February 20, 2021 01:00 AM

Quality of care may be slipping during COVID, experts warn

Getty Images

When the pandemic hit nearly a year ago, healthcare organizations instituted rapid changes to respond. As a result, usual reporting systems and practices in place to ensure high-quality care were often disrupted.

Experts are worried that patient safety has been negatively affected amid all this immense change. “The conditions and the common contributing factors that increase the risk for errors have probably risen throughout the pandemic,” said Patricia McGaffigan, vice president of patient safety programs at the Institute for Healthcare Improvement. “The normal defenses we have put in place have really been centered around our expected way of working and so much of that has really changed.”

For instance, restrictions on family members visiting patients likely contributes to oversights in safety because they are typically an extra set of eyes and ears for their loved ones, McGaffigan said.

Further, infectious-disease specialists at many organizations have been called on to respond to COVID-19, sparking concerns that usual infection surveillance has lessened, and infections may be rising.

The pandemic has also strained staff, leaving many in hospitals and long-term care settings exhausted, which can impact quality of care, said Dr. David Levine, group senior vice president of advanced analytics and product management at consultancy Vizient. “This has been a long pandemic,” he said.

Stories of nurses out sick, taking leaves of absences and quitting have emerged too, leaving providers scrambling to fill shortages.

Moving physicians, nurses and other clinicians to units they are unfamiliar with to respond to surges presents opportunities for errors too, McGaffigan added.

Kaiser regional division adapts quality approach under COVID-19

The new environment COVID-19 created presents challenges for health systems to maintain quality, and some health systems have adopted well.

Take for instance Kaiser Permanente Northern California, which includes 21 hospitals in addition to a health plan with 4.4 million members.

The health system recognized early that it was harder to prevent falls and other hospital-acquired conditions during the pandemic because of restrictions on loved ones visiting and limits on frequency of staff entering rooms of COVID-19 patients to conserve personal protective equipment.

“We noticed there were some conditions we needed to pay attention to in a different way,” said Robin Betts, vice president of quality, clinical effectiveness and regulatory services at Kaiser Foundation Health Plan & Hospitals, Northern California.

For instance, when Kaiser recognized that falls were creeping up at the beginning of the pandemic, the nursing staff increased its communication with patients about the importance of asking for help before getting up, particularly for those at high risk for falling. Nurses, who visit patients at least once every hour, also encouraged patients to use the restroom when they entered the room.

Similarly, preventing pressure injuries became more of a challenge during the pandemic for some patients, Betts said. COVID-19 patients on ventilators and proned, which is when patients are placed on their stomachs, were susceptible to pressure wounds from devices. In response, Kaiser enhanced training on proned patients, emphasized the use of cushions and dressings on areas at high risk for sores and began removing or readjusting devices daily.

Betts said COVID reinforced standard quality practices that work but also showed “there are enhanced opportunities we need to deploy to sustain and continue to reduce harm in our organization.”

What the data shows

The quality of patient care for non-COVID-19 patients during the pandemic is unclear , mainly because of a lack of data. Early on in the pandemic response, CMS announced it would suspend for the first two quarters of 2020 reporting for quality programs, which means understanding of patient safety during the initial stages of the pandemic may be uncertain. Even before the pandemic, quality data publicly posted from CMS was about two years and older on average.

For its part, the Centers for Disease Control and Prevention is releasing raw mortality data on what they call excess deaths, which are the number of deaths that are greater than what would be expected based on previous years.

There were 225,530 excess deaths from March 1 to Aug. 1, 2020, and about one-third were directly attributed to COVID-19, according to a study in JAMA. The remaining deaths can be explained by increases in deaths from other conditions like heart disease, diabetes and Alzheimer's disease. Some conditions like sepsis were relatively stable throughout the pandemic.

The CDC data has some limitations, said Dr. Steven Woolf, professor of family medicine and population health at the Virginia Commonwealth University School of Medicine and lead author of the JAMA study on excess deaths during COVID. The data relies on information from death certificates, which may incorrectly attribute the cause of death, he said.

Although there isn’t hard data to explain these excess deaths, anecdotal reports of people delaying care can in part explain the rise, Woolf said. He added circumstances in healthcare settings are also likely contributing to excess deaths. For instance, a hospital experiencing a surge of COVID cases may be delayed in treating an emergent stroke patient because resources are strained.

“You can imagine the flooding of the healthcare system getting in the way of these folks getting the care they need,” he said.

CMS data that has still been released during COVID is its hospital inspection reports, but they don’t paint a clear picture of care quality. Overall, CMS reported fewer hospital inspection reports in 2020. Through November 2020 there were 1,090 events reported and available to view on the Association of Health Care Journalists website, which compiles and posts the data. In 2019, 4,423 reports were posted. CMS did postpone routine inspections for the first few months of COVID but immediate jeopardy and abuse inspections never stopped. The drop in inspection reports can partly be explained by pausing of elective procedures and declines in hospital volumes throughout the pandemic.

The American Hospital Association argues hospitals have done all they can to adapt to the challenges brought on by the pandemic while maintaining quality of care. Nancy Foster, AHA’s vice president of quality and patient safety policy, said in a statement that early in the pandemic response, hospitals faced unknowns in terms of how to best treat the virus. Additionally, strains on resources were a major concern. But in the months since, Foster said “we’ve learned more about how the virus is transmitted, (and) we’ve been able to refine and improve these actions to be even more effective in keeping patients and staff safe.”

“America’s hospitals and health systems take very seriously their mission to care for their patients and communities. The American public can rest assured that we are taking every precaution necessary to protect you and your loved ones when you come to us,” Foster added.