Gratuitous Hand Hygiene Post: Automated Surveillance Technology

Today, May 5th, is Hand Hygiene Day. If you're looking for links to hand hygiene campaign material, the CDC page is a great place to start. Instead of the usual hand hygiene video or bundle of interventions, I wanted to highlight a recent study our group completed that was just published in AJIC.

The study was led by Melissa Ward, one of Loreen Herwaldt's star research coordinators.  Melissa, spent many months scouring the medical literature for evidence that automated hand hygiene surveillance systems are accurate, effective and cost-effective. After an initial 3,463 article abstracts were identified, she painstakingly reviewed each one to find 42 articles that were original science and evaluated at least one aspect of at least one surveillance technology.  Four types of systems were identified: electronically assisted/enhanced direct observation, video-monitored direct observation, electronic dispenser counters, or automated hand hygiene monitoring systems.

To save you some time, here are the main conclusions from the study: Few articles assessed the accuracy of these electronic monitoring systems and those that did reported "little to no hand hygiene compliance rate differences between direct observation and automated or electronically assisted systems, including electronically enhanced direct observation." However, two studies found differences favoring the automated approach, so we concluded that "more research should be done to validate the accuracy of these systems."

Most importantly there was little evidence that "these systems can improve hand hygiene compliance" and there is currently "limited evidence to recommend the adoption of one type of system or approach as no high-quality quasiexperimental studies, cluster-randomized trials or decision-analytic modeling studies have been completed or published that would allow the comparative effectiveness of system types or individual systems to be assessed."

So what is my gratuitous (second definition: "free") advice: "Facilities should pilot test systems compared to gold-standard, directly observed compliance surveillance before they are widely implemented."

Give Gloves a Chance: Benefits of Mandatory Gloving Policy in Pediatrics

We spend a lot of time discussing the importance of clean hands in preventing hospital-acquired infections (HAIs). Most of the time we equate clean hands with hand-hygiene compliance and complicated and fleeting surveillance and educational programs. It would be one thing if these efforts led to compliance levels above 90%, but even the Joint Commission could barely get compliance above 80% after massive efforts.

Which leads me to one question - are we asking the wrong question?

Instead of focusing solely on driving hand hygiene compliance above 90%, perhaps we should focus on clean hands. If we ask a new question: "What do we need to do at our hospital to get healthcare worker hands to be 90% clean?", we get very different answers than if we focus solely on increasing hand rub use. For example, we could begin studying long-acting hand disinfection products that work all day or environmental cleaning products that keep hands clean in the first place. And another thing we could consider looking at is the benefits of the humble examination glove. We just published a study in Pediatrics, led by Jun Yin a PhD student in statistics, that aimed to do just that.

At the University of Iowa, we have a policy that mandates that healthcare workers wear gloves for all patient contacts during RSV season. We wanted to see if we could take advantage of this natural experiment to see what happened to HAI infection rates during the mandatory gloving periods compared to non-gloving periods.  To do that we completed a quasi-experimental study using time series analysis (Poisson regression models) on data from 2002-2010. We studied the effect in 5 units including a 20-bed PICU, a 62-bed NICU, a 5-bed Pediatric Bone Marrow Transplant Unit, a 26-bed Pediatric Hematology-Oncology Special Care Unit, and a 35-bed Pediatric Medical/Surgical Mixed Acuity Unit.

What did we find? Universal gloving periods were associated with a 25% reduction in HAI rates after adjusting for long term trends and seasonal effects. There was a 37% reduction in bloodstream infections (BSIs), a 39% reductions in central line-association BSIs and an 80% reduction in hospital-acquired pneumonias. The reductions were statistically significant in the PICU, NICU and Bone-Marrow Transplant Unit.

Yes, this unfunded study has limitations. It's a non-randomized, single center study. There could have been other factors that started just when RSV season started every year along with the gloving policy (although we couldn't think of any). Since this intervention was turned on and off every year for 9 years (with an exemption in 2009 for the novel H1N1 pandemic), it's unlikely there were other interventions that biased these results every year at the exact same time. 

Perhaps we need further study and cluster-randomized trails. We won't have to wait long. There is an important AHRQ-funded study that Anthony Harris's group is just completing at the University of Maryland that looks at the benefits of mandatory glove+gown policies in ICUs. However, this study won't tell us if it's the gowns or gloves or if they work in Pediatrics. So what do we do in the interim while waiting for future trials and magical interventions that get hand hygiene compliance above 90%?  All we are saying is "Give Gloves a Chance."

Reference: Yin J et al. Pediatrics April 22, 2013

Image: wikipedia

Media coverage: Reuters Health and Wired (Superbug)