And now for something completely different....

I always assume that in any highly intelligent, over-educated, opinionated group of people (my people!), there will be Monty Python fans...so I'd like to use John Cleese to change the subject and post a shameless plug.

As many of you (but not enough) know, the SHEA Education and Research Foundation sponsors a scholarship program for people who are interested in getting specialized training in developing, managing or improving antibiotic stewardship programs.  The funds to support the scholarships come from a campaign that was the brain child of the brilliant Dr Judy Guzman- Cottrill.  She founded the now annual "Race Against Resistance".  SHEA members sign up as fund raisers and most of them raise money around their participation in a local 5K, marathon, triathlon, or bike race between the SHEA spring meeting and IDWeek in October.   In the first two years of the program, the racers raised about $35,000 and sponsored 6 scholarship recipients to attend training courses. This year, the illustrious Dr David Calfee agreed to coordinate the program, as well as being a fundraising team member himself.

So I have three requests for the readership of this blog.
1. Be sure your trainees, junior faculty, and members of your local stewardship team KNOW about the availability of these funds.  If you are a trainee, junior faculty, on a stewardship team or thinking about starting or joining a stewardship team, apply yourself for scholarship funds and come along t0 the SHEA spring meeting or another training course, courtesy of the foundation. We are hoping to provide more scholarships this year and next so we need more people to apply for the funds!

2. Donate!  The more money raised, the more people we can sponsor.  The more people trained in antimicrobial stewardship, the better!  There is a team of 12 brave and true SHEA members who have committed to raise money for this cause.  Head on over to the website and pick your favorite, pick the underdog, pick the one who has the best picture, or no picture, and donate a few dollars to their cause. Only one month left until IDWeek, where the winning fundraiser will be recognized at the SHEA business meeting!

Here's the shameless part.  Yes, I am one of the fundraising team.  "But Hilary," you may be thinking, "I've never seen you run a step! Or swim, or bike....in fact you hate to exercise! What happened?"  Well, I'll tell you.  I asked David Calfee why this program wasn't open to a wider range of skills than just athletic abilities?  I believe I mentioned two of my best skills: drinking wine and reading books.  It seemed wrong to ask people to donate in support of my drinking more wine so.... I started a Speed Reading Race Against Resistance!  I committed to reading at least 8 books per month between the SHEA Spring Meeting and IDWeek - and to prove I'm keeping my end of the bargain, every month, I am posting short reviews of every book I read that month. You can find the reviews for May, June and July here (click on "Updates").  If you donate, the page update with book reviews is sent right to you! And I even came up with a slogan, "Let's show the runners, reading pays off!" 

Which brings me to my last request:
3. Start thinking now of what skills you have that could be leveraged into a Race Against Resistance Team. Next year I'd love to see more reading teams, walking teams, knitting teams, Pokemon Go teams, yoga teams, and cooking teams, in addition to the athletic teams, raising more money, to give more scholarships, to train more people in stewardship, to see fewer cases of C diff. 

Because really, even though we may argue about how, we're all committed to the same cause: keeping patients and providers safe and healthy. 

Don't eliminate hand hygiene surveillance in hospitals

Yeah. Mike's correct. Hand hygiene does prevent HAI. (everyone can relax and be happy) You just can't see it or measure it and that's important. Here's why:

This past month I wrote two posts (here and here) trying to explain why you can’t link ward-level hand hygiene compliance to reduced healthcare-associated infections on the ward level. I thought the argument was pretty simple – there are so many factors in addition to hand hygiene that are important to do when preventing specific HAI (insertion checklist for CLABSI or clipping not shaving for SSI) and there are so many hand hygiene opportunities that don’t specifically impact your HAI of interest (or 30 HAI of interest) that you can’t possibly link them statistically in a study or when reporting them in your annual infection control report.

Let me be clear. I never said hand hygiene was unimportant. I said the opposite several times. Hand hygiene is critically important for infection control, particularly MDRO prevention but also HAI reduction. But for both, you can’t see the association in a graph or statistically and that’s important. Why?

