Ron Urwongse

Hospitals use various methods to monitor hand-washing by staff; some methods measure the volume of soap and disinfectant hand gel used while others employ "secret shoppers" to observe hand-washing activities. 

North Shore University Hospital in Manhasset, N.Y. is the first hospital to adopt a new video monitoring technology to track hand-washing.  The video monitor technology is made a by Arrowsight.  The technology relies on a network of sensors that monitor entrance activity around doors and a series of cameras mounted on ceilings above sinks and hand sanitizing stations both in and outside patient rooms.  Arrowsight employees monitor the footage to track whether staff wash their hands within 10 seconds of passing through the door.

The rates are published daily on large L.E.D. displays in the hallways and serve as a constant reminder to the staff.  The nurse manager also gets e-mail messages throughout the day with detailed information about hand-washing rates.

The new video monitoring technology was implemented in the surgical and medical intensive care units (ICUs).  ICUs typically have the lowest hand-washing rates because the staff there are the most harried due to large volume of patients and that most patients in ICUs are in serious medical conditions.  Since adopting the technology three years ago, both ICUs have achieved and sustained better results than before.  The medical ICU in particular, improved its hand-washing rates from 6.5% three years ago to over 80%.

Read the article in The New York Times

Abstract to North Shore's study published in Clinical Infectious Diseases

A well-known public health expert is often asked to be a keynote speaker at infection management seminars. I happened to hear him present at two different infection control gatherings about a year apart. They were both emotional speeches about the modern day dangers cause us all to face. During the first speech he talked about how he lay awake nights worrying about his daughters and their survival chances in a world of anthrax. In the next speech he talked about how he lay awake nights worrying about his daughters and their survival chances in an age of Avian Flu. Clearly he was talking about the disastrous infection of the moment.

So what’s wrong with this picture? Link to the following for the answer: http://2.bp.blogspot.com/_a9OgLbIsBns/TMpEWB-eabI/AAAAAAAAALg/gaQHkVlSf1o/s1600/sky+falling+in+cartoon.jpg.

I believe that the public and healthcare providers are suffering from a disaster fatigue. There are too many infections to worry about them all. Worse yet, many of the dire scenarios painted by the media (with the help of some public health officials) have not occurred. It is becoming more and more difficult to know what is real and what to do about it

At the same time the public has come to view health care facilities as death houses where patients are discharged in worse condition than when they were admitted. Public reporting has reinforced this perception. I think that the fact that reporting is legally required is more frightening than the actual contents of the reports. If it must be reported, it must be really bad.

Certainly, there are serious infections occurring in various places throughout the world. The recent E. coli outbreak was a sobering event. Our job as IPs is to place these events in perspective and to help people understand their personal risks of contracting a serious infectious disease.

When everyone was worried about avian flu I was asked to make several presentations about it. I used humor to try to deflate the audience’s anxiety. I showed pictures of houses built above duck ponds and asked “Does this look like your house?”

I showed pictures of people taking dead geese to market on the backs of mopeds, etc.

I think my efforts were successful in bringing listeners back to reality where they could plan rationally.

The humor was not intended to make light of the issue. Rather it was intended to reduce the level of anxiety in the audience so that we could discuss the actual threats and possible responses.

I think it is important to use a variety of techniques balance the scales of concern. In some cases stories about personal concerns are appropriate. But we must consider ourselves to be Panic Preventionists as well as Infection Preventionists. This is no easy challenge to bring people back to earthly sights when everyone else is screaming “Watch out for the birds”!

IPs spend a lot of time monitoring and educating about handwashing. There are continuous debates about what the consequences should be for staff who are “caught” not washing their hands. One question that rarely is raised in Infection Control Committee meetings is whether there is an upper limit beyond which hand hygiene will no longer play a major role in HAI prevention. The answer can have profound effects on the amount of time and energy devoted to this one particular part of the IP role.

Two recent articles have questioned the relationship between increasing handwashing compliance and reduction of health care infections. Biggs, Shepherd and Kerr (2008) performed a mathematical analysis of the transmission of Staph by healthcare workers’ hands that became contaminated by patient contact. They concluded that a compliance levels (or imperfect hand hygiene) <50% were sufficient to stop outbreaks. They also concluded that the rate of increase in hand hygiene compliance was not associated with a similar decrease in infection transmission

Silvestri, Petros, Sarginson, et al (2005) conducted a literature review of 9 studies that looked at the relationship between hand hygiene compliance levels and actual infection rates. They concluded that [poor] handwashing can only account for 40% of transmission in intensive care units.

