Infection control across the pond

An upcoming issue of the Journal of Hospital Infection has a perspective written by Dr. Stephanie Dancer, the journal's editor. Entitled "Pants, policies, and paranoia..." her piece examines the push in the UK to reduce infections by focusing on the role of clothing and poor hand hygiene compliance in infection transmission. Her primary argument is that these issues are distractors from the real problems that are not being addressed by the National Health Service, namely suboptimal facilities that are suboptimally cleaned and understaffed.

She, like many others, argues that no studies have demonstrated that clothing transmits infections. You can read my counterargument here, but I'll simply state that no study has demonstrated that you need a parachute when you jump out of a plane. Absence of evidence is not necessarily evidence of absence. But most disappointing is her fatalistic approach to hand hygiene: we can't improve it, so why bother? The reality is that with a lot of work, hand hygiene can be improved (see here and here), and I think this can have a major impact on the incidence of infections in hospitals.

I don't have any first hand knowledge about the state of hospitals in the UK, but I can tell you there are many beautiful, spacious, apparently clean hospitals in the US with terrible infection control problems. While it may be true that the NHS is using hand hygiene and bare below the elbows to divert the public's attention from infrastructure problems, I still think infection control is mostly about what happens at the bedside and how well healthcare workers observe good practices.

Infections in the ICU: New data, new insights

This week's JAMA contains an important paper and editorial for all of us in infectious diseases and hospital epidemiology. The EPIC II study was a one-day point prevalence study of infections in 1,265 ICUs in 75 countries involving 13,796 adult patients.

Key findings include:

• 51% of the patients had infections (this includes both community-acquired and hospital-acquired)
• 71% of the patients were receiving antibiotics
• Gram-negative organisms accounted for 61% of the infections (up from 39% in the EPIC-I study done 15 years ago)
• MRSA accounted for 10% of infections
  

In my medical school psychiatry course, I learned that a delusion is a fixed false belief. And it's a delusion to continue to think that hospitals should fixate on MRSA and continue with a search and destroy strategy. The gram-negatives are a major threat not only because they are increasing in incidence but also because the therapeutic options are quite limited. 

Positive deviance and common sense

When I first heard about “positive deviance” (and learned that research funding was being distributed to study it), I assumed it was a new, high-level approach to quality improvement that I needed to master. But every time I read about it, or asked someone to explain it to me, it seemed very much like common sense…..empower people to change things for the better, then recognize and learn from those who succeed.

So I enjoyed this article about positive deviance from the Boston Globe, loaded with examples (several from healthcare settings). The first sentence of the last paragraph sums it up for me:

“At bottom, positive deviance amounts to simple common sense”

Many of the controversial infection control approaches we discuss in this blog are best understood as the opposites of positive deviance. I’m thinking of legislative mandates and other dogmatic, punitive approaches to infection control (e.g. legislation requiring hospitals to adopt a single approach to MRSA control, mandating an annual vaccine under threat of dismissal, etc.).

Any of you out there who consider yourselves black-belt positive deviants, feel free to enlighten me about its many complexities.

A low-cost but effective hand hygiene observation program

The December issue of Academic Medicine has a paper that describes UCLA Medical Center's hand hygiene program, which uses pre-health career college students as volunteer observers. The students are trained to use standardized tools and the program yields about 9,000 observations per year. The authors of the paper note that the advantages of the program are that it gives the students experience in the healthcare setting and its low cost ($5,000/year). Disadvantages are the lack of nighttime observations and gaps in observations when the university is not in session. Hand hygiene across the institution has increased from 50% to over 90%. Click here to view the program's website.

At VCU Medical Center we are currently in the third year of our observer program, which also relies on students (undergraduate and graduate). Our observers are paid an hourly wage, which allows us to obtain nighttime observations as well as year-round coverage. Although our program is four times more costly (still a bargain), it yields four times as many observations, and the results in improvement in hand hygiene compliance are very similar to those at UCLA.

New Jersey hospital bans neckties

Jersey City Medical Center will now prohibit healthcare providers from wearing neckties. Bowties are still allowed. From the infection control standpoint, I think banning white coats would have a bigger impact, but it's a good start to push healthcare workers to become more cognizant of the role of clothing in infection control.

More freaky feedback, please

In a post today on his “Freakonomics” NY Times blog, Stephen Dubner continues the hand hygiene discussion Mike blogged about recently. He highlights a reader comment about “closing the loop” by providing real time reminders to doctors that their hands are contaminated. I agree that providing frequent and timely reminders is a critical part of improving hand hygiene, but I don’t think it is necessary that such reminders focus solely on the presence of microbes….I (unlike some of my colleagues) believe that most physicians have accepted the germ theory of disease, and most also realize that their hands can (and do) carry pathogens that pose risks to patients.

So I think several varieties of feedback will do: adherence rates, infection rates, bedside reminders from patients, families or healthcare workers, the intermittent presence of a discreet observer, any of these will help. It is essential, though, that such feedback be provided as close to the point of care as possible (we all know how effective feedback is when given in a large auditorium or conference room!). And as for the common refrain that we’ll never achieve sustained adherence rates over 60-70%? Wrong. We have plenty of experience now that higher rates can be both achieved and sustained.

Looking for a flu shot?

If you're wanting to get a flu shot, Google has a great tool--FluShot Finder. Click here, enter your zip code, and you'll get a listing of where the seasonal and H1N1 vaccines are available near you, along with a map. Pretty cool!

Impact of bare below the elbows on hand hygiene

A new study in the Journal of Hospital Infection evaluated the quality of hand hygiene in physicians and medical students using an alcohol based product that contained a fluorescent marker, which allowed for a highly quantitative measure of surface area that was decontaminated. (I'll post a link to the PubMed citation as soon as it's available). Hand hygiene effectiveness was compared between study subjects who were bare below the elbow and those who were not. As might be predicted, there was no difference in decontamination of hands between the two groups; however, decontamination of wrists was significantly better in the bare-below-the-elbows group.