Identifying Barriers to Hand Hygiene Audit and Feedback

This is a guest post by Daniel Livorsi MD and Heather Schacht Reisinger PhD from the University of Iowa Carver College of Medicine and the Iowa City VA Health Care System

Our research group recently published a qualitative investigation of hand hygiene in JAMA Network Open. The study describes real-life barriers encountered by 8 VA hospitals in their use of audit-and-feedback to improve hand hygiene compliance. For anyone involved in hand hygiene monitoring and improvement, the barriers we describe will probably not come as a surprise. In brief, we found that auditing hand hygiene compliance by direct observation was perceived to collect inaccurate data and created tension with frontline staff; the feedback process did not encourage positive change.

Although the importance of hand hygiene is widely acknowledged, our field’s understanding of how to improve hand hygiene compliance is still relatively primitive. All of the hospitals we visited had implemented audit-and-feedback, which was the focus of the study, but many were also using other strategies, such as environmental engineering and education. Despite these well-intentioned efforts, hand hygiene compliance rates at the participating sites were 49.8% (n = 9791) at room entry and 63.9% (n = 10 135) at room exit. It seems safe to assume that such poor compliance rates are common across all of healthcare. To meet regulatory standards (e.g. the Joint Commission), hospitals need to keep going through the motions of auditing, but wouldn’t it be great if all this effort could be directed towards interventions that actually work?

An accompanying editorial argues that all of these audit-and-feedback programs were missing one key component: immediate personalized feedback coupled to individualized action planning. In general, feedback is more effective if it is provided in real-time and is individualized, so this strategy is appealing. However, at the hospitals we describe, giving personalized feedback would likely face some logistical challenges, including limited personnel to perform these separate individualized audits and potential pushback from labor unions on the collection of individualized performance data. In addition, collecting individualized data still does not address larger questions about the accuracy of direct observations.

Like many processes in healthcare, improving hand hygiene will require both technical interventions and socio-adaptive changes. Clearly, compliance rates are not where they need to be, and the current strategies are not effective. I don’t pretend to know the answers, but as a field, let’s not give up on trying to find some solutions.

image credit: honoring University of Iowa Veterans

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.

Questions for Contact Precautions Eliminators

Over the past eight years, I've been the lone supporter of contact precautions on the blog. Of course, Tom and Hilary haven't publicly committed either way, at least on this blog. And to clarify my position, I'm greatly in favor of more studies examining the role of isolation strategies and how/where to best implement them. For example, do we need gowns or would gloves alone suffice? And should we isolate uncolonized patients instead of colonized patients since we're most interested in preventing transmission from contaminated healthcare worker to uncolonized patients? This latter question is why I currently favor exploring the benefits of universal gloving strategies. But of course, there is a growing number of studies that explore the discontinuation of contact precautions, which have led to places like Iowa eliminating contact precautions for MRSA/VRE colonized or infected patients. So with that in mind, I have a few questions for folks who are in favor of eliminating contact precautions. Specifically, I want to understand the who/what/when/where/why behind their recommendations.


Question #1: Are hospitals no longer a source for MDRO-bacterial acquisition? Do acute care hospitals or subpopulation (ICUs, hemodialysis) remain sites for patient-to-patient transmission or have we completely eliminated transmission in these settings?

Question #2: If transmission has been eliminated, how would we know? Are you aware of data that proves patients who are uncolonized on admission remain uncolonized by the time of discharge? Does your hospital do discharge surveillance cultures for sentinel organisms like MRSA, CRE?

Question #3: If you don't do surveillance culturing on discharge, do you follow patients post discharge to make sure they don't develop an MDRO infection at a subsequent point? Do patients no longer develop MDRO infections linked to a prior hospital stay suggesting that all transmission is now occurring in the community setting?

Question #4: If transmission in acute-care settings has been eliminated, how has that happened? Is it that hand hygiene compliance of 34 to 57% is enough to halt all transmission? Is it that the environment is so sparkling clean these days that clinicians can't even pick up bad bacteria on their hands?

Question #5: Perhaps you agree that hospitals (or ICUs) are still engines powering the emergence of MDRO in human populations and your hospital might even be a source for patient acquisition. Is it that you think hands are not a source of transmission and contact precautions just don't work? Do you feel similarly about hand hygiene - does hand hygiene not reduce transmission? Since we know that when caring for patients that healthcare workers gloves/gowns become contaminated 8-39% of the time, where do these bacteria go? Do they just disappear?

