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

Should surgeons be allowed to prescribe antibiotics without assistance?

It's the end of a long day on the ID consult service. You and the team have decided to recommend switching antibiotics on a post-op cardiac surgery patient since the S. aureus susceptibilities have returned and you'd prefer cefazolin over vancomycin for her MSSA bacteremia. The team text messages the primary surgical team and the intern meets the team in the ICU. You overhear the ID fellow's discussion with the surgical intern, who appears to not know the patient and who can't get approval from the senior resident, CT surgery fellow or the attending to make the antibiotic change since the whole team is scrubbed in the OR.

The above scenario is all too familiar to those who practice infectious diseases, and to be fair it could apply to other procedure-based subspecialties. But the question arrises, if only oncologists can prescribe chemotherapy, why is it that everyone is allowed to prescribe antibiotics? Is this really what is best for our patients? Yes, this is currently a controversial topic but these are the types of questions we need to ask if we're going to respond to the antimicrobial resistance crisis.

A group of researchers in the UK led by Esmita Charani and Alison Holmes began exploring the effects of culture and team dynamics on antimicrobial prescribing during surgical ward rounds and the results of their ethnographic study left me convinced that we must develop ways to improve antimicrobial prescribing on surgical services.

The research team observed the antimicrobial prescribing decision making of six surgical teams over a 3-month period. These included observation of 30 ward rounds and face-to-face, semi-structured interviews of 13 clinicians (5 consultant/attending surgeons, 3 registrars/residents, 2 nurses, 2 junior doctors/interns and the ward pharmacist). The qualitative analysis identified 4 key themes that influence antibiotic prescribing: (1) working in a constant state of flux; (2) communication jigsaw; (3) delegating antibiotic management; and (4) the need for an intervention. Here are a few quotes from the study:

Constant flux: There is a hierarchy as to who leads ward rounds (WR), but this is a shifting hierarchy whereby people are promoted or demoted from their position based on who is present on the WR...if the surgeon leading the WR is called away, for example to the OR, the line of authority shifts downwards and people must act up, for example the registrar takes on the role of the surgeon, the junior doctor ‘becomes’ the registrar and the medical student ‘becomes’ the junior doctor.

Communication jigsaw: WRs are often rushed, interrupted and dispersed and reconvened because of demands for the senior team to be in the OR. The constant disruption and people leaving and joining the WR means that members of staff will rarely be present for the entire WR. Because of being constantly split between the OR and the ward, communication within the surgical team occurs across different platforms. Key decisions are made, recorded and communicated not necessarily in medical health records but on handover sheets, text messaging, and applications on smartphones (e.g. WhatsApp). On many occasions a patient was thought to be on antibiotics by the team, and after further queries in notes and charts was found not to be on them, and vice versa.

Delegating antibiotic management: Surgeons tended to see the core elements of their role as relating to the surgical management of their patients, a role that is performed in the OR. The lack of priority given to antibiotic decision making is compounded by a lack of expertise, resulting in responsibility for antibiotic decisions being commonly delegated to others.

The need for intervention: The need and expectation to intervene means that often antibiotics are initiated for patients with no or little evidence of infection, but a high plausibility of infection in the minds of the surgeons. This process is rationalized by the surgeons as being an extension of their roles as ‘interventionists’. In the absence of evidence of infection what drives antibiotic decision making is a risk of failure, and a risk of blame. What is considered unique in surgery is that a patient has to be well enough to be able to undergo an operation, therefore any deterioration postoperatively is assumed to be a consequence of the surgery, and the decisions of the surgeon, and not the patient's underlying illness. These concerns drive a more conservative approach to antibiotic decision making leading to unnecessary and prolonged courses of antibiotics.

None of these points will appear very surprising to anyone who has cared for patients on a surgical service. However, the authors are to be commended for the care with which they completed this study and the wonderful structure they provided to the domains that influence antimicrobial prescribing. I agree with their assessment that "there is a need to explicitly assign the responsibility for antibiotic management of the surgical patient to a responsible, individual with necessary expertise... Diagnosis and treatment of infections is a specialty that requires expertise and training, therefore this is an opportunity to develop, with support from specialist microbiology laboratory and staff, a role for a clinician(s) responsible for perioperative antibiotic management. This will help to strengthen the antibiotic management for surgical patients and has the potential to facilitate continuity of care and to help overcome the substantial gaps in communication that have been identified in this study...The time is right to question whether we need to address the gap in antibiotic prescribing for surgical patients by developing this specific perioperative clinician role to manage infections. This is of critical importance considering the rising challenge of antibiotic resistance in postoperative patients."

What counts? An ethnographic study of counting central line infections

Special Guest Post by: Mary Dixon-Woods, University of Leicester

Surveillance of infections depends, of course, on being able to count them. Recent years have seen several studies (here, here and here) revealing differences in how central line infections get counted. Problems of non-comparability of infection data didn’t matter so much when institutions were conducting surveillance for their own internal purposes. Now that infection rates have become a high stakes metric, tied to financial and reputational sanctions, comparability has become much more important. But why differences in measurement occur is not clear, and one suspicion is that “gaming” – where healthcare workers deliberately manipulate the data – might be responsible. We set out to find out more.

We used the opportunity presented by Matching Michigan, a programme modeled largely on the iconic Michigan-Keystone project, to explore what English hospitals did when asked to collect and report their ICU-acquired central line infection rates. Funded by the Health Foundation, a major UK charitable foundation, we used ethnographic methods involving direct observations in intensive care units, interviews with hospital staff, and documentary analysis.

