The coronavirus disease 2019 (COVID-19) pandemic has posed unprecedented challenges and reinforced the importance of infection prevention and patient safety. The COVID-19 pandemic also underscored the important role infection prevention programs have in ensuring high-quality care, such as preventing healthcare-associated infection (HAI). Before the pandemic, the prevalence of HAIs among hospitalized acute-care patients in the United States was estimated at 3.2%. Reference Magill, O’Leary and Janelle1 This estimate includes several potentially preventable device-associated infections, including catheter-associated urinary tract infection (CAUTI), central line–associated bloodstream infection (CLABSI), and ventilator-associated events (VAE). Fortunately, many episodes of such infections may be preventable through evidence-based prevention practices. Reference Umscheid, Mitchell and Doshi2
For at least the past 20 years, numerous agencies and professional organizations have published recommendations regarding the use of key HAI prevention practices. Reference Barbut, Jones and Eckert3–Reference Tablan, Anderson and Besser9 Likewise, every 4 years since 2005, our team has conducted a national survey of infection preventionists to examine the diffusion, adoption, and implementation of these key practices by hospitals across the United States. Despite the published guideline recommendations, we found substantial variability in the adoption and regular use of infection prevention practices. Reference Meddings, Chopra and Saint10
We conducted our most recent survey during the COVID-19 pandemic, when many infection prevention programs took on additional responsibilities. In some cases, this change may have led to a reduced focus on HAIs. We were particularly interested in the impact of the COVID-19 pandemic on the current use of device-associated infection prevention practices by acute-care hospitals. We compared our results with the findings from similar surveys in the years leading up to the pandemic. Reference Saint, Kowalski and Kaufman11–Reference Saint, Greene and Fowler14 We also assessed the extent to which some newer practices, such as external urinary collection devices in female patients, were being used.
Methods
Study design and data collection
This cross-sectional survey is part of an ongoing project in which, every 4 years, we ask infection preventionists across the United States what practices their hospitals are using to prevent common HAIs. Reference Saint, Kowalski and Kaufman11–Reference Saint, Greene and Fowler14 For the first wave in 2005, a national random sample was selected from all nonfederal, general medical, and surgical hospitals with an intensive care unit and at least 50 hospital beds using the 2003 American Hospital Association (AHA) database. This same sample was used for the 2009 and 2013 surveys. In 2017, we selected a new random sample of 900 hospitals from all nonfederal, general medical, and surgical hospitals with an intensive care unit based on data from the 2013 AHA annual survey. Unlike prior years, hospitals of all bed sizes, including those with <50 beds, were included in this new random sample. In this 2021 iteration of the survey, we used the same sample as in 2017. Before the survey mailing, an Internet search was conducted to identify and remove any hospitals that had closed or were ineligible, resulting in 881 hospitals included in the 2021 survey.
The survey followed a modified Dillman approach. Reference Dillman15 A presurvey letter was sent to the infection control coordinator at all hospitals, notifying them to expect the survey mailing in the next week. The initial surveys were mailed in mid-April 2021 and included $10 as an incentive to complete the survey. Two weeks after the initial mailing, a reminder letter was sent to all nonrespondents. Additional reminder surveys were mailed to nonrespondents ∼1, 2, and 3 months after the initial mailing. Respondents were given the option of completing the survey on paper and returning in a postage-paid envelope or completing the survey electronically using REDCap electronic data capture tools Reference Harris, Taylor and Minor16 hosted at the University of Michigan. At hospitals that employed >1 infection preventionist, we asked that the lead infection preventionist serve as the primary respondent, although we encouraged consulting with others as needed to complete the questionnaire. This study received an exemption from the local institutional review board.