Question #6: Finally, even if transmission is occurring via the hands of healthcare workers maybe you're convinced it's not your problem? If you can't see the benefits directly in your hospital, it's not important. Tragedy of the commons? - meh. Perhaps, it's up to me to detect all MRSA colonized patients in my clinic or on admission to my hospital and decolonize them?

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

Hand Hygiene and The Power of Labbit

Yesterday, Mike wrote about "The Power of Habit" and taught us that "40% of our daily activities occur without any active decision making" and suggested that "the trick...is for us to figure out how to get hand hygiene and stethoscope wipedown established as habits."  Of course, this all sounds reasonable. Besides hand hygiene, wouldn't it be great if we could get primary care doctors to stop prescribing antibiotics? Surely, poor stewardship is also a habit.

I used to believe, as Mike does, that infection prevention was a matter of education and re-education until good practice becomes habit. But after years of watching us fail to improve antibiotic prescribing and increase hand-hygiene compliance, I no longer believe in the magical thinking surrounding education and habits. First, there is minimal evidence that we can encourage folks to develop better habits - such as hand hygiene compliance. Take for example this recent systematic review on hand hygiene trials by Kingston et al. The authors reviewed studies published since 2009 and reported a baseline hand hygiene compliance of only 34.1% with a mean improvement to 57%. Some folks may look at this data and become excited about a 23% compliance improvement!!  But a realist would look at the data and realize that these trials couldn't have been the first time the healthcare workers in the intervention hospitals were exposed to hand hygiene interventions - their baseline compliance of 34% was after numerous rounds of "habit-forming" educational training.

Thus, we need to be honest with ourselves and acknowledge that difficult system changes are needed to improve practice. For hand hygiene, for example, we need shelves outside rooms so nurses can rest things they're carrying while cleaning their hands. For clinicians we need rapid diagnostics and health information systems to inform antibiotic prescribing. Any talk of habits suggests that change can occur at an individual healthcare worker or prescriber level. And any suggestion that this is an individual healthcare worker problem will necessarily lead to learned helplessness and blame, neither of which will be productive.

In the end, we're going to need to move past our focus on "habit" and its flipside, blame. Let's work towards system change and innovation that directly address the barriers to hand hygiene compliance and proper antibiotic prescribing. You might have another name for it, but I'm gonna call it The Power of Labbit.

Labbit image source: Kidrobot Blog

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

Even with the Hawthorne Effect, Hand Hygiene Compliance Still Hideous

One way to deal with low hand hygiene compliance

A recurring theme has emerged in hand hygiene science - when you really look, compliance is very very low. A study 5 years ago reported that compliance was below 10% when hidden video monitoring was utilized. Our group has quantified the impact of the Hawthorne Effect, improved behavior when subjects know they're being observed, on hand hygiene compliance. In a multicenter study, we found that both measured exit and entry compliance increased the longer direct observers remained on the unit.

There is a report of a new APIC abstract in ABC-News that further quantifies that impact of the Hawthorne Effect and highlights the lack of investment in hand hygiene programs. Investigators from Santa Clara, California compared compliance measured by well-recognized Infection Prevention nurses, to observations collected by unknown high-school and college-aged volunteers who were trained to use the same surveillance methods. Here are their findings:

So, what do I make of these findings? First, even 57% is too low. Second, hospitals and healthcare systems continue to throw hand hygiene programs under the rug. We are much happier to report compliance rates of 100% collected by nurse managers on the floor (or compliance of 57% by recognized IPs) and ignore the problem than spend time and money detecting compliance rates of 22%, which would then require additional investments in proven hand hygiene interventions.

Any administrator, who thinks compliance in their hospital is higher than 70% or 90%, won't invest in hand hygiene programs. Since hospitals are happier to report compliance of 90% to the Joint Commission, we also won't invest in technological and socio-adaptive interventions that will finally improve the safety of our hospitals. We must work to create a safety culture where it is better to report hand hygiene compliance of 20% than falsely high compliance rates of 90%.

image source: montonara.com

May The 5th Be With You - #SafeSurgicalHands

There are so many commemorative days, that I sometimes get them confused. We just missed Star Wars Day and today (May 5th) is even International Day of the Midwife, which seems appropriate if you understand the Semmelweis story - his control group was a maternity ward staffed by female midwives with one-fifth the mortality compared to the doctor/medical student ward.

Which brings us to a very important day in infection prevention - 5th of May - WHO Hand Hygiene Day! I can't do better than Professor Didier Pittet when talking about hand hygiene, so I've added his video above and provided his letter with important links for #SafeSurgicalHands below.  Thank you all for what you're doing to create a safer healthcare environment starting with clean hands.