Why do these studies make sense in a time when hand washing is the first commandment of health care delivery? Both the literature and everyday observation provide some answers. First, glove use is becoming a universal practice. There are few studies that test how much hand contamination occurs with the use of gloves. Second, think of all of the environmental surfaces and healthcare equipment becomes contaminated and is used without cleaning. Stethoscopes, phones (both patient and clinician), bath basins, computer screens and on and on have been found to be contaminated. How effective are clean and gloved hands if contaminated equipment is used between patients without cleaning in between. I recently conducted a study in which we found that pens became contaminated within a single work shift. How many staff take pens into patients rooms, mark dressings and put the pen back into a pocket?

I think the time has come to take a harder look at housekeeping surfaces. I have found that most housekeepers want to do a good job but are hampered by a workload that allows only the most cursory of cleaning. It is about time that we stopped using precious resources on hand hygiene compliance and use them to provide more housekeepers with better equipment.

Beggs, C.B, Shepherd, S.J., and Kerr, K.G. (2008). Increasing the frequency of

handwashing by healthcare workers does not lead to commensurate reductions

in staphylococcal infections in a hospital ward. British Medical Journal of

Infectious Disease,8, 114. Available at: http:/www.biomedcentral.com/1471-

2334/8/114.

Silvestri, L., Petros, A.J., Sarginson, R.E., de la Cal, M.A.,Murray, A.E. and Saene, H.K.

(2005). Handwashing in the intensive care unit: a big measure with modest effects.

Journal of Hospital Infections, 59(3), 172 – 179.

Think about the most complicated infection control patient you have ever had. My worst patient was admitted with necrotizing fasciitis that had eroded almost the full circumference of of her trunk and spread to her perineal area. Naturally, she had an indwelling urinary catheter and several central lines. Her wounds were constantly draining and she was able to spend, at most, an hour a day out of bed. Our goal was to keep her from acquiring both a BSI and an SSI. She was with us about 2 months before she acquired each type of infection.

Zero tolerance is generally accepted as the mantra for demonstrating commitment to reducing HAIs. According to APIC zero tolerance generally means that no one on a healthcare team believes that even one HAI is acceptable. The assumption is that zero tolerance will eventually result in zero HAIs.

The zero tolerance approach represents a shift from believing HAIs as a normal risk of hospitalization. Certainly no one wants to go back to that way of thinking. But is zero tolerance realistic? Does it support the culture of blame that many quality officers are trying to eliminate?

We all know that healthcare is a complicated service compounded by the fact that peoples’ bodies break down, including their immune systems. Was it realistic to think we could prevent our patient from getting HAIs given the massive assault on her body from her first infection? Good nursing care during her admission resulted in a reduction of her initial wounds to about half of their original size. Unfortunately, the initial infection was not treatable and it spread to other sites despite aggressive care. It was at the time of that spread that the other infections occurred.

If I had strictly ascribed to the zero tolerance policy, my course of action would have been to conduct quality analyses and try to determine which staff performed poorly and/or what they had done that was wrong. That would have been followed by remedial actions including the possibility of staff discipline.

But in this case I believed that the concept of zero tolerance was not appropriate. There seemed no point in discussing the infection prevention strategies that might have been breached. The staff were familiar with prevention strategies. They were devastated when the HAIs developed. Reviewing prevention strategies or threatening punishment would have been viewed as a punishment and, I believe, a disincentive for future prevention efforts.

The question was whether, given this patient's underlying condition, any prevention strategies would have been successful? The answer was probably not. So I wondered what the teachable moment would be directed toward. I wondered if there was anything positive that could be taken from this situation. It occurred to me that, given the massiveness of the patient's initial infection, what the staff had done was to prevent HAIs for a relatively extended period of time. They had taken the necessary infection control precautions that were successful until the patient’s immune system was overwhelmed.

Is there a place for zero tolerance? Yes, but not as an inviolate goal. To hold that belief without allowing different perspectives may be detrimental to prevention efforts. Sometimes we must give ourselves credit for keeping patients infection-free for as long as possible given the forces that both patients and staff are fighting against. Supporting staff even in the face of failure can be an effective way to reinforce good practice for the many other patients whose conditions will challenge our best efforts.

The FDA sent warning letters to four manufacturers of over-the-counter hand sanitizer products that claim to prevent infection from MRSA, H1N1, and E. coli.  The FDA found insufficient data to support the claims made by these companies regarding their products and considers their labeling a violation of federal law.

