Annual US Deaths from MDRO: 23,000 - Deaths from Alcohol Hand Rub Fires: Zero

I just returned from the Healthcare Epidemiology Training course in Ho Chi Minh City, Vietnam where I had a wonderful time interacting with the students and other faculty. Thanks to Professor Le Thi Anh Thu, we had the opportunity to tour an 1800-bed hospital in the city and observed many barriers to infection control including an average daily census greatly exceeding the bed capacity; many patients are forced to share beds with other patients. However, in one area Vietnam is far superior to the United States - they allow alcohol hand rub at the bedside! You can see Joost Hopman, Andreas Voss and I touring a medical ICU in Vietnam - notice the green hand rub dispensers at the end of the beds.

In the US, fire code prevents alcohol hand rub from being placed at the bedside rendering the practice of the WHO 5 moments impossible. Healthcare workers simply don't have the time to leave the room to practice hand hygiene after each contact with the environment or patient. 

Here is the WHO's take on the fire risk of alcohol hand rubs: The benefits of the alcohol in terms of infection prevention far outweigh the fire risks . A study in Infection Control and Hospital Epidemiology (Kramer et al 2007) found that hand rubs have been used in many hospitals for decades, representing an estimated total of 25,038 hospital years of use. The median consumption was between 31 L/month (smallest hospitals) and 450 L/month (largest hospitals), resulting in an overall consumption of 35 million L for all hospitals. A total of 7 non-severe fire incidents were reported. No reports of fire caused by static electricity or other factors were received, nor were any related to storage areas.

So let's review the US situation:

Deaths from resistant bacteria? 23,000

Deaths from alcohol hand rub fires? 0

Changing state fire codes to allow alcohol hand rubs at the patient bedside? Priceless

Patient - Wash Thy Own Hands!

There has been increasing attention over the past decade in engaging patients in patient safety. In infection control this trend has manifest through efforts to have patients monitor and encourage hand hygiene compliance among health care workers. In a related trend, there is also increased interest in patients washing their own hands in a framework called "patient-centered hand hygiene." My understanding of this approach is that having patients clean their own hands could potentially increase their engagement in infection control initiatives including encouraging health care workers to practice hand hygiene. This approach might also have the additional benefit in decreasing the organism burden on patients' hands and interrupting direct or indirect transmission of MDROs in healthcare settings.

It is with this background that Kundrapu and colleagues at CWRU and the Cleveland VA completed a randomized trial of soap and water versus alcohol hand rub in reducing C. difficile spore burden on patients' hands. Forty-four infected or colonized patients were included in the study. Hand cultures were positive in 32% of patients with CDI and 38% of colonized patients prior to hand hygiene. As you can see from the figure below, soap and water significantly reduce the proportion of positive cultures and mean CFUs, while alcohol hand rub did not. Interestingly, around 10% of patients still had C. difficile recovered after washing with soap and water. Seems like a trial is in order to determine the role of patient hands in transmission and whether cleaner patient hands reduces the incidence of CDI and other MDROs in hospital settings. One major limitation is that this intervention could not be implemented in settings where the need is the greatest, namely ICUs, since most patients would be too sick to wash their hands.

Searching for an Optimal Hand Hygiene Bundle

One of the things we frequently discuss is the central role that hand hygiene compliance plays in preventing the horizontal transmission of resistant bacterial pathogens. 16 "hand hygiene" posts so far in 2013. Hand hygiene compliance is consistently lower than we wish for and it's common that healthcare workers are blamed for poor compliance. I've often mentioned the 2011 Cochrane Review of "Interventions to Improve Hand Hygiene Compliance in Patient Care" and how only 4 papers made the cut, as it struck me that the inclusion criteria were too restrictive. We then wondered if expanding the number of studies included would offer any additional guidance for developing a standardized hand hygiene improvement program.

With the support of the VA National Center for Occupational Health and Infection Control (COHIC) and VA Office of Public Health, Marin Schweizer and our group at Iowa City have completed an extensive meta-analysis of interventions (and bundles) targeting hand hygiene compliance (just published in CID). The review included all studies published from 2000-2012; The year 2000 was selected since ABHR became more widely utilized around that time. 8148 articles were identified and 46 studies were reviewed and included with 1/3 from the US and 1/3 from Europe.