Dear All,

I am pleased to invite you to celebrate the WHO Hand Hygiene Day in Healthcare on 5 May 2016.

The 2016 year campaign promotes #SafeSurgicalHands on Twitter and Instagram.

All WHO tools to participate are available at: www.tinyurl.com/WHOtool5May16

Post your photos/selfies at : www.cleanhandssavelives.org/safesurgicalhands/

Safe Hands in Surgery-WHO 2016 message together with colleagues surgeons: www.tinyurl.com/WHOadd2016

#SafeSurgicalHands Pictures' Wall (updated in real time): https://walls.io/SafeSurgicalHands

Additional educative videos are accessible at:

• Your WHO 5 moments for Hand Hygiene along the patient journey in surgery www.tinyurl.com/5momentsSurgery
• WHO surgical hand preparation technique www.tinyurl.com/SurgScrubTech
• For those who want to conduct a Hand Sanitizing Relay: http://tinyurl.com/HHRelay
• Any information at handhygienerelay@cleanhandssavelives.org
• Or see the best relays in 2015 : http://tinyurl.com/GlobalHandSanitizingRelay2015
• Or simply look at 10 years of Clean Care is Safer Care http://tinyurl.com/CleanHands10

I am looking forward to seeing you all participating.
Let’s improve hand hygiene, reduce infections, limit resistance and save lives.

With best wishes,
Professor Didier Pittet

Peace, Love and Hand Hygiene

Sanjay Saint, Professor of Medicine at the University of Michigan and Chief of Medicine at the Ann Arbor VA Medical Center, discusses changing healthcare's culture through conformity, social learning (monkey see, monkey do) and mindfulness in a new TEDx talk. Worth a listen.

 

Efficacy versus effectiveness

Take a moment to check out this video from today's NY Times.

If a hand hygiene method demonstrates marginally better reduction in bacterial counts on hands, but is also more complicated and takes longer to complete, should it become the standard?

Related question: does the difference in log10 bacterial counts between 2.58 CFU/ml and 2.88 CFU/ml translate into a greater risk for pathogen transmission in healthcare settings?

I’ll let you ponder the above questions, as I don’t have the answers. One thing I do know: when a hand hygiene paper in Infection Control and Hospital Epidemiology is being covered by the NY Times, we’re winning!

I’ll let Eli and Mike comment on how many of the people depicted in the video are bare below the elbows!

Guest Post: The National Hand Hygiene Initiative in Australia

This is a guest post by Nicholas Graves, Professor of Health Economics at Institute of Biomedical and Health Innovation, School of Public Health, Queensland University of Technology Queensland Health, Australia. Nick is currently the Academic Director for The Australian Centre for Health Services Innovation (AusHSI) and the Academic Director for the Centre of Research Excellence in Reducing Healthcare Associated Infections (CRE-RHAI), Queensland University of Technology / Institute of Health and Biomedical Innovation.

Between 2009 and 2012 Hand Hygiene Australia implemented an initiative to improve hand hygiene compliance in all Australian hospitals. Federal and state governments provided the funding and there was political support for this high profile patient safety program. My research group at QUT obtained funding of almost $1M in 2012 to evaluate whether it was cost-effective and here are the results just published in PLoS ONE.

We found the annual maintenance costs to be $2.9M per year. This investment of scarce resources prevented 67 cases of S. aureus bloodstream infection and 96 years of life were gained. The cost per one life year gained was $29,700. Hand Hygiene Australia have indicated the program is today likely to be less costly, due to a 50% reduction in their own running costs and that compliance auditors now spend 50% less time on their tasks. Testing these scenarios in our cost-effectiveness model suggest the cost per one life year gained falls to $25,094 and then $18,960.

The only outcome measure for which reliable data were available was S. aureus bloodstream infection. Because SAB is very expensive to treat and has large mortality risk it is a good outcome measure to demonstrate cost-effectiveness. We did evaluate other infection outcomes in a separate paper and found a statistically significant reduction in 11/23 rates, no change for 9/23 and increases for 3/23. Whether we underestimated the health benefits of the initiative by only including SAB outcomes is uncertain.

This was a challenging and difficult study, but that made it interesting. Now that the project has finished, what do I think?

Estimating the value for money of infection prevention programmes is important. Particularly in today's climate where health funding is tight, and there are multiple competing demands on scarce resources. If this Hand Hygiene initiative displaced other infection prevention programmes that deliver larger health benefits for the same or less money, then has been an opportunity cost measurable in health benefits lost.