In infection control, we can audit and feedback two things: process measures and outcomes.

Process measures are metrics like CLABSI checklist compliance or hand hygiene compliance. We know process measures are important for patient safety and they are easy to measure and directly remediable to education or other improvement interventions. If you see hand hygiene compliance is falling, you can educate clinicians about hand hygiene.

Outcomes measures are metrics like CLABSI rates or CAUTI rates. These are typically more difficult to measure and are delayed compared to process measures. SSI rates take a lot of person-time to track and surveillance occurs over many months for some procedures. When reviewing the literature in 2016 before giving a SHEA talk on Outcomes vs Process Measures, I found a general consensus that risk-adjusted outcomes measures are preferred to process measures because that's what the public wants to see – lower infections.

So here is why this is important. When manuscript reviewers or bloggers say ward-level hand hygiene reduces ward-level HAI, they are really saying they don’t care about hand hygiene monitoring. Specifically, they are saying – “If your intervention increases hand hygiene compliance but you can’t show me reduced HAI, I'm not interested.” We all know hand hygiene monitoring is time-consuming, costly and biased by the Hawthorne effect. So why monitor it? If hand hygiene can be linked so clearly to 30 HAI as Mike proposes, we should just go ahead and report the outcome measures (HAI rates), which will save us time and money. One less thing to do.

Let me summarize. Hand hygiene is critically important for MDRO prevention and HAI prevention. Yet, you can’t link these in clinical studies nor will you see a genuine association in your hospital’s annual report. Not seeing an association DOES NOT mean hand hygiene is unimportant.

Overcoming dogma is hard and seeing Mike’s arguments affirms my earlier trepidation. I’ll take full blame that I didn’t reference CDC and other papers like he did (although he misquoted them, to be clear). One of the things I like about blogging is that I can give you the gist without citations. But I was a bit sloppy. I’m sure I could be a better writer, but many criticisms in Mike’s post don’t hold water – perhaps I will respond in the comments or in a future post (when I am not 35,000 feet above the Pacific). For example, hand hygiene is part of the insertion bundle, but I find no mention of monthly hand hygiene compliance as being important. I'll also add that when I write these posts you are seeing my struggle to understand something. What I really appreciate about the twitter comments, both positive and negative, and Mike's post is that they make me critically determine where my ideas need more work or better explanation.

However, if we take dogma and Mike’s arguments to their logical conclusion, they suggest we can eliminate the process measure hand hygiene compliance in studies and in hospitals and replace it with HAI outcome reporting. I will say I’m surprised with this inevitable conclusion. I think that’s a huge mistake.

So there’s no misunderstanding: KEEP MONITORING HAND HYGIENE COMPLIANCE

Hand hygiene MOST CERTAINLY prevents healthcare associated infections

I’ve spent some time trying to process Eli’s last two posts on hand hygiene. It’s tough to untangle his logic and I’m not sure what he’s trying to prove. But here’s my point-by-point response:

In the first post, he notes: “if puerperal fever was a CDC HAI and clinicians didn't wear gloves, we could still say hand hygiene prevents HAI. However, that's not the current reality.” Well, puerperal fever is a CDC HAI (see here, page 23).

Next he states that CDC defines HAI as CLABSI, CAUTI, SSI and VAP. That’s a true statement, but I think he’s implying that CDC defines HAIs as only those 4 (particularly in light of the paragraph above). Actually, CDC has defined over 30 HAIs (definitions here, page 4).

He goes on to say that the WHO hand hygiene moment #2 (hand hygiene before clean and aseptic procedures) is not part of the CLABSI bundle published by Peter Pronovost. But Pronovost’s article (to which he links) states otherwise:

Per Eli, “Do we really think that interns and nurses practicing hand hygiene on the wards prevents SSIs to any measurable extent compared to pre-operative CHG bathing or peri-operative antibiotics?” Well, to Eli I would say, the next time one of your family members has a surgical procedure, tell the surgical team that they don’t need to perform hand hygiene before touching your loved one’s fresh surgical wound.