• Tec Laboratories for Staphaseptic First Aid Antiseptic/Pain Relieving Gel
• JD Nelson and Associates for Safe4Hours Hand Sanitizing Lotion and Safe4Hours First Aid Antiseptic Skin Protectant
• Dr. G.H. Tichenor Antiseptic Co. for Dr. Tichenor’s Antiseptic Gel
• Oh So Clean, Inc dba CleanWell Company for CleanWell All-Natural Foaming Hand Sanitizer, CleanWell All-Natural Hand Sanitizer, CleanWell All-Natural Hand Sanitizing Wipes, and CleanWell All-Natural Antibacterial Foaming Handsoap

Updates from NHSN about HAI Reporting

I recently returned from the SHEA conference where I attended as many sessions as I could that dealt with NHSN’s thoughts about current or future reporting. You will be happy to know that someone has heard IP’s cries of pain when it comes to the amount of time that we spend on data collection! Here are some of the specific messages from the forums I attended.

The overall theme was that NHSN has a mandate (that they call their Action Plan) to reduce the time, effort and money spent on surveillance. They spoke several times about the need to (a) provide definitions that will track the effects of interventions, (b) will have clinical as well as surveillance meaning, and (c) will give IPs more time on clinical units helping patients and staff to improve care.

They will be issuing a new SSI form as soon as OMB approves it. They have changed the form so required data is more relevant to specific surgeries. For instance, information about implants will be required for orthopedic procedures but not for hysterectomies.

NHSN is currently having consensus meetings to finalize the criteria for VAP. They expect to have a statement by mid-summer. It will then take them some time to develop the software for NHSN submission. They expect that VAP reporting will become “mandatory” no sooner than January 1, 2013.

The biggest changes they are considering related to the definition of VAP include:

- making the chest x-ray a confirmatory finding rather than a key criterion of the definition,

-specifying PEEP settings and FiO2 readings as the specific indicators for worsening gas exchange, and

- specifying the time on a vent at 4 or more days before considering pneumonia as a possibility.

The SHEA forums with NHSN content were very satisfying. For the first time in memory the phrase “I’m the government and I’m here to help” wasn’t the introductory joke of the sessions.

The APIC Film Festival committee notified us yesterday that Ron's music video, "I Watch the Line," has been selected to be shown at the APIC Film Festival.  The Film Festival will take place during the Annual APIC Conference from June 27 to June 29 in Baltimore, MD.

• Keep patients from getting injured or sicker by reducing preventable hospital-acquired conditions by 40% by 2013.  Achieving this goal would mean approximately 1.8 million fewer injuries to patients and more than 60,000 lives saved over three years.
• Help patients heal without complications by reducing hospital readmissions by 20% by 2013.  Achieving this goal would mean more than 1.6 million patients would recover from illness without suffering a preventable complication requiring re-hospitalization within 30 days of discharge.

As mandatory healthcare-associated infection (HAI) reporting takes hold, and as NHSN data becomes available publicly on CMS Hospital Compare, what are the likely outcomes?

Will healthcare consumers become more savvy?

Let’s take a look at existing international reporting systems as analogues. University of Exeter performed a study in 2000 on seven health reporting systems. The study found that consumers and purchasers rarely sought out publicly available information, and did not understand the data when it was found. AHRQ similarly makes the case that public reporting does not affect consumer behavior. ARHQ’s Talking Quality web site states: 1) that information is not used, 2) quality data can be misleading, and 3) quality data can be difficult to understand.

Will infection rates decrease?

While public reporting may not affect consumer behavior, it still holds the potential to positively affect health outcomes and quality improvement. The same University of Exeter study found that hospitals tended to be the most responsive to publicly reported data with some correlation between public performance data and quality of care improvement. Another 2008 study published in the Annals of Internal Medicine similarly states that “publicly releasing performance data stimulates improvement activity at the hospital level.”

Let’s hope this holds true for the latest iteration of public reporting in the US. Perhaps self-scrutiny (rather than consumer pressure) will be part of the solution.

Ron, Joan, and I will be attending SHEA in Dallas this weekend.  You can find us at booth #302.  We will be posting throughout the conference.

