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

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.

Metrics, Decision Makers and Hospital Epidemiologists

This is a guest post by Silvia Munoz-Price, MD, PhD, Enterprise Epidemiologist and Professor of Medicine, Division of Infectious Diseases, Froedtert and the Medical College of Wisconsin.

During the past few weeks I have been mulling over two issues related to Quality and Infection Control that have to do with metrics, their use, and the impact that they have in our hospitals. Two separate topics but related to a certain degree.

1. My hospital has a strong Quality Department and a stronger culture of safety. For the most part we have very few serious infections and even fewer MRSA, VRE, and almost no multidrug resistant Gram negative rods. Our compliance with hand hygiene is 73% (as per >5000 observations collected over a couple of months by managers from units that are not their own and concordant readings obtained by the Infection Control Department. I am trying to tell you that 73% is probably close to accurate). From my perspective, if indeed true, this is an acceptable rate. I think we should concentrate on preserving this rate and maybe focus on areas/providers that need more attention. However, my hospital wants this number to be close to 100%. So, here are my questions: should we invest more time, effort, and money to push for higher compliance with hand hygiene? What would be the return on investment of increasing our hand hygiene compliance and how could we measure its impact? What type of infections would we prevent by increasing hand hygiene compliance? Yes, our CLABSIs and CAUTI rates could be better, but would they noticeably improve by pushing hand hygiene above 80%? (I’m intentionally not discussing C. difficile infections as these have a different etiology in my hospital). And most importantly what other interventions would we be overlooking by focusing so much on hand hygiene? Who decides where to allocate time, effort and money?

2. Over the past couple of decades I have observed a shift in Infection Control throughout the various places I have worked at from minimal interest/resources given to Infection Control, to a phase where more visibility was given to Infection Control matters --probably due to metrics--to the allocation of more interest/resources, to publicly reported metrics, to institutional notoriety and reimbursements linked to metrics, to a tunneled vision about metrics. On this topic, many years ago I observed a human behavior that since I have observed multiple times: when we started placing fluorescent powder on surfaces and giving feedback to providers on the degree of removal, cleaning rates improved (https://www.ncbi.nlm.nih.gov/pubmed/21460514). Feedback was then given weekly and in a public manner, with a substantial amount of pressure placed on EVS to improve. The numbers got much better. We eventually figured out that EVS providers bought their own ultraviolet lamps to find the fluorescent markers and spot clean them. What happened? The metric made sense at the beginning, initially it probably achieved its intended outcome (more frequent cleaning) but then a threshold was crossed, after which what mattered was the metric (as a number) and no longer the intended outcome (more frequent cleaning).  I think the same is happening to our hospitals. Metrics were beneficial initially (more resources for Infection Control, more visibility, more engagement of staff, lower infections) but I would argue that we are on the other phase of the metrics (unintended consequences).  All the pressure we are placing for lower and lower metrics (get to zero CAUTIs!) might be backfiring. We are deploying large teams and resources to decrease certain conditions which is shifting our capability to address issues that might be equally or even more important in our respective hospitals   (e.g. post craniotomy  SSIs).  So, who decides how to allocate our limited resources? I would argue that Quality is now the main decision maker and that these decisions are strongly guided by publicly reported metrics. Is this good or bad for our patients? I am not sure. Is this good for the field of Hospital Epidemiology? I don't think it is. Hospital Epidemiologists need to re-think their involvement in Quality and become their hospitals’ Chief Quality Officers. That is the only way I see that we will impart some sense to the decisions of resource allocation. However, the opportunity for our specialty to lead in this field might have already passed.     

Hand hygiene: facilitators and barriers

Although there are many papers on hand hygiene, this new one in American Journal of Infection Control caught my eye. In this study 3,260 hand hygiene opportunities among 64 ICU nurses in 4 hospitals were overtly observed. When HH noncompliance was observed, the reason was documented. Nearly 20% of missed opportunities were accounted for by 4 activities: carrying something, even as small as a syringe or 4x4 (9%), donning gloves or PPE (6%), pushing or pulling a work station (2%), and using a mobile device (1%).

The investigator observed that nurses who were super compliant (90-100% compliant) found ways to deal with the barriers. For example, if they were carrying something, they shifted the object to one hand and reached for gel with the other. They were positive deviants.

The high performers were asked to explain why their compliance was high and four themes emerged: (1) they had internalized standard precautions; (2) they had experienced a previous exposure and were determined to not allow it to occur again; (3) bonuses and pay raises were linked to compliance; and (4) pregnancy and concern for their unborn child.

A better understanding of the barriers and facilitators may allow us to move the needle a bit on one of the most perplexing problems in infection prevention.

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?

____________

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