The results, published in the recent Milbank Quarterly,  showed that even though all hospitals in the programme were given standardised definitions based on those used by the US CDC, variability in how they gathered and interpreted the data was rife. But gaming played little or no role in explaining what happened. Most variability in fact arose because of what we called “mundane” reasons. These included challenges in setting up data collection systems (we identified three distinct systems in use), different practices in sending blood samples for analysis, and difficulties in deciding the source of infections. 

One interesting and unusual feature of Matching Michigan was that it asked units to distinguish, based on the CDC definitions, between catheter-associated infections and catheter-related infections. The difference between them relates to the standard of evidence needed to establish whether an infection originated in the central line or not.

To satisfy the catheter-associated infection, only one blood sample (or catheter tip) is needed, plus a clinical judgement about where the infection is coming from. This definition tends to increase sensitivity at the expense of specificity, but that may be good enough if the main purpose is to guide clinical decisions and provide a reasonable estimate of how well infections are being controlled. Satisfying the catheter-related definition, on the other hand, requires two blood samples: one from the central line and one from somewhere else in the body. Both must test positive for the same micro-organism, determined using semi-quantitative or quantitative techniques. While it provides a better standard of proof, it requires a lot more resources; many laboratories in England were not equipped to support it, and didn’t necessarily consider it a clinical priority to do so. A majority of infections reported to the program therefore relied on the catheter-associated definition.

Using the catheter-associated infection definition, because it relied on clinical judgement, invited inevitable ambiguities about what counted as a central line infection. Those decisions were typically made by ICU physicians (not infection preventionists as in the original Keystone study), and those decisions were made using different kinds of evidence in different ways. For instance, physicians varied in their practices for routine screening of catheter tips; in their propensity to initiate treatment in cases of suspected infection; and in the number and kinds of samples they sent to laboratories for analysis. This meant that those charged with counting the infections were using very different source information.

Despite absence of evidence of deliberate manipulation, the fact that data had to be reported externally to the programme did appear to have some bearing on “what counted”, though not in consistently predictable ways. For instance, some units decided that patients at low risk for central line infections (such as those who had a line in for just a few hours after cardiac surgery) were not eligible for counting in the programme, while others excluded those seen to be unusual in some way (such as those with multiple lines in after complex surgery). This meant that neither the denominators nor the numerators for calculating the infection rates were counted in exactly the same ways across all the ICUs in the programme.

We concluded that unless hospitals are deploying the same methods to generate the data, using their reported rates to produce league tables or performance or impose financial sanctions is probably not appropriate. Much more needs to be done to ensure that reported infection rates are credible, useful, fully integrated with clinical priorities, and comparable.

claimtoken-50eef241193c3

What does 'antibiotic resistance' mean to patients?

We've all heard a patient or family member claim that "they've become resistant to an antibiotic." Clinicians and public health campaigns often attempt to communicate the importance of appropriate antibiotic use, yet how patients interpret the concept of 'antibiotic resistance' may impede their best efforts. Thus, could patient misunderstanding hinder antibiotic stewardship efforts?

In July's JGIM (abstract free here), Lucy Brookes-Howell and colleagues from nine European countries completed semi-structured interviews of 121 patients with a recent lower respiratory tract infection, in order to determine their understanding of 'antibiotic resistance'. The most common theme that emerged from this study was that patients conceptualized antibiotic resistance as being 'the resistant human body' with 43 of 121 expressing this idea. Only 28 patients correctly understood that resistance was a property of the bacteria. Thus, substantial confusion was present in the majority of patients.

With almost two-thirds of patients not understanding the basics of antibiotic resistance, it is unclear if current public health campaigns that suggest that individual misuse promotes resistance can ever be effective. The authors of this study correctly wonder whether a community focus might be a better approach and also mention that using terms like 'superbug' might improve patient understanding. Maryn McKenna might be onto something...

Image source: (here)

Addendum: Really nice editorial by Timothy Edgar accompanies the study.

Empowering patients to ask providers to wash their hands

"2000 miles

Is very far through the snow

I'll think of you

Wherever you go"
- Chrissie Hynde

We moved our family to Iowa City last week. There is something about being back in the Middle West that gets me singing old Pretenders' songs. I can't really explain it. One thing I've immediately noticed is that people say "hand washing" here and not "hand warshing" like I heard often back east.

Enough of that. There is a qualitative study out in the June issue of the Journal of Patient Safety by Amanda Garcia-Williams and colleagues from the CDC's DHQP that assessed the CDC video "Hand Hygiene Saves Lives" as a tool of patient empowerment. They conducted four focus groups using laypersons without hospital exposure in the past year, laypersons with hospital exposure, nurses and physicians. There are a lot of interesting findings within the study and many should be subject to further analysis.

The primary finding was that laypersons were much more likely to ask a nurse to wash his/her hands after watching the video, however, those with recent hospital exposure stated that they would still be "nervous" or "scared" to do so. Interestingly, laypersons with hospital exposure were more likely to ask physicians to wash their hands after watching the video but those without hospital exposure were not influenced by the video to ask physicians to wash their hands.

A very interesting finding was that laypersons with hospital exposure had lower levels of perceived risk for HAIs than persons who hadn't been in the hospital recently. Perhaps fear of the unknown is playing a role here. I suspect this fear could be used positively to get them to monitor compliance among their healthcare providers. Overall, I found the results of this study promising. Hopefully they will continue to analyze the impact of this video through quasi-experimental study or using other methods to see if this video intervention actually results in changed patient behavior, improved hand hygiene compliance, and dare I dream, reduced HAIs.

Article in the Journal of Patient Safety (here)