Feedback loops! Feedback loops! Feedback loo...

Feedback loop photo from wired.com

Several years ago (yikes!) Dan blogged about 'closing the loop' by providing real time reminders to doctors that their hands are contaminated.  To paraphrase his money quote: "So I think several varieties of feedback will do..It is essential, though, that such feedback be provided as close to the point of care as possible."

There is a very interesting piece in last months Wired that discusses the success of just the type of feedback loops that Dan suggested.  The initial example they give of a successful feedback loop is those real-time dynamic speed displays, or driver feedback signs, that have a speed limit posting coupled with a huge sign announcing “Your Speed.” In this example, speeds fell 14% and were below the speed limit!  I guess you can change behavior.

Could we incorporate such feedback, "as close to the point of care as possible" as Dan suggested, and improve hand hygiene compliance by 14%? Anyway, a very interesting article and they even included a podcast/mp3 that is a good listen.

Source: Thomas Goetz "Harnessing the Power of Feedback Loops" Wired June 2011

Another benefit of hand hygiene!

We are always looking for ways to improve hand hygiene. Researcher Spike Lee at the University of Michigan has just published a creative study in the journal Science. In the study, subjects were asked to make a difficult decision. The subjects who washed their hands after making the decision, had lower cognitive dissonance; they were more at ease with their tough decisions. You can hear more about the study on this weeks Science Friday on NPR (here). Now if we could get our clinicians to round in the room (as some used to) and make decisions in the room, we could really increase our exit compliance. As it is, we could at least improve our entry compliance if we made the study results more available. Feel good about yourself: wash your hands!

You're Fired!

Those are the two words that hospital epidemiologists everywhere wish they could say to non-compliant healthcare workers. At least it's one of my dreams. According to a story in the Philadelphia Inquirer, if you're the lucky infection preventionist at Abingdon Memorial Hospital in Pennsylvania you can actually say that to clinicians that don't wash their hands on room entry and exit. After several years of trying to improve compliance with education and constantly retelling a tragic story of a patient's death from MRSA (the mother of one of the hospital's primary care physicians), they were able to improve hand hygiene compliance from 31% to a plateau of around 80%. With this improvement they report reductions in CLABSI, VAP and SSI but not UTIs.

However, they weren't satisfied. Their new plan is to give index cards to compliant staff that make them eligible for a raffle (carrot). What do non-compliant individuals get? The same cards but with a message that they have one strike against them (stick). If they get three strikes, they will receive a letter that their reappointment is conditional and they might lose their job. It will be interesting to see if compliance improves and if anyone is fired. I suspect the observers may be hesitant to give out that third strike, but I hope not. I also hope my title doesn't infringe a Donald Trump trademark.

Compliance with contact precautions: Not so much

Elaine Larson's group has a new study in the American Journal of Infection Control that examines compliance with contact precautions at 3 hospitals in New York City. She found that 15% of patients who had indications for contact precautions were actually not isolated. For patients who were isolated, hand hygiene by healthcare workers on room entry was very low at 22% and on room exit at 59%. Compliance with gowns was 71% and with gloves 72%.

With the compliance levels demonstrated here it seems unlikely that these hospitals could be successfully preventing infections. I am increasingly convinced that effective infection prevention hinges on high levels of compliance with very basic practices. It's not rocket science.