teams and the federal government’s waiver of infection reporting requirements has some in the field worried patients are more vulnerable to hospital-acquired infections, or HAIs, particularly in settings experiencing COVID-19 surges.

“The major concern is the impact this is going to have on HAIs,” said Dr. Michael Stevens, associate chair of infectious diseases at VCU Health in Richmond, Va. The battle to prevent the spread of COVID-19 often takes precedence. “The traditional things that people do to prevent infections—they go by the wayside.”

While the most recent data from the Agency for Healthcare Research and Quality shows hospital-acquired conditions such as catheter-associated urinary tract infections and C. difficile infections are decreasing, infections remain a leading complication for inpatients and are estimated to cost hospitals overall $28 billion to $45 billion annually.

Even when infection data is available from the federal government, it’s unclear if it will be complete. As part of its slew of waivers to hospitals, CMS made reporting infections to the Centers for Disease Control and Prevention optional for the first two quarters of 2020.

Some infectious disease physicians are expecting CMS will ask for the data to be reported later, but hospitals likely took advantage of the waiver, especially if their infection rates rose. Hospitals that opted to report data in the first quarter of 2020 will be subject to CMS’ Hospital-Acquired Condition Reduction program. Hospitals receive a 1% Medicare payment reduction if they perform in the bottom 25% on the conditions compared with their peers.

“If you are given a choice to report or not, when reporting could hurt your finances more, then you are going to take the path of least resistance, which is not to risk more financial ruin. You’re talking about millions of dollars in reimbursement,” said Dr. Bernard Camins, medical director of infection prevention at Mount Sinai Health System in New York.

There is anecdotal evidence that patients hospitalized for COVID-19 are more vulnerable to some infections like central line-associated bloodstream infections because they are hooked up to devices, have lengthy stays in intensive-care units and receive antibiotics.

“The more exposure you have to devices and antimicrobials, the more at risk you are for complications,” said Dr. Anurag Malani, medical director of infection prevention and antimicrobial stewardship programs at St. Joseph Mercy Health System, based in Michigan.

The risk for infections was likely higher at the beginning of the pandemic when little was known about effective treatments, Malani said. As testing has improved and clinicians have learned more about the virus, antibiotics are administered less and patients aren’t hooked up to ventilators as often.

Considering the important role played by infectious disease physicians and infection preventionists during the pandemic, those in the field say it’s highlighting a need for health systems to invest more in infection control. 

Steed said she’s heard from APIC members that their employer has laid off or furloughed some of the infection control staff during the pandemic. “Now is a time when they (hospitals) really need an increase of infection prevention resources, not less,” she said. 

While required for hospital  accreditation, infection control programs don’t generate revenue, so not all hospitals invest in having a robust program. It’s also why administrators may choose to shrink the program as they face financial strain during COVID-19.  

A survey this year of 2,030 APIC members found the average number of infection preventionists in an acute-care hospital is 3.4. Infection preventionists can be nurses, microbiologists, public health professionals or medical technologists who are trained in infection control. Infectious disease physicians are typically referred to separately and specialized in that expertise during residency training.

The pandemic has demonstrated the need for more infectious disease physicians; in 2017 there were approximately 9,100 infectious disease physicians. That’s much smaller than other specialties like emergency medicine, which boasted 42,348 physicians the same year.

A portion of infectious disease residency slots also routinely stays vacant. This year, 20.7% of its 406 slots went unfilled, according to the National Resident Matching Program.

“We are a small field given how many hospitals there are in the U.S. and the fact that HAIs are in the top 10 leading causes of death,” said Dr. David Weber, medical director of infection prevention at UNC Health Care in Chapel Hill, N.C.

Interest in the field may be small because infectious disease specialists are low on the physician pay scale. The average annual salary for such doctors is $246,000, making it among the lowest-paid specialties, according to 2020 survey data from MedScape.

Physicians in the specialty don’t perform surgeries, which are big profit makers for hospitals, but rather spend much of their time reading charts, analyzing data and acting as a teacher for both staff and patients on best practices for infection control. Under fee-for-service, that work translates to low billable payment.

“We aren’t revenue generators, but we are huge (cost) avoiders,” said Dr. Aaron Glatt, chief of infectious diseases at Mount Sinai South Nassau in New York. “The specialty doesn’t get the recognition it should, nor does it get the financial recognition it should. That is a big difficulty for recruiting people to the field.”

The importance of a robust infectious disease program has played out at UNC Health Care. Although the system hasn’t been overrun by COVID-19, it has experienced a surge of patients; yet infection rates are lower or the same overall across the system compared with last year, according to Weber.

The system also has 20 full-time employees in its infection control program. Weber acknowledges that’s likely higher than other hospitals. “In all fairness, we may have more resources than other hospitals have.”

APIC urges its members to advocate for infection control resources by giving frequent presentations to C-suite executives showing how the work saves money by reducing HAIs. There is evidence that infection prevention programs are cost-effective for hospitals. “We have to show our value,” Steed said.