Rolling out a national program of this complexity requires massive energy. Hand Hygiene Australia did a remarkable job achieving improvements in hand hygiene compliance. They were successful by being single minded and building momentum for the initiative. They did not let obstacles get in the way. Hand Hygiene Australia achieved the task they set themselves.

The timing of our evaluation was wrong. If it were done during a pilot phase then the results might have been useful to change the national initiative. Presenting the study and results after the programme had gained momentum and had political support reduced the usefulness of the findings. 

Doing this project has been interesting and I learned a lot, and I hope the papers and talks I have given are valuable for others interested in estimating the cost-effectiveness of infection prevention programs.

This blog presents my views alone.

Orange is the new nudge

A few year's ago, I read the book Nudge, and ever since I've been fascinated by the concept. A nudge is a stimulus that leads to a desired behavior but doesn't force it. For example, in school cafeterias placing fruit at eye level results in more fruit consumption. No one is forced to eat more fruit and potato chips aren't banned, but more fruit gets eaten. Another example is painting horizontal lines on highways, which causes drivers to slow down. So, the million dollar question for hospital epidemiologists is: how can we nudge healthcare workers to wash their hands?

There's a very interesting paper in Health Psychology that attempts to identify hand hygiene nudges (free full text here). At the University of Miami, investigators randomized approximately 400 HCWs and visitors at the entrance to an ICU into three groups: a control group that received no stimulus, a group that was given an olfactory stimulus (citrus smell dispersed by an aroma dispenser), and a group given a visual stimulus (a photograph of eyes placed above the alcohol gel dispenser). The last group was subdivided: for some the photo was middle age male eyes and for others the photo was female eyes.

Hand hygiene in the control group (no stimulus) was 15%. Those who received the olfactory stimulus had a hand hygiene compliance of 47% (p=.0001). The photo of female eyes was associated with a compliance of 10% (p=.626), and male eyes, 33% (p=.038). So, a photo of male eyes above the alcohol gel dispenser doubled hand hygiene compliance and citrus smell tripled it.

The same investigators in a previous study showed that citrus scent was associated with significantly higher rates of hand hygiene compliance when medical students and interns examined standardized patients in a simulation center.

Start slicing the oranges!

Hand Hygiene Interventions: A Network Meta-Analysis

Summer is in full blaze (especially for those in Rome, France and the western US), so we don't have much time for long posts. However, I had to point you to an excellent study in the BMJ (open access) by Luangasanatip et al. that utilized a systematic review and network meta-analysis to determine the comparative effectiveness of the WHO 2005 hand hygiene campaign and other interventions. The WHO-5 Campaign (not to be confused with the WHO 5 Moments) recommended a multimodal strategy consisting of five components: system change, training and education, observation and feedback, reminders in the hospital and a hospital safety climate.

The authors completed a systematic review of interventions from 2009-2014 and used prior reviews to identify other studies. A strength of the analysis was that they looked beyond randomized trials and included high quality quasi-experimental studies including non-randomised trials, controlled before-after trials, and interrupted time series studies. They then completed a network meta-analysis which suggested that the WHO-2005 campaign was effective and compliance could be improved if other interventions were added including goal setting, reward incentives and accountability.

For those interested in reading more about network meta-analysis, I suggest you read John Cornell's editorial and the PRISMA Extension Statement in this past June's Annals. Briefly, it allows direct and indirect comparisons of interventions. For example, if two interventions are not directly compared they can still be compared if they were both directly compared to a third intervention (see Figure 1 above - Treatment D vs Treatment B or C through their direct comparison to Treatment A). Additionally if there is a closed-loop of studied interventions, additional information can be gained from indirect comparisons even if direct comparisons also exist. For example, in Figure 1 above, we can learn about Treatment A vs Treatment B from their direct comparison but also indirectly through Treatment C.

I encourage you to read the full study and the editorial by Matthew Muller. Very nice to see that the BMJ published this important study. And for those in the southern hemisphere, enjoy your cool weather...these summers seem to be getting worse and worse.

