Learned Helplessness and Hand Hygiene
MSKCC's Kent Sepkowitz has a recent commentary in Lancet ID on hand hygiene. He thinks that modern hospitals are too clean to benefit from hand-hygiene improvement efforts (I guess he hasn't read this paper). He concludes:
"The time has come for the infection control community to move on;
please, no more cheerleading louder and harder to get thousands of
people to improve their hygiene. We have to accept that our age-old
dream of solving a complex problem cheaply and simply has failed.
Instead, we must reacquaint ourselves with that lonely feeling familiar
to clinicians when they realize a case is much more difficult than it
appeared at first glance. In other words, we should embrace the
intellectual audacity of our beloved Semmelweis but let go of his how-to
manual. As he might tell us (loudly): an ineffective remedy is much
worse than no remedy at all."
Is he right? I don't think so. There have been only 4 hand-hygiene intervention studies in the past few decades of high enough quality to warrant inclusion in the 2011 Cochrane Review. I say before we throw in the towel, bury our collective heads in the sand and go all Eeyore, we should probably do a few more than 4 good studies. I also suspect that if we could really figure out why MRSA has declined in recent years, it would come down to hand hygiene improvements and not some expensive PCR.
This argument is pathetic. The problem is a tricky one but it's not hopeless.
ReplyDeleteHere's a couple of examples: one that I watched happen, with outcomes:
http://www.nejm.org/doi/full/10.1056/NEJMoa1007474
or http://www.nytimes.com/2011/04/14/health/14infections.html
(At the outset this must have been the most unpopular program I saw in nearly 10 years at VA HQ.)
One that I worked on, just with process data: http://www.springerlink.com/content/nt14360404731823/
(By the way, the latter one is one that the Cochrane review considered but didn't include.)
Some have speculated that the VA MRSA study was so effective (note that rates of CLABSI, VRE, Cdiff, and VAP went down at the same time) because all the money spent on PCR and other testing convinced people that the program was serious and not "a joke", which is something that people tend to conclude about many other patients safety improvement projects. One thing it did do, was make clear which patients acquired MRSA in the hospital, in the ICU, at home (on testing when readmitted), etc., because it tested on all the transitions -- which may have been another motivator to be serious about hand hygiene, gloving, terminal cleaning of rooms, etc..