What is your name sir?...Ignaz

Loreen Herwaldt (and thanks to John Boyce) just forwarded along this cinematic depiction of Ignaz Semmelweis and his early investigations into the benefits of hand hygiene. The piece was written/directed by Jim Berry at NYU back in 2001 and funded by a Sloan Foundation grant for scripts featuring positive depictions of scientists. The film is a bit graphic/realistic. 

My favorite quote is from the mother pictured above: "You have a gentle touch sir, I want you to be my baby's namesake. What is your name, sir?"  A: "Ignaz"

Another moving section:  Semmelweis: "I believe that this practice will save lives."  Senior physician: "but this is not our way, at this hospital, doctor, we must be unbending in our practice."

The film is available for viewing on the Sloan Science and Film website (here)

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

I need your vote!

Last week I posted an idea on the 2011 VHA Employee Innovation Website.  Now VA employees are being asked to vote.  The instructions say that I should share my idea with my colleagues - that would be you. If you work for the VA and like my idea, please vote! Hvala lijepa.

Idea Title: Driving Patient Safety with Point-of-Use Signs for Hand Washing

Idea Description: One of the biggest threats to patient safety is hospital-acquired infections. Hand hygiene is the #1 method for preventing the spread of infections. VA has done a great job placing alcohol hand rub dispensers in patient care areas, but hand washing isn't 100%. Placing point-of-use reminder signs directly next to hand-rub/soap dispensers to encourage providers to wash their hands has potential to significantly improve hand washing compliance. Signs that offer encouragement and information and not just say employees must wash hands would be simple to design, test, implement and be very cost-effective.

Vote: Here

Is a graduation handshake a risk factor for bacterial pathogens?

University of Maryland dean, Dr. E. Albert Reece,
shakes hands during a graduation

In all likelihood, many of us have just suffered through enjoyed sitting through a recent preschool, high school, college or medical school graduation. The astute readers of this blog probably noticed the alcohol hand rub dispensers on stage for use by the graduates prior to shaking their dean's hand. You also noticed how few graduates actually used the dispensers.  Maybe they were nervous or rushed or were already wearing gloves to go with their graduation gowns...cool contact precautions.

So, should a dean worry about catching bad bugs from their students?  According to a new study published in the Journal of School Nursing, there is very little risk of acquiring a bacterial pathogen during a brief hand shake. In the study, cultures were collected from school officials' hands before and immediately following graduation. From a sample of 5,209 hands, Staphylococcus aureus was separately detected on one pregraduation right hand, one postgraduation right hand (different strain), and one postgraduation left hand, while nonpathogenic bacteria were found on 93% of the hands. They estimate the acquisition risk as 0.019 pathogens acquired per handshake. Of course, the study didn't test for viral transmission, which to me is a bigger worry.

Bishai D et al. Journal of School Nursing, May 11, 2011

New York Times LA Times May 23, 2011 (Dr. Reece from U. Maryland School of Medicine is quoted in this article)

Cute story of the day

At lunch today, one of my anthropologist colleagues was telling the story of her kindergarten-age daughter and her daughter's friend.  They were discussing hand washing and the children said, "You know, it is much quicker to wash your hands if you don't use soap."  It's impressive that a 5-year old could be an efficiency expert.  What is sad is that many clinicians use the same logic in hospitals when they are 45 or 55 years old.

Those deviants!

Photo: OpenIDEO

I have a bookshelf that is filled with many books on leadership and management that I read while working on my Master of Public Administration degree. While each of them might have a kernel or two of unique insights, most of these books contain a great deal of fluff. The basic formula for these books is to take concepts that are often common sense, give them a new name, and create the illusion of a totally new discovery about human behavior.These books often focus on a magic number--7 principles, 10 milestones, 12 steps (wait, that's something else!), and they continue to be steadily churned out (just take a look at any airport bookstore). Of all of these books that I've read, one did stand out as different and important, and that was Robert Greenleaf's Servant Leadership.

One recent book in this genre caught my eye given it's potential application to HAI prevention: The Power of Positive Deviance: How Unlikely Innovators Solve the World's Toughest Problems. Positive deviance was a part of the interventions implemented in the Veteran Affairs initiative to reduce MRSA that was recently reported in the New England Journal of Medicine (see Dan's comments here and here). My colleague in Sao Paulo, Alex Marra, has published on his use of positive deviance to improve compliance with hand hygiene. You can read an interview with Alex focusing on the use of positive deviance here.

