Discussion

Blood culture contamination rates were 19% higher during the COVID-19 period. Even though the blood culture policy did not change, several nurses acknowledged the following lapses in infection control practices: (1) using skin disinfectant for less time than the manufacturer’s recommendation, (2) collecting serial cultures from the same site, and/or (3) failing to collect multiple blood cultures. Moreover, staff disclosed that specimens were frequently obtained from CVCs to decrease time in patient rooms as collecting cultures through a CVC is easier and quicker. Studies demonstrate that such collection practices are associated with lower-quality cultures and higher contamination rates. ^{Reference Garcia, Spitzer and Beaudry8} The most common reason cited by staff for deviations from best practices was limited time secondary to staffing shortages.

Additionally, the CLABSI rate during the pandemic increased 325%. Notably, 8 CLABSIs (26.7%) within the COVID-19 cohort occurred during the 5 days following insertion compared to 1 (16.7%) in the pre–COVID-19 cohort (P = 1.0) (Table 1). Although these results are not statistically significant, data exist to implicate timing of infection as clinically relevant. CLABSIs that develop within 5 days following CVC placement are likely caused by deviations from sterile technique during insertion and/or suboptimal site placement. ^{Reference Davis9} Of the 6 CLABSIs in the pre–COVID-19 cohort, none were placed in the emergency department, compared to 4 (13.3%) in COVID-19 cohort (P = .87) (Table 1). CVCs inserted during emergent circumstances are less likely to be sterile because the urgency for lifesaving treatment exceeds aseptic technique. ^{Reference O’Grady, Alexander and Dellinger3} Moreover, 7 patients (21.9%) within the COVID-19 cohort had a femoral line, compared to none in the pre–COVID-19 cohort (P = .48) (Table 1). Physicians likely chose the femoral vein for placement to decrease time exposed to patients. Femoral CVC placement is quicker because ultrasound guidance is rarely required and the femoral vein is further away from the patient’s mouth and nose compared to internal jugular and subclavian veins. Although such variations were made in an effort to decrease the risk of SARS-CoV-2 exposure, national guidelines still discourage the use of femoral line placements. ^{Reference O’Grady, Alexander and Dellinger3}

Notably, 18 (60%) patients from COVID-19 cohort tested positive for SARS-CoV-2, and studies show that patients with COVID-19 have an increased probability of developing secondary infections. ^{Reference Langford, So, Raybardhan and Leung10} However, if patients with COVID-19 were excluded from analysis, the CLABSI rate still increased from 0.40 to 0.77 per 10,000 central-line days, representing a 194% increase. Therefore, it is likely that increased demands placed on the healthcare system, regardless of inclusion of COVID-19 patients, contributed to the increased incidence of CLABSIs.

Our study has several limitations. First, our cohort size was small, especially for the period before the COVID-19 pandemic. Additionally, no audits were conducted on CVC insertion and maintenance to determine adherence to CLABSI prevention bundles; the lapses in infection control metrics were anecdotal evidence provided by clinicians. We were unable to compare our 2020 CLABSI rates to similar hospitals because the NHSN opted against collecting these data from January through June 2020 due to the COVID-19 pandemic. ⁷

These data demonstrate higher rates of blood culture contamination and CLABSIs during the pandemic. Both rates reached peaks in April 2020, when the hospital’s COVID-19 case load was greatest. Reasons for such increases are likely attributed to stresses placed on the healthcare system, resource shortages, and consistent surges of high-acuity patients. ^{Reference Adalja, Toner and Inglesby4} The present report justifies greater investment in infection prevention to accommodate patient quality-care needs during a pandemic.