He argues that hand hygiene is not a significant component in the causal pathway for HAI, then four paragraphs later goes a step further and states that hand hygiene is not in the causal pathway. While for some HAIs hand hygiene may not be the most important risk factor, it is nonetheless a risk factor and it is indeed in the causal pathway. Then we come to twisted logic. Per Eli, hand hygiene prevents transmission of microorganisms but it doesn’t prevent HAIs. However, transmission of microorganisms is an intermediate outcome that can lead to HAI. It’s like saying: guns don’t kill people, bullets do.

He states that interventions to improve hand hygiene are not used for outbreak control. That’s contrary to my experience. We focused on hand hygiene in almost every outbreak that I managed over two decades as a hospital epidemiologist. In some cases, it was one of our first interventions while we proceeded with the investigation.

His next post focused on how you cannot correlate ward-level hand hygiene compliance with HAIs. Given the relatively small number of observations collected, and the relatively small range of compliance, I agree.

He shows an Ishikawa diagram of factors leading to CLABSI, but it and his subsequent logic ignore the fact that CLABSIs are not just associated with catheter insertion. In fact, we rarely see insertion-related CLABSIs anymore because the CLABSI bundle (which includes hand hygiene!) is so effective. The typical CLABSI now occurs in patients who have had a central line for weeks to months. So, the important factors now are associated with line maintenance (e.g., the line dressing, skin hygiene, minimization of entry into the line for lab draws, etc).

He next estimates how many months of hand hygiene observations are necessary to witness one opportunity where the HCW touches a CVC? But his focus is on how many observations are performed not on how many opportunities exist. I’ve previously estimated that in a 700-bed hospital there are 15 million hand hygiene opportunities per year. Using Eli’s estimates (which I have no reason to doubt), that translates to 30,000 direct manipulations of a central venous catheter yearly. I sincerely hope that every one of those was preceded by hand hygiene, and I suspect almost every hospital epidemiologist and every patient hopes so, too.

I get Eli’s point that trying to precisely measure hand hygiene compliance is dumb. But I think there is value in the process of monitoring hand hygiene because it keeps hand hygiene top of mind. It’s the Hawthorne effect in action. And the past decade or so of all this measurement has made a difference. If I compare the present to when I was a house officer 30 years ago, it’s amazingly different. There was zero focus on hand hygiene in the 1980s. There were many fewer sinks and no alcohol-based products available. We have made enormous progress.

My thoughts on hand hygiene are simple: It’s important. It’s really important. Keep doing it. Keep measuring it. It eventually becomes a habit. And someday, it will be so ingrained we won’t need to talk about it anymore.

Trying to link ward-level hand hygiene compliance and healthcare-associated infections

I've spent 15 years studying hand hygiene, so I obviously think it is critical to safe healthcare delivery. As I mentioned in my prior post on hand hygiene and HAI, sometimes these posts are difficult to write. The difficulty stems from the inertia required to confront dogma, while simultaneously bracing for the inevitable criticism. And of course, I could be completely wrong. Often times, dogma is correct.

But as I've gazed out of my office in the old Singapore CDC (soon to be replaced by a shiny new NCID), I've had moments to consider various causal diagrams linking hand hygiene to various outcomes, like CLABSI. (see below or source) If you carefully examine (click to expand) this or other causal models you see that hand hygiene is there, but it is only one of many possible causes of CLABSI. So, strictly speaking hand hygiene is in the causal pathway to CLABSI development. That's the dogma and it's true, to a point.

But let's move on to my contention: ward-level or ICU-level hand hygiene compliance changes can't be linked to reductions in HAI. For example, no amount of raising hand hygiene from 0% to 100% can be associated with reductions in HAI, such as CLABSI. It's just not mathematically possible. Sure, some study might show such an association, but I wouldn't believe it.

So to borrow a strategy used often by fellow blogger Mike, I'll use math(s).

Most facilities monitor hand hygiene compliance with direct observation. On the ward level, we reported that less than 30 opportunities/ward/month are collected. That was in 2012, so let's say things are much better and we observe 100 opportunities. This actually doesn't matter - you could observe 10,000 per month with an automated system, but let's stick with 100 opportunities.