There were several important findings:

1) Only 46 studies from 45 populations have been completed in over a decade. For a critical intervention, this is an unacceptably low number of studies. Funding agencies (and folks that blame HCW for poor compliance) should take note.

2) Meta-analyses of single interventions could not be performed because there were too few studies. It's surprising that we are building bundles without examining individual components first.

3) Increasing the number of interventions included in a bundle was not associated with greater improvements in compliance. For example, bundles with only 1 or 2 interventions were associated with more than a 3-fold increase in hand hygiene compliance while bundles of 3-4 or >5 interventions were associated with a smaller 2-fold improvement in compliance.

4) Several bundles were frequently studied and deemed effective. One bundle that included education, reminders, feedback, administrative support, and access to alcohol-based hand rub was associated with improved hand hygiene compliance (pooled odds ratio [OR], 1.82, Group B below) and another bundle that included education, reminders, and feedback was also associated with improved compliance (pooled OR, 1.47 - Group A below). See the figure below.

More work to do!

Reference: Schweizer ML, Reisinger HS, Ohl M, Formanek MB, Blevins A, Ward MA, Perencevich EN. Clin Infect Dis; 2013.

The Jumbo Squirting Bow Tie - Infection Prevention Dream Attire

There are so few effective interventions available to improve hand hygiene compliance. In addition, there are other infection policies, such as bare below the elbows, that are gaining acceptance as methods to prevent pathogen transmission. For example, Mike posted a few months ago about a JHI study that quantified the transmission of organisms from long vs short sleeved shirts and tie vs. no tie. The study reported that the lowest transmission from clinician to mannequin occurred when the attire was short sleeves and no tie. However, the significant flaw in this study was that ties were narrowly defined as neckties and excluded bow ties.

Enter a solution to all of our infection control problems: the Jumbo Squirting Bow Tie! This often overlooked clothing accessory is a veritable infection prevention dream. A bow tie can increase our professionalism and limit pathogen transmission. Add in the "Jumbo Squirting" action and you can squirt alcohol hand rub into the eyes of non-compliant clinicians (operant conditioning) and also into your own hands to improve compliance with the WHO 5 Moments. When you think about it, it doesn't get much better than that.

image source: halloweencostumes.com

Feeling sick? Maybe someone is poisoning you with hand rub!

What if you suddenly developed a low-grade temperature, stomach pains and felt exhausted at the end of the day?  Would you think that someone was poisoning your tea with 60% alcohol hand rub?  Me neither. But that's what started happening to a Newport News (Virginia) middle school teacher starting this past fall.  She didn't find out that she was being poisoned until this month. Two 13 year-old students have been charged with felonies.

Now what's going to happen? Will hand-rub be banned from schools resulting in more preventable URIs and other viral infections each winter? I hope not but it's eerily similar to something I remember happening back in the early days of the community MRSA epidemic in Baltimore. Marc-Oliver Wright and other's noted that hospitalized prisoners were at high risk for MRSA colonization and infection. When we approached the healthcare officials at the prisons, we were told that they couldn't install hand rub or soap since the former would be lit on fire or ingested and the latter would be used as a blunt weapon.

After the Sandy Hook School tragedy, some have suggested we arm our teachers with automatic weapons. Now we may have to remove alcohol hand rub from schools. Maybe we should just move the schools into the prisons...they already have the weapons protection, cafeterias, libraries and playgrounds. They may soon add the lack of hand hygiene.

Additional source: WVEC 3/28/2013

Alcohol Hand Rub Fire?

There is a very sad report about a fire at an Oregon hospital (OHSU's Doernbecher Children's Hospital) possibly linked to static electricity and alcohol-based hand rub. It appears that an 11 year old girl might have been inducing sparks with her hospital blankets when a fire started on her shirt, causing third degree burns. This is a very infrequent event, but fear of possible fires has led to draconian fire regulations that probably end up harming patients more than the very rare fire.  For example, in a 2003 study by Boyce, none of 798 facilities, covering 1430 hospital-years of observation, reported a dispsenser-related fire. When it's an 11 year old girl that's harmed, there's potential for overreaction. However, I hope this doesn't lead to more limitations in hand rub placement and more hospital-acquired infections and I hope she gets better very soon!

Sources: Huffington Post 2/20/2013 and The Oregonian 2/18/2013