In a nutshell, the concept of positive deviance is to simply involve not just experts but everyone in identifying solutions to problems. And it recognizes that a few individuals (the positive deviants) devise solutions to problems that the vast majority of people never realize. The deviants then share their successes with others and in doing so previously intractable problems are solved. Importantly, change is driven bottom-up, not top-down. The book uses several case studies, including the Pittsburgh VA hospital MRSA initiative.

Like the overwhelming majority of leadership/management books, this is another one that essentially follows the same formula as many others--a relatively simple, commonsense concept is given a new name, and presto, problems appear to be solved. I have no doubt that positive deviance can be used successfully in infection prevention, but it's simply another way to achieve the outcomes we want. It's not magic and it's not the be-all, end-all. But it's another tool, and if it works for your organization, well, you go girl!

When soap goes bad

Photo: Funny Blog

A new paper in the Journal of Applied and Environmental Microbiology (free full text here) describes a trial in which liquid soap was intentionally contaminated in grade school restrooms. The investigators found that when children washed their hands with contaminated soap there was a 26-fold increase in gram-negative rods on the hands. On the other hand, when uncontaminated soap was used there was a 2-fold reduction in hand contamination. It has previously been shown that soap dispensers which require refilling have been linked to outbreaks, and CDC recommends that soap not be added to partially empty dispensers (i.e., topping off). The solution to this problem is to use sealed soap-dispensing systems.

Blame them, shame them, and fire them! Or give them bonuses. Or something.

In part two of the NY Times “Fixes” blog piece on hand hygiene, Tina Rosenberg tackles the perplexing challenge of improving hand hygiene practices in hospitals. An excerpt from the summary paragraph:

“Health care workers have difficult jobs, and it is important for hospitals to take their views into account when they institute measures to improve hand-washing rates. But if it takes public posting of hand-washing rates and firing of individual doctors or nurses who don’t comply to bring down infection rates, it should be done.”

We covered this ground before, the proper role of reward versus punishment for influencing health care worker behavior. I would love comments from our readers on this. I’ll merely remind everyone that direct observation of “entry-exit” hand hygiene adherence, even in centers that do the most intensive monitoring, captures only a tiny fraction of HH opportunities. And entry-exit adherence is the tip of the iceberg. Try working an 8-hour shift as an ICU nurse while adhering perfectly to all “5 moments”.

High tech hand hygiene monitoring

There is a new online commentary in the New York Times on the use of technology to improve hand hygiene compliance in hospitals. This piece, the first of two parts, appears in an online column called Fixes, which looks at solutions to social problems. Dr. Phil Polgreen from the University of Iowa is interviewed in this piece.

MRSA Video - If this doesn't get you excited "almost" nothing will

The video was made by The University Hospital of South Manchester.

Things to note:
1) They start off by washing their hands and not swabbing their noses
2) Ties are tucked, sleeves are rolled up and they're mostly bare below the elbows.

Source: BBC News

Banning hands-free faucets: Is Hopkins throwing the bathwater out with the bathwater?

I hope everyone enjoyed SHEA.  Overall, a good meeting with good weather and good science.  I pinch-hit as a moderator for a hand-hygiene session on Saturday.  The original moderator (i.e. Mike Edmond, have you heard of him??) was scheduled to moderate two sessions at the same time and for some reason wasn't able to pull it off.  ;)

There were interesting studies presented in the session including an abstract highlighting iScrub, which Dan has mentioned before.  One particular abstract garnered a lot of press attention - I'm not used to hearing about data in the morning newspaper before the abstract is presented, for example. The study was conducted by Emily Snydor, Lisa Maragakis and colleagues at Johns Hopkins Hospital and aimed to determine the safety of touchless water faucets in their hospital.  They compared 20 newly installed automatic faucets with 20 old standard faucets and found that 50% of the automatic faucets had 15% of standard faucets were contaminated with Legionella. After chlorine dioxide, 29% of the automatic faucets and 7% of standard faucets were still contaminated with Legionella.  Hopkins is now removing all of the automatic faucets from their facility.