Now, let's estimate how many opportunities are related to HH moment #2 (before aseptic procedure). Most estimates that I've seen are close to 10%. And how many of HH moment #2 involve directly manipulating a central venous catheter - let's go with 2%. You can estimate a lower or higher rate depending on ward acuity, but I'm going to stick with 2% since the vast majority involve peripheral lines. So, 2% of 10% is 0.2% or 0.002.

So, how many months of 100 observations/month are required before we witness one opportunity where the HCW touches a CVC? Answer: 5 months.

Now over those 5 months, let's assume we have observed a hand hygiene compliance of 50%, so 250/500. Let's also assume the worst and say that HCW were 0% complaint with CVC-related moment #2 in those 5 months. Now, let's assume they were 100% compliant over the next 5 months after we targeted a hand hygiene education program to moment #2. Our compliance would increase to 251/500 or 50.2%. Any other increases in hand hygiene would not be in the causal pathway for CLABSI, so even if compliance shot up to 80%, we would only care about the 0.2% increase.  In fact, this highlights why it's difficult to link ward-level hand hygiene compliance to reduced CLABSI, since most of the increase does not involve CVC-related moment #2. It's almost all noise.

And if you still want to install the automated monitoring system, you can multiply the numerator and denominator by 100, and still have 25000/50000 (50%) with an increase to 25100/50000 (50.2%). And if your hand hygiene education was super successful and compliance increased to 80% (40000/50000), it would still be true that only 100 of the 15000 additional compliant opportunities would be CVC related. 100/15000 is 0.67%. Thus, CVC related hand hygiene opportunities are a needle in a haystack.

I encourage you to check my math, choose different rates or numbers and correct me in the comments below or on Twitter. Sadly, it's hard to link ward (or ICU) level hand hygiene compliance to ward-level CLABSI rates. But as I've said before, keep washing your hands and monitoring hand hygiene compliance in your hospital. No one wants a CRE outbreak.

Hand hygiene doesn't prevent healthcare associated infections

Not all transmission leads to infection and not all infections are preceded by transmission. Hand hygiene prevents transmission, not infection.

....some posts are just hard to write.

One of the persistent beliefs in infectious diseases and infection prevention is that hand hygiene compliance prevents healthcare associated infections. Perhaps this harkens back to Semmelweis and the prevention of puerperal fever through hand disinfection. Of course, if puerperal fever was a CDC HAI and clinicians didn't wear gloves, we could still say hand hygiene prevents HAI. However, that's not the current reality.

CDC defines HAI as CLABSI, CAUTI, SSI and VAP. We can even consider hospital-onset BSI and almost any other infection we can track using CMS or EMR data and monthly aggregate hand hygiene compliance is not a significant component in the causal pathway for the development of an HAI.

Sure, hand hygiene/sterile gloves before catheter insertion and hand antisepsis prior to invasive surgical procedures are standard practice. However, when I talk about hand hygiene compliance, I mean monthly hand hygiene on room entry/exit or following the WHO 5 My 5 Moments during care on medical wards and in ICUs. And yes, there are instances where Moment #2 - before clean/aseptic procedure could potentially reduce CLABSI, but the proportion of CLABSI caused by such breaks in moment #2 pale that occur outside of the insertion bundle pale in comparison to those prevented with the highly effective CLABSI bundle. Otherwise, monthly aggregate hand hygiene compliance would have been included in the CLABSI bundle. It wasn't.

Let's discuss SSI prevention. Do we really think that interns and nurses practicing hand hygiene on the wards prevents SSIs to any measurable extent compared to pre-operative CHG bathing or peri-operative antibiotics?  No, I didn't think so.

How about we look at this another way. If you were called by a CT surgeon because of an outbreak of SSI in CABG patients or an outbreak of CLABSI in her ICU, would you first (or second or third) start a hand hygiene campaign? I assume no and thus, you don't think hand hygiene prevents SSI or CLABSI. 

