By mid-September of last year, the doctor at Glenwood Regional Medical Center in West Monroe knew there was a dangerous mold called Aspergillus lurking in the hospital. Three COVID patients in the intensive care unit had tested positive for mold in their respiratory tracts.
“We have a problem,” the doctor said, according to a hospital inspection report by the federal Centers for Medicare and Medicaid Services. Aspergillus outbreaks are rare – any more than one infected patient would be unusual. Three was an indication of a serious threat to a group whose bodies were highly susceptible to Aspergillus infection, which can travel from the lungs and potentially make its way to the brain, kidneys, heart and skin.
By the time an infection plan was implemented, the outbreak had grown to five patients. Four of them, all simultaneously struggling with serious COVID infections, died.
As COVID cases surged in Louisiana, so did hospital-acquired infections, spurred by close quarters and less monitoring from a strained staff. Between patients lined up in hallways and overcrowded emergency rooms, other infections blossomed: drug-resistant staph, commonly known as MRSA, and central line infections spiked in Louisiana. Candida auris, a dangerous, drug-resistant superbug, was found for the first time in the state.
Health care-associated infections are a measure of quality in a hospital, one that has improved since federal agencies have tied compensation to infection rates and preventable injuries over the last decade. But as a flood of patients requiring a high level of care descended on Louisiana hospitals during the pandemic, years of progress were erased.
“This is what happens when a health care system gets stretched to a breaking point,” said Dr. Nasia Safdar, a professor of infectious disease and health sciences learning at the University of Wisconsin, Madison. “Something had to give, and what typically gave was the usual practices and procedures that are followed so carefully for device infection prevention.”
For hospital employees suited up from head to toe in plastic gowns, goggles and masks, it’s simply not as easy to see infections, said Safdar. Burned-out employees were going into retirement or seeking other jobs, and that meant fewer eyes on infections in general.
And some of Louisiana’s hospitals were already struggling with infection control, according to data from the CMS, which penalizes hospitals with high rates of preventable infections or injuries such as falls or bedsores.
This year, CMS levied penalties on 15 Louisiana hospitals for high rates of infection among Medicare patients, which reflects pre-pandemic discharges from July 2018 to the end of 2019. But some hospitals are dinged far more often than others, potentially setting the stage for a more dangerous pandemic environment.
“If you look at just who’s been penalized through Medicare, across the state, there are what I would call repeat offenders,” said Mark Diana, a professor in the department of health policy and management at Tulane University. “My suspicion is … that some of those were the ones that were slammed with COVID patients, and so that might have contributed to that overall rise.”
Medical staff from multiple departments gather on the COVID ICU floor at Ochsner Medical Center on Jefferson Highway in Jefferson on Tuesday, August 10, 2021. (Photo by Chris Granger | The Times-Picayune | The New Orleans Advocate)
In Louisiana, two hospitals have been penalized each of the last eight years: University Medical Center and Ochsner LSU Health Shreveport. Two others – Christus St. Frances Cabrini Hospital and Tulane Medical Center – have been penalized seven of eight years.
The hospitals penalized the most often receive some of the sickest and most frail patients, Sheree Stephens, vice president of quality at Ochsner LSU, noted in a statement.
“When these challenges were exacerbated by the pandemic with longer lengths of stay and other characteristics typically associated with increased infections, we maintained the highest priority on patient safety and quality control and continued reducing infection rates,” Stephens said. The other hospitals issued similar statements.
But hospitals with a history of infections may have had fewer processes in place to limit spread as hospitalizations of very sick patients grew.
“If you’re already struggling, then you’re slammed with a COVID surge, then your protocols and your procedures just can’t hold up,” Diana said.
COVID patients vulnerable
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Patients can check the hospital’s infection rates at data.medicare.gov, said Erica Washington, coordinator of the state’s health care-associated infection program. Patients should also keep in mind the type of facility they’re viewing – acute care hospitals will have more severely sick patients, for instance – and the type of services the facility provides.
“You want to make sure that you’re comparing apples to apples,” said Washington.
COVID patients are also especially vulnerable to infection, and Louisiana has been a hotspot for hospitalizations many times in the pandemic. Many COVID patients are elderly or immunocompromised in some way, and ICU patients typically are connected to a half-dozen or more tubes that act as a vector for fungus and bacteria. Often, those patients linger for weeks, widening the opportunity for infection.
“You’re giving them a highway right into the body of someone who’s already immunocompromised and not doing well,” said Rodney Rodhe, a professor whose research focuses on hospital-acquired diseases at Texas State University. “You basically are creating the perfect storm for things like Candida and Aspergillus.”
But metrics that normally act as a measure for how well hospitals follow infection control plummeted significantly in Louisiana, according to a report from the Centers for Disease Control and Prevention.
Louisiana had an increase in standardized infection ratios, a metric used to compare the expected number of infections to the actual number of infections, for a number of issues hospitals use to measure quality.
Central line blood stream infection ratios increased by 71% during the second quarter of 2020 compared to the previous year; in New York, which also had an early, devastating wave of COVID, the infection ratio decreased by 1.6%.
Drug resistance increasing
Louisiana may have been hit especially hard by infection during the pandemic for the same reasons the state at times was among the highest in the world for deaths and hospitalizations, said Dr. David Mushatt, an infectious disease specialist at Tulane University. People in Louisiana are in poor health compared to many places, and they face a number of other obstacles: high poverty, low education, poor access to nutritious food and more gender and racial inequity. That leads to more sickness.
“We have some of the highest rates of diabetes in the country, of obesity, of end-stage renal disease, requiring that hemodialysis,” said Mushatt. “These are a few of the many comorbidities or health variables that increase the risk of poor outcomes for people in the hospital.”
But it wasn’t just COVID patients that suffered. While 2021 data on infections won’t be out for at least a year, the pandemic affected everyone in hospitals, said Mushatt.
“What we’re seeing across the country is that COVID has basically led to the degradation of the quality of care and patient safety across the board, even with non-COVID patients,” said Mushatt.
Several drug-resistant bugs have been on the rise, including MRSA. And in January 2022, officials announced two cases of Candida auris had been detected at University Medical Center, the first in the state. At least four additional cases have been found through screenings, according to a presentation from the Louisiana Department of Health.
Drug-resistant microbes set off flaming red flags for experts, because they mean our tools to treat infections are getting duller. But experts also aren’t surprised. In the early stages of COVID, doctors were throwing whatever antibiotics they had at infections. Now they’re waiting for the other foot to drop.
“Antimicrobial resistance is a huge global pandemic that’s just been kind of quiet,” said Rodhe. “It’s been an ember waiting to explode.”
It’s unclear whether the trend will continue in 2022, though experts have hope that fewer COVID patients will give hospital staff time to regroup. But the next threat isn’t far away.
“We’ve got to redouble our public health efforts,” said Mushatt. “Because this virus will come back and there will be new viruses. And we don’t want to recapitulate the same mistakes that we made in the last two and a half years.”
At Glenwood, air quality tests revealed Aspergillus in multiple rooms and the nursing station. Nearly two months after the initial case, air quality tests were still pending, according to the report. But the unit was not closed and patients were not moved from the contaminated rooms. There was nowhere else to put them, an administrator told the inspector.
The hospital did not answer questions about the situation or the plan of correction.
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