Fake News in Your Hospital: Hand Hygiene Compliance

Fake news and how it influences policy and politics has been grabbing headlines lately. I'm sure many who read this blog are rightly concerned about this development. If we can't even agree on the truth, how can we set about making policy and solving problems?  What struck me about the fake news discussions is that we have an example of fake news in our hospitals - reported hand hygiene compliance!

A few weeks ago, I wrote that hand compliance in your hospital is likely between 34% and 57%, since a review of trials published since 2009 reported those levels before and after interventions were implemented. Apart from that study, how can I know your true compliance rates when you're reporting hand hygiene compliance rates over 90%?  I have several reasons.

First, harken back to this 2010 interview of Mark Chassin, then and current President and CEO of The Joint Commission. In the interview, he shared the initial results of their "proven effective solutions for improving hand hygiene compliance in hospitals", which were developed in 8 center hospitals and further evaluated in 29 additional hospitals.  At the beginning of this project, hand hygiene compliance was 48%. Look at what Dr. Chassin said about the baseline rate - "It’s interesting that a number of the hospitals were misled by faulty data to believe that they were doing as well as, say, 85%, at baseline rather than 48%."

Second, even after their huge hand hygiene initiative, they were only able to get compliance up to 82%. Interesting, so even The JC acknowledges that you can't get to 90% compliance. Yes, but that was 2010, what about 2017?

Third, The Joint Commission's National Patient Safety Goal 07.01.01 for 2017 doesn't require hand hygiene compliance over a specific threshold (see Figure below). Hospitals only have to set goals for improving compliance and then improve compliance based on those goals.  So why do hospitals continue to set unreachable goals for hand hygiene compliance (say over 90%)? Are there downsides with setting fake goals - do they hurt our credibility, do they result in a feeling of learned helplessness among clinical and infection prevention staff and do they harm our patients?

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Side note: One of the things that struck me when rereading the Chassin interview is the dissonance between the primary barrier to hand hygiene compliance that The Joint Commission identified and their planned "next steps" to get compliance above 82%. I pasted the quotes below. Do you think their interventions addressed the identified barrier?  Me neither.

Primary Barrier: "So, for example, for one of the causes (“hands full”), which was a surprise for many of the participants, caregivers approach a patient’s room with their hands full—for example, a nurse is carrying materials to do a dressing change—and there’s no place to put the materials down. The hand-gel dispenser is right there, on the wall, but there’s no place to put the materials down, so what do you do?"

Joint Commission Solution: "We’re looking to industry to address one of the more difficult parts of sustaining and getting past 80%, namely, replacing this very labor-intensive measurement system with devices, software solutions, and applications that are relatively inexpensive but will provide real-time feedback on performance."

Image Source: AIM

Getting rid of the white coat

I was just given a copy of the DecisionHealth publication Inside the Joint Commission.  The March 21 issue includes an article (posted below) that mentions our old white coat contamination study (free full text AJIC 2008). We reported that 23% of white coats were contaminated with S. aureus and 64% of physicians had not washed their white coats in more than a week.

The IJC article quotes the CEO of a healthcare consulting firm who suggests that many clinics have eliminated laundering services for cost-cutting reasons and didn't consider infection control.  The money quote:

"The best solution from an infection-control perspective may be to get rid of the white coat altogether, but “it’s part of the old culture,” Searfoss says, and may be difficult for some physicians to part with."

I couldn't agree more.

Multidisciplinary, multifaceted approach to C. difficile prevention - It works!

Clostridium difficile - bad.

Many good people doing a lot of good things to prevent C. difficile - Priceless

That's the basic summary of a recent report in The Joint Commission Journal on Quality and Patient Safety by Len Mermel and colleagues at Rhode Island Hospital. Faced with a high burden of CDI, they implemented a series of six "interventions" targeting C. difficile between 2006 and 2012.  These interventions were: (1) develop a C. difficile hospital infection control plan based on a risk assessment; (2) monitor hospitalwide morbidity and mortality associated with C. difficile infection; (3) improve sensitivity of C. difficile toxin detection in stool specimens using a PCR assay; (4) enhance environmental cleaning of patient rooms and equipment; (5) develop a C. difficile infection treatment plan; and (6) conduct other interventions including attempting antimicrobial stewardship.

Overall, the results were impressive with a 70% reduction in incidence. From a peak of 12.2 cases per 1000 discharges in 2006 rates fell to 3.6/1,000 discharges in 2012 with comparable declines in CDI-related mortality. Using time-series analysis they reported a change in slope of quarterly healthcare-associated CDI cases per 1000 discharges after each intervention, which you can see in the figure below. The slopes of each line are associated with (from left to right) the (1) pre-intervention period, (2) education, outcome reporting and room cleaning monitoring, (3) bleach product use for room cleaning, (4) PCR testing (5) additional room cleaning personal hired with defined responsibilities, (6) equipment cleaning training and monitoring.