Study measures
The current and prior surveys included questions about how often hospitals use various practices to prevent CAUTI, CLABSI, and VAE. The surveys assessed (1) practices that are generally recommended; (2) special approaches when infection rates are uncontrolled; (3) practices that are not recommended for routine use; and (4) newer prevention approaches. Reference Lo, Nicolle and Coffin6,Reference Marschall, Mermel and Fakih7,Reference Klompas, Branson and Eichenwald17 The frequency of use for each practice was assessed on a 5-point Likert scale (1 = “never use” through 5 = “always use”). Binary variables for each practice were generated with regular use defined as a rating of 4 (almost always) or 5 (always) coded as 1 and 0 otherwise. All surveys also asked questions about general hospital characteristics and characteristics of the infection control and prevention program. Our survey instrument is provided in the Supplementary Appendix 1 (online).
Statistical analysis
Descriptive statistics, N (%) for categorical variables, and mean (±SD) for continuous variables were calculated for hospital characteristics and regular use of specific CAUTI, CLABSI, and VAE prevention practices. To investigate cross-sectional changes in the regular use of device-associated infection prevention practices, we used Poisson regression with robust standard errors. In all models, the 2017 wave was used as the reference wave to look at changes over time before the pandemic (2005–2013 vs 2017) as well as changes during the pandemic (2021 vs 2017). Incidence rate ratios (IRRs) and 95% confidence intervals (CIs) are presented for each infection prevention practice by survey wave as applicable. IRR values <1 indicate lower use of the respective practice, and IRR values >1 indicate greater use (relative to 2017). A P value <.05 was considered statistically significant. SAS version 9.4 software (SAS Institute, Cary, NC) was used for all analyses.
Results
The 2021 survey response rate was 47% (415 of 881). Of 415 surveys, 306 (74%) were completed on paper, with the remainder completed electronically. Hospital characteristics are provided in Table 1. The average bed size of responding hospitals was 214 beds, and 34% of hospitals were affiliated with a medical school. Only 64% of hospitals reported receiving strong to very strong support for the infection control program from hospital leadership.
Select Hospital Characteristics in 2021 (n = 415)
SD, standard deviation.
Practices to prevent CAUTI in 2021
The most regularly used practice for CAUTI prevention was aseptic catheter insertion and maintenance (89.3%), followed by portable bladder ultrasound scanner (65.6%) and nurse-initiated catheter discontinuation (52.4%). More hospitals reported regular use of external catheters in female patients (42.1%) than in male patients (36.2%). Almost all hospitals (98.8%) reported having an established surveillance system for monitoring urinary tract infection rates. In total, 78.7% of hospitals indicated that it was very to extremely important to hospital leadership to prevent urinary tract infections.
Practices to prevent CLABSI in 2021
Nearly all responding hospitals reported regularly using 2 key recommended practices: maximum sterile-barrier precautions during central line insertion, and chlorhexidine gluconate for insertion-site antisepsis. The percentage of hospitals with an established surveillance system for monitoring CLABSIs was 97.2%. In total, 81.9% of hospitals indicated that it was very to extremely important to hospital leadership to prevent central venous catheter–related infections.
Practices to prevent VAE in 2021
The practice regularly used by most hospitals (93.4%) to prevent VAE was semirecumbent positioning of the patient, followed by sedation vacation (85.8%). Most hospitals (88.8%) had an established surveillance system for monitoring VAE rates. In total, 62.3% of hospitals indicated that it was very to extremely important to hospital leadership to prevent VAE.
Cross-sectional comparisons of CAUTI, CLABSI, and VAE practices: 2005 to 2021
The percentages of hospitals regularly using several practices to prevent CAUTI, CLABSI, and VAE between 2005 and 2021 are listed in Table 2, along with results from the Poisson regressions examining cross-sectional differences in the regular use of these practices relative to the 2017 wave. Additional survey findings related to CAUTI, CLABSI, and VAE prevention between 2005 and 2021 are presented in Supplementary Appendix 2 (online).
Cross-Sectional Comparison of Practices to Prevent CAUTI, CLABSI, and VAE (2005–2021)
CAUTI, catheter-associated urinary tract infection; CLABSI, central line–associated bloodstream infection; VAE, ventilator-associated events; IRR, incidence rate ratio; CI, confidence interval; CHG, chlorhexidine gluconate.
a Presented values represent the percentage of hospitals reporting regular use (defined as responses of almost always (4) or always (5) from 5-point Likert response questions) of the prevention practice.
b All model results based on Poisson regression with robust standard errors and 2017 used as the referent group. IRR values <1 indicate lower rates of use and values >1 indicate higher rates of use, relative to 2017.