Some thoughts: 1) It appears that Legionella is a problem in their system and the automatic faucets are only part of the problem.  Removing them isn't enough.  2) The faucets in the study were not installed at the same time since the automatic faucets were new and the standard faucets were likely years old - could biofilm play a role here?  3) Not all automatic faucets would be the same, perhaps different designs would have different risks.  4) What about other pathogens?  How do you balance lower risk of C. diff or acinetobacter with touchless faucets compared to Legionella?  5) Could the faucets be "reprogrammed" or designed to allow flow of the stagnant water prior to contact with the HCW hands?  This might reduce one benefit of these automatic faucets since they do save a lot of water.

What do you guys think? Is this enough data to ban automatic faucets in hospitals? My other concern is that this study will be misinterpreted and people will become afraid of automatic faucets in places such as airports.  I doubt the Legionella risk in airports outweighs the influenza risk, for example.

NBC - Dallas article, March 31, 2011
VOA article, April 5, 2011

The definitive hand hygiene video!

Tired of explaining (and re-explaining) the importance of hand hygiene? Fatigued from answering questions about various aspects of hand hygiene, such as what to say about jewelry and fingernails, or fire hazards?

Then let the New England Journal of Medicine explain it for you! Didier Pittet and colleagues have put together an instructional video on hand hygiene--many of you have probably seen it already, but if you haven't, take a look.

One concern is whether anyone will have the stamina to stick with the video for the full 15 minutes, but the player allows you to click around to a topic of interest if your attention begins to wane. Also, it might have been more effective with a human voice (if it is a human voice, my sincere apologies to that person--but it sounds robotic or synthetic). On second thought, robots may be just what we need on the units: robotic hand hygiene observers who confront healthcare workers on their way out of the room with a detailed assessment of their HH performance!

Blaming the health care worker: KPCs in Ireland

Mike posted yesterday about KPCs in LA, and now there is a report of a KPC outbreak in Ireland. I have read several reports of the outbreak, which involved 5-7 patients (two infected, three colonized) at the Mid-Western Regional Hospital in Limerick, and there is one consistent aspect to what is reported:  It's the health care workers fault. See the article "Hospital Staff Warned" in the Irish Times.

The articles state that "steps had been taken to improve hand hygiene standards among hospital staff but warned that a zero-tolerance approach was being enforced in respect of anyone who failed to comply with these standards" and that "This will include disciplinary action and or notification to relevant professional registration bodies if warranted in any particular case." 

Mike has written before about the dangers of this adversarial approach to infection prevention, so I won't belabor the point.  However, when the authorities state that they are already doing everything right since MRSA and C. diff prevention efforts are all you need to control KPC, I get a bit worried.  There is no evidence that this one-size-fits-all approach works for infection prevention.  Yes, compliance with infection prevention is important, but there must be other approaches besides punishing the health care worker that will protect our patients. 

The larger problem is that little to no research funding is available to study the epidemiology and optimal prevention methods for Gram-negative (or Gram-positive) bacteria.  Before we blame the health care worker, perhaps we could ask why there is almost no funding for infection prevention research and implementation and why there are no new antibiotic classes in the pipeline.  You do get what you pay for...

Another use for the checklist

A press report from the Society of Critical Care Medicine Meeting outlines a study with a simple, novel intervention to improve hand hygiene compliance. In this study, investigators in a surgical/trauma ICU added a question to their daily care checklist: Has anyone seen anyone else touch the patient without washing their hands in the past 24 hours? If the answer is yes, the name of the offender is recorded. The result of this simple intervention was improved hand hygiene compliance from 69% to 89%. Though there isn't much detail about the study given in the report, one could envision how this would integrate front-line providers into a continuous vigilance that could be quite powerful. One downside is that this would likely not work well outside the critical care setting.

Wash 'em

Here's a new hand hygiene video, which comes from Thomas Jefferson University Hospital.



Sure beats $1,000 fines!

Click here to read more about the hospital's hand hygiene efforts.

Extreme infection prevention

The new "didn't wash hands!"

There are differences of opinion on how to motivate healthcare workers to comply with infection prevention measures. Some hospitals favor carrots. Others prefer sticks. And then there's the University of Pittsburgh Medical Center's Rambo approach. As reported in the Pittsburgh Post-Gazette, the hospital has implemented a new policy to improve handwashing compliance. Attending physicians who fail to wash their hands are fined $1000, residents and fellows $250, and all others will be sent home. It makes the old Far Side cartoon with an alarm and sign (didn't wash hands!) seem quaint.