Here is the link to the full text of the article (subscription required). Is it me or should Joint Commission's journal be open access in 2013?

Joint Commission and Influenza Vaccination: IC.02.04.01

This seal in no way suggests that the
Joint Commission approves of this blog

The Joint Commission has just released proposed requirements addressing influenza vaccination of staff and licensed independent practitioners. Revisions to current requirements are proposed for Hospital, Critical Access Hospital, and Long Term Care accreditation programs with new requirements proposed for Ambulatory Care, Behavioral Health Care, Home Care, Laboratory, Medicare Based Long Term Care, and Office-Based Surgery accreditation programs.  Comments will be gathered until May 17, 2011.

You can review the proposed standards and leave comments on the JC site here.

For the Hospital Accreditation Program IC.02.04.01, elements 1-3 remain the same, elements 4 and 5 have been revised and elements 6-9 have been added. The new text is bolded below and the revised elements are:

1. The hospital establishes an annual influenza vaccination program that is offered to licensed independent practitioners and staff

2. The hospital educates licensed independent practitioners and staff about, at a minimum, the influenza vaccine; non-vaccine control and prevention measures; and the diagnosis, transmission, and impact of influenza. (See also HR.01.04.01, EP 4)

3. The hospital provides influenza vaccination at sites accessible to licensed independent practitioners and staff.

4. The hospital annually evaluates vaccination rates and the reasons given for declining the influenza vaccination.

4. The hospital includes in its infection control plan the goal of improving influenza vaccination rates. (For more information, refer to Standard IC.01.04.01)

5. The hospital takes steps to increase influenza vaccination rates.

5. The hospital sets incremental influenza vaccination goals, consistent with achieving the 90% rate established in the national influenza initiatives for 2020.

6. The hospital develops a written description of the methodology used to determine influenza vaccination rates. All hospital staff and licensed independent practitioners are to be included in the methodology for determining the influenza vaccination rates. (See also IC.02.04.01, EP 1)

7. The hospital evaluates the reasons given by staff and licensed independent practitioners for declining the influenza vaccination at least annually.

8. The hospital improves its vaccination rates according to its established goals and at least annually. (For more information, refer to Standards PI.02.01.01 and PI.03.01.01)

9. The hospital provides influenza vaccination rate data to key stakeholders including leaders, licensed independent practitioners, nursing staff, and other staff at least annually.

Two new NPSGs from the Joint Commission target VAP and CAUTI

University of Iowa, Class of 2013

The Joint Commission has just released new National Patient Safety Goals for 2012-13 for full implementation by January 1, 2013.  They cover VAP and CAUTI in hospitals and LTCF and are open for public comment until 1/27/2011.  The strategies were published in the October 2008 SHEA Compendium in ICHE. 

Two comments: (1) I thought the world was going to end in December 12, 2012, so probably not much to worry about, apart from the world ending and (2) VAP may be going away in NHSN to be replaced by process measures, so I wonder how VAP outcomes will be tracked, as required, when no one can decide on a definition? I'm sure you have comments and they want to hear from you.

Note: It looks like even if the Mayans were wrong about 2012, we may still not make it through 2013.

Example for VAP, NPSG.07.06.01 in Hospitals requires 7 steps:
1) A plan
2) Hand hygiene before/after caring for ventilated patients
3) Semirecumbent position of patient
4) Regular antiseptic oral care
5) Daily weaning assessment
6) Daily sedation interruption
7) Measure VAP process measures and outcomes

Hospital Program draft versions of NPSG.07.06.01 (VAP) and NPSG.07.07.01 (CAUTI) (PDF)
LTC Program versions (PDF)
JC page that provides links for submitting comments.

h/t Marc Wright

It's a slippery slope....

The Joint Commission issued press releases yesterday to announce its new initiative, the Joint Commission Center for Transforming Healthcare. The concept is that the Joint Commission will play an active part in assembling key organizations to develop solutions to some of healthcare's toughest problems. One of the first initiatives is on hand hygiene. While the goal of this new center is laudable and the intent seems to be pure, what is concerning to me is that this project has corporate sponsors, at least some of whom would appear to have vested interests in the solutions that may be developed. Given the intense spotlight on conflict of interest currently, I'm surprised that TJC would allow corporate sponsorships.

Help!

If there is anyone out there who thinks they understand the Joint Commission's National Patient Safety Goal on multidrug resistant organisms, please let us know. We really worked on it today, but you get the feeling that it was written by someone with fluent aphasia. You read a sentence and the words sound good, but then as your brain processes it, you have the uncontrollable urge to say "huh?"