For CAUTI, the regular use of portable bladder ultrasound scanners, urinary catheter reminders or stop orders or nurse discontinuation, and intermittent catheterization was significantly lower in 2005, 2009, and 2013 compared to 2017. Although the regular use of these practices increased every 4 years between 2005 and 2017, use of these practices decreased from 2017 to 2021: portable bladder ultrasound scanners (IRR, 0.90; 95% CI, 0.82–0.98; P = .02), urinary catheter reminders or stop orders or nurse discontinuation (IRR, 0.88; 95% CI, 0.81–0.96; P = .005), and intermittent catheterization (IRR, 0.79; 95% CI, 0.67–0.92; P = .003). External catheters in men (eg, condom catheters, glans-adherent devices) were used less frequently in years prior to 2017, but use increased in 2021 (IRR, 1.41; 95% CI, 1.15–1.71; P < .001). For CLABSI, regular use of antimicrobial dressings with chlorhexidine was significantly lower in 2005, 2009, and 2013 compared to 2017 but stabilized between 2017 and 2021 (IRR, 1.03; 95% CI, 0.99–1.07; P = .20). Regular use of maximum sterile barrier precautions and chlorhexidine gluconate for insertion-site antisepsis has been nearly universal and stable since 2013. For VAE, compared to 2017, use of antimicrobial mouth rinse and subglottic secretion drainage was also lower in 2005 and 2009 but has remained stable since 2013. Additionally, although use of semirecumbent positioning was significantly lower in 2005 (vs 2017), this practice has been nearly universal since 2009.
Discussion
We conducted a national survey to ascertain what US hospitals were doing to prevent 3 common device-associated infections in 2021, and we compared these findings with previous surveys dating back to 2005. The timing of the most recent survey allowed us to assess whether progress in the adoption of infection prevention practices continued during the COVID-19 pandemic. We report 3 main findings. First, the use of certain practices to prevent CLABSI and VAE continued to increase or reached a plateau over this 16-year period. These practices include the use of maximum sterile-barrier precautions during central catheter insertion and alcohol-containing chlorhexidine gluconate or antimicrobial dressing with chlorhexidine for site antisepsis (to prevent CLABSI), and sedation vacation (to prevent VAE). Second, use of several recommended practices to prevent CAUTI has decreased significantly since 2017, after rising from 2005 to 2017. This decrease included the use of a portable bladder ultrasound scanner for determining post-void residual, urinary catheter reminders or nurse-initiated catheter discontinuation, and intermittent catheterization. Third, over 40% of hospitals reported regularly using the newer tools of external urinary catheter devices for female patients, which exceeded the percentage reporting regular use of external catheters in male patients.
Infection prevention programs played an integral role in the COVID-19 response, helping to navigate and suggest safe COVID-19–related care. However, the need to focus on preventing endemic device-associated infections did not abate during this period, and some device-associated infection rates increased during the pandemic. For example, in a 148-hospital study conducted by Baker et al Reference Baker, Sands and Huang18 between March and September 2020, rates of CLABSI were 60% higher and CAUTI were 43% higher than the levels predicted if there had been no COVID-19 cases during this period. Reference Baker, Sands and Huang18 Our most recent survey, conducted in 2021, provides an overview of what US hospitals reported doing to prevent common device-associated infections during the COVID-19 pandemic. Moreover, these data, along with data collected before the pandemic, present a unique perspective on how the use of device-associated infection prevention practices was potentially affected by the COVID-19 pandemic.