This approach worries me. It's punitive and adversarial, and in the end, may damage the trusting relationship between hospital epidemiology and healthcare workers that I think is needed for effective infection control. Other hospitals have had successes in improving hand hygiene compliance without resorting to such extreme measures. It's really quite rare for a healthcare worker to refuse to wash when confonted, and offenders can still be held accountable. It makes me wonder how bad hand hygiene compliance must have been to drive this approach.

Well, I sure hope this strategy works, since I shudder to think what could be next. Public stocks? Caning? Finger amputations?

Oh, one last question:  who gets the money?

'Tis the data season

After 2 great weeks off, it was back to clinic, and meetings, and all the other stuff. And we've entered into January, my least favorite month. Cold and dark. But there is one thing I do like about January--the stream of data that hits my desk and the review of trends for our annual report. Today I received the hand hygiene data for 2010. Our group captured over 50,000 hand hygiene opportunities last year, a record for us. And our observers did this with the great app, iScrub, created by Phil Polgreen at Iowa. Overall compliance was 92%; 94% for nurses, and 85% for doctors. Not bad!

Pardon the interruption...

Photo: Society of Robots

There's a front-page article in this morning's New York Times on computer vision systems. The article discusses many different uses of computer vision, such as surveillance monitoring in prisons, but also describes applications in health care. Of interest to those of us in infection prevention is the capability for a computer to watch a healthcare worker interact with a patient and remind him when hand hygiene should have been performed. In the model in use at Bassett Medical Center, when the computer notes a missed opportunity for hand hygiene, it says, "Pardon the interruption. Please wash your hands." So for those hospitals that really want to drive hand hygiene compliance to high levels, here's a new high-tech, Big Brother option.

One more time: Wash. Your. Hands.

A new paper in Anesthesia and Analgesia takes a look at hand hygiene by anesthesia providers and transmission of organisms from their hands to anesthesia equipment and patients' IV stopcocks. The study was performed at Dartmouth and Kathy Kirkland was one of the authors. The study looked at 1st and 2nd cases in selected operating rooms. After cleaning, the anesthesia machine was cultured. Then the anesthesia provider's hands were cultured and after the case the anesthesia machine and patient IV stopcocks were cultured. The room was then cleaned, and the same algorithm for cultures was followed for the second case. Bioptyping of isolates was performed to determine whether the organism on the providers' hands matched the environmental isolates.

The major findings were:

• The hands of the anesthesia provider were contaminated with one or more major pathogens 66% of the time
• Bacterial transmission to the IV stopcock set occurred in 11.5% of the cases, with 47% of the isolates matching those on the anesthesia provider's hands
• Bacterial transmission to the anesthesia machine occurred in 89% of the cases, with 12% of the isolates matching those on the anesthesia provider's hands

Over the past several years much attention has been paid to improving compliance with surgical antimicrobial prophylaxis and improving hand hygiene compliance outside the OR. Moreover, surgical hand hygiene has been an integral part of the OR routine for eons. However, little attention has been paid to hand hygiene compliance by anesthesia personnel. Kathy and her colleagues have probably now changed that. Ok Anesthesia people, wash up!  

Global Handwashing Day

Only 13 or so hours (depending on your time zone) to the third annual Global Handwashing Day,which occurs October 15, 2010. This should not be confused with World Hand Hygiene Day, which occurred May 5, 2010 or even World MRSA Day or for those of you really in the know, "MDR-Acinetobacter Day," which occurred on Oct.4.2010.  All kidding aside, tomorrow is an important day to recognize the lack of access to basic soap and water that many children in the developing world need to prevent illness and death.  This day is for the children.

The graph below, from a 2005 Lancet paper by Luby et al., highlights why tomorrow is so important.  In Karachi Pakistan's squatter settlements, investigators randomized 300 households to plain soap/water, 300 to antibacterial soap and 306 to usual practice.  Both groups randomized to soap (antibacterial soap didn't matter) had 50% less pneumonia, 53% less diarrhea and 34% less impetigo compared to the control group. This day tomorrow is about making sure each child is on the green (or red) line and not suffering on the blue line.

Luby et al, Lancet 2005 doi link