The Fact-Filled Infection Control Guideline - A New Year's Wish

I'm not sure what about the above tweet got me to thinking about infection control. Before hopping on the twitter this morning, I was happily building Lego scenes with my kids and thinking about this afternoon's Indiana-Iowa basketball game (Dan - thanks for the tickets!). In infection control, there isn't a direct equivalent to the "mindless symmetry" in political journalism mentioned by Jay Rosen, which treats talking points on both sides of the aisle as equivalent without considering the facts. However, there is a similar "mindless" glossing-over of the facts by public health and society guideline committee members that appears in every HAI-guideline - recommendations based on minimal data. Instead, many (can I suggest most) of the recommendations in HAI guidelines are based on uncontrolled before-after quasi-experimental studies, expert opinion and perpetuated dogma. 

Mike pointed out a few days ago what can happen when a medical specialty, such as hospital epidemiology, recommends policies like mandatory masks for unvaccinated healthcare workers during influenza season, which are based on minimal data. I'm not even going to mention mandatory influenza vaccination for healthcare workers... But what about other claims in guidelines and by policy makers? Do we have enough evidence to support many of our interventions including most stewardship recommendations? And what about the claim that MDR-Gram negative outbreaks could be controlled if not for the unwillful healthcare worker? 

What happens when we perpetuate opinion and dogma? Although 270-page hand hygiene guidelines may make us feel good, I'm worried that they prevent us from identifying areas where we need research (hand hygiene improvement interventions, anyone?) and lead us to spending days and weeks implementing ineffective or even harmful interventions. Does anyone stop to think how these fact-challenged guidelines might be hurting our patients and eroding our reputations? It seems to me that we shouldn't be spending our political capital implementing "expert opinion" since it will hinder our efforts when we actually are armed with evidence-based interventions. Imagine that day!

So my wish for the new year is that guideline committees only include recommendations based on evidence, not opinion or dogma, no matter how hard politically that is for them in the short term. In the long term, if we insist on evidence, we might actually get evidence - someone might notice and start funding infection prevention studies. (e.g. What do you mean we don't know how to halt the spread of MDR-GNRs??) And if our guidelines are shorter and filled with evidence-based recommendations, clinicians in the field will be able to focus on interventions that actually work and not spend their valuable time on willy-nilly dogma-of-the-day recommendations that harm our reputations or worse, our patients. 

Hand hygiene compliance at your hospital is not 90% and it's probably not even 80%

A few weeks ago, we got a review back on a manuscript (fortunately accepted with minor revision) but one of the reviewer's comments was an example of truthiness invading infection prevention.  The comment was one we hear often and since you can't typically communicate with a blinded-reviewer, I thought I'd mention the comment and what my response would be here.

Reviewer: "...only 63% of HCWs performed hand hygiene on exiting the room...in the year 2012, compliance rates of 50-63% is just plain depressing..." This comment and the other comments by the same reviewer seem to suggest that the four hospitals in our study were outside the norm and that we should clearly have hand hygiene compliance above 90%.

My (theoretical) reply: Hand hygiene compliance rates are not as high as reported.  Many things can explain this from the Hawthorne effect to only collecting data during 9-5 business hours. Fortunately, we have data from The Joint Commission Center for Transforming Healthcare.  In 2009 they began a hand-hygiene project.  Dr. Mark Chassin, President of The Joint Commission, described the project in a 2010 interview:

"We are collecting data from all Center hospitals. We are continuing to do so even for the eight hospitals that participated in the hand hygiene project, past its formal closure. In April 2009, at the beginning of the project, performance was collectively at 48% and has now stabilized at around 82%. 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%. So getting reliable measures was understandably a big issue at the start of the project."

When we do hand hygiene studies we use a uniform extraction sheet and collect data from all hours. We also collect 1000's of hours of data. From our experience, it is likely that hand hygiene in most hospitals is closer to the 50% reported in the 2009 Joint Commission study and not near the claimed 90% that everyone likes to see.

Final note:  If we think compliance is 90% we will do nothing, but if we accept the fact that it is 50% or 63%, we can address that with further interventions or initiatives. Acknowledging this is a necessary first step in making our hospitals safer.

Source: An Interview with Mark Chassin, The Joint Commission on Quality and Patient Safety, October 2010.

Did "Getting to Zero" contribute to the death of Facts?

The Chicago Tribune just published an obituary for "Facts, 360 B.C.-A.D. 2012", stating that it finally succumbed after years of fighting against the 24-7 cable news cycle and the internet. Apparently, the final straw was when "Florida Republican Rep. Allen West steadfastly declared that as many as 81 of his fellow members of the U.S. House of Representatives are communists."  I can see how that could do it; even enterococcal bacteremia can kill you if you're already close to dead (i.e. APACHE II score ~70). After first checking to make sure I wasn't reading the Onion or QFever, I realized that Facts probably did die, as I think it died in infection prevention several years ago.

We've written often about the problems with the "Getting to Zero" campaign or mindset. In one of this blog's very first posts, Mike wrote about how the false premise of Zero leads to a culture of blame. Dan has written about how APIC's "I Believe in Zero CLABSIs" campaign shows that it's "unwilling or unable to speak honestly about HAIs" and that "they will eventually lose credibility with their members who fight daily to prevent them."  There are other examples of post-factual truthiness in HAI prevention, including the claim that the only way to prevent MRSA is through a nasal PCR swab.

In closing, it's a sad day when an idea dating back to Aristotle has officially died.  At least those of us working in HAI prevention can take comfort in the idea that we've done our part through paving the way to a post-Factual "Getting to Zero" world.

Addendum: Rex Huppke, the author of the Tribune obit, speaks about how and why he wrote "one of the best op-ed pieces ever."

the American Journalism Review's excellent take on the obit, can be found here.