The most striking finding involved CAUTI prevention practices. In our previous surveys between 2005 and 2017, we observed a general increase in the use of recommended CAUTI preventive practices. However, the reported regular use of urinary-catheter reminders or stop orders for catheter discontinuation, nurse-initiated removal protocols, portable bladder ultrasound scanners, and intermittent catheterization all decreased significantly in 2021 (compared with 2017). Notably, these practices were all part of a previous national CAUTI collaborative that reported a 32% decrease in CAUTI rates among medical-surgical patients. Reference Saint, Greene and Krein19 The reason that use of these recommended practices has decreased is unclear, but given how overworked many of the nursing staff were during the COVID-19 pandemic, CAUTI prevention may have been considered less of a priority. Additionally, because use of intermittent straight catheters, bladder scanners, and non-catheter strategies for urinary collection require more time and visits by nurses to the bedside, these practices may have been utilized less to reduce contact with COVID patients.
One exception to the general decrease in the use of CAUTI preventive practices was a significant increase in the use of condom catheters in male patients. Such devices have data supporting their use including both a randomized trial Reference Saint, Kaufman, Rogers, Baker, Ossenkop and Lipsky20 and observational data, Reference Saint, Lipsky and Baker21 revealing that patients prefer them to indwelling urethral catheters. Similarly, but more surprising, was the 42% of responding hospitals reporting regular use of external catheters in female patients. These devices are a newer catheter alternative for female patients (first available in 2016) and can be used for the same clinical indications as condom catheters in male patients. Reference Meddings, Saint and Fowler22 Although data on the benefits and risks of female external catheters are still evolving, Reference Lem, Jasperse and Grigorian23–Reference Warren, Fosnacht and Tremblay25 several studies have shown reductions in CAUTI or indwelling catheter use after the introduction of external catheters for female patients. Reference Rearigh, Gillett and Sy24,Reference Zavodnick, Harley, Zabriskie and Brahmbhatt26,Reference Eckert, Mattia, Patel, Okumura, Reynolds and Stuiver27
For CLABSI prevention, the reported regular use of maximum sterile-barrier precautions during catheter insertion and alcohol-containing chlorhexidine gluconate for insertion-site antisepsis is nearly universal in US hospitals, likely related to the robust evidence for their use Reference Chaiyakunapruk, Veenstra, Lipsky and Saint28,Reference Buetti, Marschall and Drees29 and their incorporation as part of CLABSI “bundles” used in large-scale collaboratives. Reference Patel, Olmsted and Hung30,Reference Patel, Greene and Jones31 Two additional practices to prevent CLABSI (ie, use of antimicrobial catheters and antimicrobial dressing with chlorhexidine) also showed increases in use between the 2017 and 2021 surveys. Antimicrobial catheters are now routinely used in nearly half of US hospitals. The use of chlorhexidine-containing antimicrobial dressings has increased since our initial survey in 2005, and they are now used in over 90% of US hospitals. Although we cannot differentiate by type (Biopatch® chlorhexidine-impregnated disks vs TegadermTM CHG dressings), we suspect that chlorhexidine-impregnated disks have been used most. Additionally, our data suggest that newer, advanced securement devices (eg, Tegaderm™ IV Advanced and SecurAcath®) were also used in over 90% of US hospitals in 2021. This widespread use could be related to continued focus on CLABSI prevention as a measure of hospital quality, overall comfort with using chlorhexidine-containing products, and the effort to minimize life-threatening infections.
For VAE, the percentage of hospitals reporting regular use of the practices we asked about remained generally similar over time, except for semirecumbent positioning, the use of which declined significantly from ∼98% regular use in 2017 to ∼93% in 2021. Some of this decrease may be directly related to the increasing use of prone positioning in patients with acute respiratory distress syndrome, as seen with severe COVID-19. Reference Langer, Brioni and Guzzardella32 Notably, the reported use of antimicrobial mouth rinse seems to have plateaued, with nearly 80% of US hospitals reporting regular use.