1. Keep the head of the patient’s bed raised between 30 and 45 degrees, unless other medical conditions prevent this
2. Check the patient’s ability to breathe on his or her own every day so that the patient can be taken off the ventilator as soon as possible
3. Clean their hands with soap and water, or an alcohol-based hand rub before and after touching the patient or ventilator
4. Clean the inside of the patient’s mouth on a regular basis
5. Clean or replace equipment between use on different patients

1. Washing hands with soap and water, or an alcohol rub
2. Wearing sterile clothing and taking barrier precautions such as wearing a mask, gloves, and hair covering, and fully covering the patient with sterile drape, except for a very small hole where the line is inserted
3. Cleaning the patient’s skin with chlorhexidine when the line is inserted
4. Finding the best vein to insert the line
5. Checking the line for infection each day

• Prolonged antimicrobial treatment without clear evidence of infection
• Treatment of a positive clinical culture in the absence of disease
• Failure to narrow antimicrobial therapy when a causative organism is identified
• Prolonged prophylactic therapy
• Excessive use of certain antimicrobial agents

Some of you might remember the previous post here titled “Thanks, Andrew Wakefield,” talking about the anti-vaccine movement and its negative consequences on infectious disease rates. Lately, according to Orac over at ScienceBlogs, anti-vaccine activists have been demanding a study of vaccinated versus unvaccinated children. As pointed out, a randomized, double-blind study of vaccinated vs. unvaccinated children would be highly unethical given that vaccines are already proven to reduce disease among the vaccinated.

In response, some anti-vaccine activists have taken to demanding an observational study rather than an experimental one – a study where the differing rates of infection in vaccinated vs. unvaccinated children are merely observed, rather than controlling who is vaccinated or not. Never mind that there are a large number of confounding factors that would make it difficult to conduct such a study (subjects would have to be matched for age, sex, socioeconomic group, geographic location, urban vs. rural vs. suburban setting, race), and that there are only approximately 50,000 unvaccinated children ages 3-6 in the U.S.; this observational study is apparently the way to go.

“Fine,” said a study just reported in Deutsches Ärzteblatt International. Roma Schmitz and colleagues from the Robert Koch Institute reviewed results from the German Health Interview and Examination Survey for Children and Adolescents, double-checking the responses against medical records for accuracy. Schmitz and her co-authors compare the occurrence of infections and allergies in vaccinated vs. unvaccinated German children and adolescents – exactly the kind of observational study requested by anti-vaccine activists. The authors even specifically state that they did the study because of the anti-vaccine movement.

The findings shouldn’t be surprising – the only difference between the vaccinated vs. unvaccinated children was in the incidence of vaccine-preventable infectious disease. In other words, vaccines work, and if your child isn’t vaccinated, they are more likely to get the disease that the vaccine would have prevented.

However, the controls that the authors used in the study are extremely interesting; they looked at incidence of infectious disease in general between the two groups, as well as incidence of allergies and immune dysfunction. They found that unvaccinated children were just as likely to have other infectious diseases, were just as likely to have allergies, and were just as likely to have immune system dysfunction as the vaccinated children. I.e., vaccinated children aren’t at any higher risk of developing some of the negative consequences that anti-vaccine activists are so worried about.

The study doesn’t measure prevalence of autism, because, as explained by Orac, “there were only 94 unvaccinated children, which makes it impossible to compare autism and ASD [Autism Spectrum Disorders] prevalence with the vaccinated cohort, because the expected prevalence of autism is only approximately 1 in 100 anyway, which means that on average less than one autistic child would be expected in such a cohort. To look at differences in autism prevalence between the groups, many times more than 13,000 subjects would be needed.”

So, the study shows that vaccines work, and don’t cause any harm (as measured in the study). Ironically, the study was just what anti-vaccine activists said they wanted, though they most likely won’t like the results.

Deutsches Ärzteblatt International paper: http://www.aerzteblatt.de/int/article.asp?id=80869

Orac’s post on ScienceBlogs, a good discussion of the paper: http://scienceblogs.com/insolence/2011/03/for_the_anti-vaccinationists_out_there_t.php

Results from a state-wide hospital-acquired conditions reporting program were published last week by the state of Maryland.  Hospitals were required to report data in 49 categories of potentially preventable complications including HAIs.  Of the 45 hospitals that submitted data, 9 hospitals had higher rates than the state's target.

Maryland is currently the only state that ties payment to hospital performance on dealing with hospital-acquired conditions.  The state sets target rates for each reportable condition and payments to hospitals are tied to meeting the state's targets.

In 2008, Maryland's hospitals collectively had approximately 53,000 cases of hospital-acquired conditions out of a total of 800,000 inpatients and these conditions amounted to approximately $500 million in potentially preventable hospital payments.  The initiative was put in place in 2009 in an effort to address hospital-acquired conditions and to improve the quality of care for patients.

More info can be found at the Maryland Health Services Cost Review Commission website