Blame them, shame them, and fire them! Or give them bonuses. Or something.

In part two of the NY Times “Fixes” blog piece on hand hygiene, Tina Rosenberg tackles the perplexing challenge of improving hand hygiene practices in hospitals. An excerpt from the summary paragraph:

“Health care workers have difficult jobs, and it is important for hospitals to take their views into account when they institute measures to improve hand-washing rates. But if it takes public posting of hand-washing rates and firing of individual doctors or nurses who don’t comply to bring down infection rates, it should be done.”

We covered this ground before, the proper role of reward versus punishment for influencing health care worker behavior. I would love comments from our readers on this. I’ll merely remind everyone that direct observation of “entry-exit” hand hygiene adherence, even in centers that do the most intensive monitoring, captures only a tiny fraction of HH opportunities. And entry-exit adherence is the tip of the iceberg. Try working an 8-hour shift as an ICU nurse while adhering perfectly to all “5 moments”.

Will Berwick survive at CMS?

Bob Wachter’s latest post gives me some (slim) hope that my earlier post about Berwick’s tenure at CMS being over was premature. Read for yourself—it seems like a double-bank shot to me, and the “political zombie” argument is a more plausible explanation for some of his recent statements. But who knows?

Wee bitty BABIES and their wee bitty SCABIES

zazzle.com

You never want to see the words babies and scabies in the same sentence.  That's why I added 'wee bitty' so as to add as much distance as possible between them.  Come to think of it, you don't actually ever want to see scabies in a sentence - ewey ewey. 

In the May 2011 ICHE, investigators at New York-Presbyterian Hospital describe what appears to be the first reported scabies outbreak in a newborn nursery.  You can imagine that the typical 4-6 week incubation period seen with first exposure coupled with the fact that babies typically go straight to the nursery without leaving the hospital, keeps at least detectable scabies out of newborn nurseries.

In 2007 there were three cases of scabies over 3 months in infants born at the hospital, which were recognized by a pediatric dermatologist. Extensive investigation identified 7 additional cases including 3 NICU babies. And the cause was:

The team identified that one per diem nurse, had contributed to 10 of the 10 electronic medical records examined. Upon evaluation, she was noted to have a rash and wore a noticeably dirty compression glove for lymphedema while on duty, making it impossible for her to clean her hands effectively. She also reported that she had been treated for scabies at least 5 times in the previous year. During the same 7-month period as the cluster, she reported that she also worked in a Florida hospital’s nursery. The staff at the Florida hospital stated that they had identified a cluster of scabies in infants in their institution also.

At NYP Hospital, they found that this nurse had cared for 392 patients including mothers and a letter was sent to each patient describing the outbreak investigation. This process identified 3 additional cases. I agree with their conclusion that "a single case of scabies in a newborn should be considered a sentinel event of a nursery outbreak.

Ross BG et al. ICHE May 2011

Good news, bad news

Here’s a nice “good news, bad news” report by Becky Miller and colleagues from DICON (the Duke infection control network). First the bad news: Clostridium difficile has now replaced MRSA as the most common HAI in this 39 hospital network in the southeastern United States. The good news? This development is driven largely by a steady and substantial decline in healthcare-associated MRSA infections between 2005-2009. Check it out:

We’ve discussed this trend before, a trend documented by CDC investigators in the NHSN and EIN programs, and confirmed in the VA system as well. The challenge now is to find a way to make the C. difficile trend line resemble that for MRSA….

High tech hand hygiene monitoring

There is a new online commentary in the New York Times on the use of technology to improve hand hygiene compliance in hospitals. This piece, the first of two parts, appears in an online column called Fixes, which looks at solutions to social problems. Dr. Phil Polgreen from the University of Iowa is interviewed in this piece.

Accentuate the negative

Dan has posted previously on how difficult it is for authors to get negative studies published.  Perhaps this is the real reason why the STAR*ICU study took 4+ years to make it to press.  I suspect that if the study was completed the exact same way that it was but found a benefit for barrier precautions, it would have appeared in press around 2009 or even earlier.  Just a guess.

Mike has posted at least twice on Ben Goldacre and his blog/book called Bad Science (part 1 and part 2).  Ben has a new post in the Guardian that discusses how medicine, academia and popular culture all favor positive, eye-catching and potentially spurious trial results and ignore important negative studies.  His discussion centers around a paper published last year that seemed to provide evidence of precognition - you know it before it actually happens.  That "positive" paper received tons of press, while a new negative study can't see the light of day.  I think this sort of bias plays a large role in infection prevention research - it is so much easier to publish a positive quasi-experimental study showing a benefit than a negative study.  This is why it was so great that after 4+ years of waiting the STAR*ICU study, which was a negative study, was published at the same time as the VA study, which showed a benefit.  This way, we could have a rational discussion with the positive/negative evidence receiving "almost" equal billing.

Ben Goldacre "Backwards step on looking into the future" Guardian 4/23/2011

Getting soap to those who need it

The Starwood Hotel Group has entered into an agreement with Clean the World to recycle soap and shampoos from its hotels with the products donated to the developing world. It is estimated that as much as 1.6 million pounds of soap will be recovered yearly in this program.

What a cool program!