Our survey did note decreased use of some device-associated infection prevention practices in 2021 compared to 2017, which could be indirectly related to COVID-19. For example, issues around reducing face-to-face patient care in the setting of COVID-19 (due to personal protective equipment shortages or personnel shortages) may have decreased the number of encounters in which patients were assessed for device removal. Indwelling catheters may have been used in lieu of intermittent straight catheterization to reduce staff burden or to reduce the number of encounters between healthcare staff and patients. Shared devices, like bladder ultrasound machines, may not have been available to patients in isolation rooms. Eliminating some of these recommended infection prevention practices may have contributed to increased national HAI rates, as noted by Baker et al, Reference Baker, Sands and Huang18 during the COVID-19 pandemic. As shown by Lastinger et al, Reference Lastinger, Alvarez and Kofman33 VAE, CLABSI, and (to a modest extent) CAUTI rates continued to increase during the second year of the pandemic in 2021, potentially stemming from the different types of patients admitted to hospitals during this time, increased device use (particularly ventilators), COVID-19–related comorbidity, and increased lengths of stay.
Despite using national sampling and achieving a reasonable response rate for healthcare worker surveys, especially during a pandemic, this study had several limitations. First, our surveys relied on self-reporting by respondents. Thus, it is possible that our respondents understated or overstated the use of various practices, though we expected that the lead infection preventionist would be aware of practices used in their hospital to prevent common device-associated infections. Second, although we surveyed ∼10% of all US hospitals and employed a sampling strategy to obtain a nationally representative sample, the hospitals choosing to participate may differ from those choosing not to participate, affecting the generalizability of these results. Third, during the 16 years our survey instrument has been used, we did change the term “ventilator-associated pneumonia” to VAE; the Centers for Disease Control and Prevention transitioned to this term about a decade ago. 34 Importantly, the 2017 and 2021 survey instruments both used VAE. Finally, although the sampling scheme used for the 2017 and 2021 waves was the same, it differed from earlier waves. Notably, the sample for the 2017 and 2021 waves was expanded to include smaller hospitals with total bed sizes of less than 50. Relatedly, our findings across 5 survey waves do not reflect pure longitudinal changes among a specific group of hospitals. Still, we are confident that, despite sampling differences, our findings are robust and nationally representative across all periods of our repeated cross-sectional survey.
Despite these limitations, our national survey provides a timely overview of the practices US hospitals were using to prevent common device-associated infections in 2021, and how the use of those practices has changed over time and in the context of the COVID-19 pandemic. The regular use of practices intended to prevent CLABSI and VAE continue to increase, with several key practices reaching levels of near universal use, whereas some practices to prevent CAUTI have decreased since 2017. Dynamic patient characteristics and structural issues relating to care during the pandemic may have contributed to a decrease in some infection prevention practices. Still, our results demonstrate the importance of hard-wiring processes and routinizing infection prevention practices to withstand future pandemics, other healthcare emergencies, or organizational disruptions or system shocks (eg, the introduction of new electronic medical record systems, financial hardships, or changes in leadership). Reference Vaughn, Saint and Krein35 Surveys such as ours allow clinicians, hospital epidemiologists, infection preventionists, and other key decision makers to tailor their approaches to device-associated infection prevention with the goal of reducing this common complication of hospitalization.
Supplementary material
To view supplementary material for this article, please visit https://doi.org/10.1017/ice.2023.65
Acknowledgments
The study sponsors had no role in the design or conduct of the study; the collection, management, analysis, and interpretation of the data; or the preparation, review, or approval of the manuscript.
Financial support
This study was supported by US Department of Veterans Affairs (VA) via the VA National Center for Patient Safety–funded Patient Safety Center of Inquiry. Dr. Krein was supported by a VA Health Services Research and Development Service Research Career Scientist award (no. RCS 11-222).
Competing interest
Dr. Saint reports personal fees related to CAUTI prevention and serving on medical advisory boards of Doximity and Jvion, outside the submitted work. Dr. Meddings reports personal fees related to prevention of and value-based policies involving CAUTI and hospital-acquired pressure sores, outside the submitted work. Drs. Saint and Meddings are listed as inventors on US patent no. 10279145, a catheter-placement assist device that was not used in this study. All other authors report no financial conflicts of interest.
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