Impact of the coronavirus disease 2019 (COVID-19) pandemic on infection control practices in a university hospital

As the coronavirus disease 2019 (COVID-19) pandemic spread, our center had to increase its capacity and was transformed to attend to COVID-19 patients. This transition included the creation of new intensive care units (ICUs) and the incorporation of untrained personnel in infection control practices and ICU patient care. Infection control activities were shifted to deal with COVID-19–related tasks. ¹ Hand hygiene audits were suspended. A double-glove protocol was implemented for COVID-19 patient care. These factors may have affected the optimal compliance with basic infection control practices. ² In our center, blood culture contamination rates increased from 1.1% in the prepandemic period (March 2019–February 2020) to 2.7% in the pandemic period (March 2020–February 2021) and peaked at 4.8% in April 2020. Central-line–associated infections increased from 0.2 per 1,000 patient days to 0.4 per 1,000 patient days between these periods. To assess the effect of the pandemic on infection control practices and to identify issues needing urgent attention, we conducted a survey among frontline HCWs at a university hospital.

Methods

The survey was conducted at the Bellvitge University Hospital, a 700-bed hospital in Barcelona, Spain, where 2,486 patients had been hospitalized with COVID-19. The survey was distrributed via institutional e-mail on March 9, 2021, to 762 HCWs responsible for caring for COVID-19 patients (in the departments of infectious diseases, internal medicine, respiratory medicine, ICUs) and 5 infection preventionists. HCWs completed the survey once using a personalized code. The survey included questions assessing the World Health Organization (WHO) Five Moments for Hand Hygiene, ³ central venous catheter (CVC) insertion and maintenance practices, and use of personal protective equipment (PPE). Other questions focused on HCW perceived workload or changes in infection control activities. Data were collected in an anonymized REDCap database and were analyzed using SPSS version 25.0 software (IBM, Armonk, NY). The local ethics committee approved the study, and respondents provided informed consent.

Results

Overall, 159 HCWs and 4 infection preventionists completed the survey (response rate, 21.3%). Among HCWs, 72 (45.3%) were nurses, 67 (42.1%) were physicians, and 20 (12.6%) were nursing assistants. By department, 69 (47.8%) worked in ICUs, 37 (22.7%) worked in infectious diseases and internal medicine wards, and 33 (20.2%) worked in respiratory medicine wards. Also, 20 HCWs (12.2%) were employed temporarily in these units.

Regarding hand hygiene, 52 respondents (32.7%) never or occasionally performed hand hygiene before touching CVC hubs (clean or aseptic task; WHO moment 2) and 25 respondents (15.7%) performed hand hygiene after touching a patient’s environment (WHO moment 5). The main factors interfering with hand hygiene compliance were inappropriate location (reported as “much” or “often” by 98 respondents, 61.7%) and shortages of hand sanitizers (reported as “much” or “often” by 88 respondents, 55.3%), and double gloving (reported as “much” or “often” by 72 respondents, 45.3%) (Table 1). For CVC insertion bundles, hand hygiene compliance and rates of sterile gowns and glove use rates were 100% (26 of 26) among physicians performing this procedure. Among these physicians, 22 (84.6%) reported using ultrasound-guided CVC insertion always or frequently. For catheter maintenance, 38 (52.7%) of 72 nurses reported that changing dressings was challenging with double gloves. Among these 72 nurses, 38 (52.7%) stated that prone position complicated blood culture collection, and 42 (58.3%) reported that they obtained blood samples for culture through CVC hubs.

Table 1. Barriers to Compliance With Standard Infection Control Practices During the COVID-19 Pandemic

Note. IQR, interquartile range; PPE, personal protective equipment.

Data are presented as n/N otherwise specified.

^a All respondents except the 4 infection preventionists.

^b Includes nurses and nursing supervisors.

^c Performed with a Kruskal-Wallis test.

^d Only applicable to surveys answered by nurses.

The shortage of PPE during the first COVID-19 wave (March–June 2020) was reported by 129 HCWs (81.1%). This issue was recognized as a problem, together with increased HCW workload (reported by 89 HCWs, 55.9%), staff deficits (reported by 45 HCWs, 28.3%), and the incorporation of nontrained personnel in ICU patient care and infection control practices (reported by 73 HCWs, 45.9%). Finally, at the beginning of the pandemic, 70%–90% of infection preventionists duties involved COVID-19–related tasks.

Discussion

Our survey identified significant barriers for optimal infection control practices during the pandemic. Contact and airborne precautions and the use of PPE (ie, masks, face shields, goggles, gloves, and gowns) were implemented during patient care. ⁴ However, the use of PPE is protective but also may hinder infection control practices. ⁵ During the first COVID-19 wave, the PPE stockpile was insufficient, and HCWs used the same gloves and gown when treating different patients and when performing different tasks. ⁶ As the survey shows, suboptimal hand hygiene practices were an issue. ⁷ Previous studies have identified changes in PPE use and hand hygiene practices as key elements associated with multidrug-resistant outbreaks, ⁸ increased blood culture contamination rates, and central-line–associated infections. ^9,10 Indeed, the double-glove protocol, patient prone position, and the increased workload hampered CVC manipulation and made blood extraction more difficult and less aseptic than it should have been. Additionally, the need to reallocate untrained staff to COVID-19 units was a recognized problem. To optimize staffing, we had to reassess the adequate nurse–patient ratio, and a pool of nurses was daily redeployed to areas with more need. To mitigate the insufficient preparedness of the new staff on infection control practices, we planned to replace face-to-face training (which was suspended during the COVID-19 pandemic) with online training. Compensating for the shift of infection preventionists activities to SARS-CoV-2–related issues in the pandemic situation was even more challenging. ¹ Perhaps better coordination between regional hospitals with common protocols would help infection preventionists deal with conflicting guidelines.

Our study had several limitations. The survey was conducted in a single center with a moderate response rate and potential recall bias. We do not have information on nonrespondents, who might have identified different problems. However, the respondents included a variety of HCWs and medical departments, making data more generalizable to a range of contexts.

Our survey results emphasizes the negative effect of the COVID-19 pandemic on basic infection control practices. The use of double gloves, suboptimal hand hygiene practices, the incorporation of untrained personnel, and the reassignment of infection preventionists to COVID-19 duties have been major issues. Seeking to achieve infection control excellence should be a priority during future pandemic waves.