Removing C. difficile spores from hands: Enter Sandman

Exit, light 

Enter, night 

Take my hand 

We're off to never-never land
-Metallica "Enter Sandman"

It is well known that hand washing, particularly with soap and water, is critical for preventing the transmission of C. difficile in hospitals. Evidence suggests that the mechanical friction of hand washing is the mechanism behind spore removal. However, is there a way to improve the friction when practicing hand hygiene? To answer this question, investigators at UCSF reported results of a study that compared C. difficile spore removal after washing with 5 different methods including: (1) negative handwashing control: 30 seconds of rubbing with 5 mL of water and 30 seconds of tap water rinsing; (2) 30 seconds of rubbing with 5 mL of 0.3% triclosan soap and 30 seconds of rinsing; (3) 30 seconds of rubbing with a paste consisting of 15 mL of sand mixed with 15 mL of tap water and 30 seconds of rinsing; (4) 15 seconds of rubbing with 5 mL of a 50% baking soda–50% vegetable oil mix and 15 seconds of rubbing with 5 mL of liquid dish detergent followed by 30 seconds of rinsing; and (5) 60 seconds of rinsing.

Lo and behold, washing with sand and water was superior to both the water rub/rinse (0.36-log reduction in spores) and tricolosan soap (0.50-log reduction) - see Table 2, below.

The authors claim that the sand/water method was well tolerated after a single use, although it's hard to imagine that repeated use would be well tolerated. Still, this study raises many interesting questions. For example, what if we used Lava soap containing pumice, or Brillo pads or what if we placed our hands in a rock polishing machine after seeing patients? All kidding aside, you could imagine high-density soaps that have increased friction without the nasty abrasion. In the meantime, I'm going to keep rubbing my hands on my corduroys. 

Reference: D. Isaacson et al. AJIC, May 2015.

ECCMID 2015 - "Best Of" Infection Control Literature (Part 1)

Every year it seems that one of us at the University of Iowa is roped into giving one of these "Best of Infection Control" talks at an annual conference. This year it seems that almost all of us have been asked and for some inexplicable reason, we all said yes! I was the lucky one to kick off the 2015 season with this talk I gave last week at ECCMID in Copenhagen. I covered S. aureus, MRSA, VRE, VRSA, surgical site infections and hand hygiene. I look forward to Mike's talk at SHEA. Loren Herwaldt's talk at ICPIC and Dan's talk at IDWeek. On Iowa.

Give Directly-Observed Hand Hygiene Compliance Monitoring a Chance

As I've said before, "It's amazing how little evidence is required before infection prevention interventions are adopted." This phenomenon is particularly evident in the setting of automated hand hygiene monitoring systems. Few trials have been completed that have assessed the efficacy, effectiveness or cost-effectiveness of these systems, at least as of our recent systematic review.  However, it appears that many facilities are purchasing these systems anyway. Why is this?

It appears that there are two potential limitations of directly-observed hand hygiene monitoring driving the purchase of automated systems: (1) the fear that the Hawthorne effect renders all direct observations invalid and (2) the idea that all hand hygiene opportunities must be counted, i.e. it's unacceptable to sample opportunities. There is a third potential reason for adopting these systems - anecdotal reports that automated systems improve compliance. However, there is little published evidence that compliance increases are sustained and some evidence that automated systems actually decrease compliance.

With the potential limitations of directly observed compliance monitoring in mind, our research group just completed a study published in ICHE that sought to determine if/when the Hawthorne effect appears in hand hygiene observation data. The idea being, if it takes some period of time for HCW to know they are being observed, shorter periods of hand hygiene monitoring could be less susceptible to bias from the Hawthorne effect. After 3,432 hours of observations and 11,444 witnessed opportunities in a multi-center study, we calculated that room-entry compliance increases after 38 minutes and room exit compliance increases after 14 minutes and then again after 50 minutes (Figure below). Thus, it appears that limiting direct observation periods to less than 15 minutes limits the impact of the Hawthorne effect.

The other aim of our study was to determine the number of hand hygiene opportunities that must be observed to have an adequate sample size for comparison. For example, if hand hygiene compliance in your ICU is 80% this month and you would like to get it to 90% next month, you would need to observe 108 opportunities in each month to have enough power to detect a difference. We provide a table (below) so that anyone can quickly determine the number of observations in a month/quarter/year needed to compare time-periods or units/wards or facilities. We hope you find this information useful and that you'll still give directly observed hand hygiene compliance monitoring a chance.

More power to the fist bump

Last year, I blogged about a study that suggested that fist bumps replace the handshake, since the fist bump has less surface area contact and the duration is shorter. More recently I blogged that some physicians in Los Angeles were recommending that handshakes be banned in hospitals. Now a new study in the American Journal of Infection Control demonstrates that the transfer of bacteria is 20-fold higher with a handshake than a fist bump.

Ok, all you infection preventionists and hospital epidemiologists: what are we waiting for? Well, of course, the randomized controlled trial demonstrating lower rates of healthcare associated infections. Because, you know, common sense is quaint.

Photo: Craig Lassig / EPA