Thus, for all practical purposes, we won't be able to do studies associating improved hand hygiene compliance on the wards or ICUs with reduced infections. Even when such studies are done and do show an association, they have minimal basis in causal reality. Requiring hand hygiene bundles and intervention studies to show reduced HAI is incorrect and counterproductive. Since hand hygiene on wards and ICUs is not in the causal pathway for HAI incidence, we shouldn't expect hand hygiene to prevent them.

But all is not lost. Hand hygiene does prevent MDRO transmission (and indeed transmission of susceptible pathogens) in healthcare settings. Hand hygiene is critical to tackling the MDRO crisis but these benefits aren't currently captured by CMS and most EMR systems. To document the benefits of hand hygiene, we would need to complete surveillance for important pathogens on admission and discharge and document acquisition or transmission. This is expensive and likely not necessary nor feasible.

Keep your heads up and continue to drive hand hygiene compliance. Continue to do hand hygiene surveillance and improvement studies! Hand hygiene is critical to MDRO prevention and likely the future of healthcare. Just stop it with the HAI target.

Addendum: This post was written in response to the question: "Do you care about increases in monthly hand hygiene compliance if you can't document reduced HAI?" I would answer yes. Hand hygiene is an important clinical outcome in itself and requiring HAI reductions is a trap. Don't fall into that trap. I've attempted to explain why here.

Addendum 2: In response to this post, others have mentioned CDI as an HAI that could be targeted with hand hygiene interventions. As Dan mentioned back in 2013, CDI might not be the optimal target since a minority of cases appear to be related to in-hospital transmission. This was shown back in 1994. Stewardship might be a more appropriate intervention for CDI prevention.

Is the CLABSI metric now doing more harm than good?

It’s a good news, bad news situation. 

The good news is that we’ve got an effective bundle of practices that can prevent most central line associated bloodstream infections (CLABSIs). Public reporting and pay-for-performance have added to the incentive for hospitals to implement these practices, leading to a dramatic nationwide decline in CLABSI rates. 

The bad news for most hospitals is that the remaining events that meet the NHSN CLABSI definition represent a motley assortment of “one-offs” that aren’t clearly preventable (see this great post from Scott Fridkin for more detail, and to share your “one-offs”). Given how low the CLABSI baseline now is, just a slight “blip” in these one-offs can push a hospital’s SIR above 1 and contribute to financial penalties (for some perspective, the post-intervention CLABSI rate in the widely cited Keystone ICU project (1.4 per 1K line days) now translates to an SIR of >1 at many hospitals). 

These blips result in a tremendous amount of effort by unit leadership and infection prevention programs, as they examine each event for preventability or for common themes—often concluding that the events are either secondary or mucosal-barrier injury (MBI) attributable, but don’t meet the requisite NHSN definition (so must be reported as primary CLABSIs).

HAI definitions, like lab diagnostics, perform best when applied to individuals with moderate-to-high pretest likelihood of disease (or, populations in which the disease is prevalent). This leads to a paradox for HAI surveillance—as prevention approaches improve and HAI rates fall, the positive predictive value of surveillance definitions also declines (if one defines a “true positive” as an event that meets an intuitive clinical definition of the HAI in question—e.g. an old-fashioned primary CLABSI likely to be due to breaches in the process of line insertion and care).

Aside from the time and energy spent chasing one-offs, the continued pressure on the CLABSI metric is going to result in some counterproductive approaches to reach “zero”. After all, there are really only two ways to eliminate CLABSI as it is currently defined: (1) stop using central lines, and/or (2) stop obtaining blood cultures in patients who have central lines.

Hope ya' don't mind if I pay ya' in change!

Many of you may have heard that CMS is proposing to change the payment rates for outpatient care, including that provided by ID physicians. A detailed explanation of the proposal can be found here, but for a simple illustration please see the short video below:

Yes, it’s almost that bad. How many hours do you invest in seeing a new outpatient with a complicated problem, including review of voluminous records, the clinic appointment itself, the follow up calls, the time spent obtaining authorization for various tests or scans, and the EMR time to document it all? Now divide $135 by that number.

So yea, please submit comments directly to CMS and contact your congressperson!