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

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.

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."

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.

Shouldn't evidence guide our selection of hand-hygiene surveillance systems?

It's amazing how little evidence is required before infection prevention interventions are adopted. A current example of this is the installation of automated hand-hygiene surveillance systems that track healthcare worker room entry and hand hygiene compliance. Hospitals are committing significant resources, both financial and person-time, to implement these systems with minimal evidence that they sustainably improve compliance or are accurate and cost-effective. To channel Jerry Maguire, before hospitals "show them the money", shouldn't they ask companies to "show me the meta-analysis"?

With that in mind, I really enjoyed reading the study in February's ICHE by Luke Chen and colleagues at Duke describing the implementation of an electronically-assisted, directly-observed hand hygiene surveillance system. The investigators recognized that directly observed compliance remains the gold standard, but also realized that economic and time costs, along with potential biases such as the Hawthorne effect, limit its utility. Thus, they set out to improve on the gold standard by modifying it to address potential biases and reduce costs.

Beginning in 2009, non-secret (they wore ID badges) auditors began monitoring compliance in 40 wards/clinics. They observed two moments of compliance, before/after room entry. All data was entered into wireless-PDAs that were linked to a centralized server allowing instantly updated 30-day tracking reports.

Overall, the compliance rate reported was 88% after 100,000 observations. That's pretty good. What's more, they reported compliance by the order of observation. For example, they calculated the average compliance for the first opportunity observed, the second opportunity and so on. The reason they did this, is they hypothesized that the Hawthorne effect wouldn't kick-in until the observer was seen by the healthcare worker and that this would become more likely the longer the direct observer remained on the ward. What did they find? Look for yourself:

What do you see? They found compliance for the first five observations was less than 86% while the average over the 35th to 43rd observations was 95%. We see an actual Hawthorne effect. Excellent. After seeing this, and for other reasons as well, they created standard operating procedures that observers used. The most important change to their procedures was they limited observations to 10 minutes or 10 total opportunities before moving to the next ward. Following these changes, compliance was reported to be 86%.

Of course there are limitations to this study in that it was a single-center study and lacked economic data to help guide its broader adoption. The authors acknowledged these and are addressing them already in a future study. My sense is that this method will be more effective and cost-effective than fully-automated systems and also keep infection preventionists visible on the wards to identify and address other important issues, which they can't do from behind their computer screens. But unlike many pushing for a new hand hygiene monitoring system, I'm going to start collecting the data and let the evidence guide my decision making.

Image: Luke Chen, MBBS MPH

Happy Global Handwashing Day!!

Hey everybody!  Break out the soap and water and clap those soapy hands together as we celebrate the 5th anniversary of Global Handwashing Day! October 15, 2012

 

And if you're heading to IDWeek in San Diego, come to session #5, a symposia titled: "Hand Hygiene, State-of-the-art: Surveillance and Compliance" where I will be moderating and the good Dr. Edmond will be speaking about creative ways to improve hand hygiene. Other speakers include Dinah Gould, Phil Polgreen and Kate Ellingson.  Should be a great sesssion.