I'm having a (hand-hygiene) moment

We have been working on a hand hygiene surveillance project here in Iowa City. One of my collaborators, Heather Reisinger, just went through and listed all possible "moments" for hand hygiene listed in the various guidelines, which I've pasted below.  Yes, I know there is overlap.

However, I think this list exemplifies why we fail in our infection prevention efforts. How can we take such a simple thing as hand-hygiene and make it this complicated? How can the WHO Guidelines on Hand Hygiene be 270 pages long?!?!?! How can we have directive after directive and keep making it more complicated?

Solution: the Iowa City ONE Moment For Hand Hygiene: After you touch anything

And no, you don't need the before since if you haven't touched anything after you practiced hand hygiene, then there hasn't been a moment for hand hygiene.  It is only AFTER you touch something/anything! that you have to practice hand hygiene.

Take off gloves - you touched them, wash your hands! 

Did you touch a patient, then use hand rub and then exit the room? Do you need to practice hand hygiene? NO; but did you touch anything on your way out, such as a door handle? If yes - practice hand hygiene! 

EOR

16 Moments For Hand Hygiene
___entering patient room
___before touching a patient
___before handling medication
___before clean/antiseptic procedure
___before putting on sterile gloves
___after removing gloves
___after exposure to body fluid
___after visibly dirty/soiled
___moving from a contaminated body site to another body site during the care of the same patient (say that one three times while rubbing your belly and head)
___after touching equipment or patient surroundings
___after touching a patient
___exiting a patient room
___before eating
___after using the restroom
___when preparing food
___after delivering food (if worker touches patient, bed linens, or objects in the room)

20 years ago, Magic Johnson changed the AIDS epidemic

Twenty years ago, Magic Johnson announced his retirement from the NBA because of HIV infection.  I remember that moment well. I was in medical school and we all knew that HIV could infect all people.  However, at the time little national attention was given to the broad risks of the disease, since the general public and politicians thought that only homosexuals, Haitians, hemophiliacs and heroin addicts (the 4 H's) could contract the virus.

Magic's honesty and subsequent appointment to the National Commission on AIDS changed the whole discourse. Magic didn't have to do what he did.  He didn't have to go public. He could have retired and probably lived his life. He took a risk and it paid off for all those with HIV and AIDS. Back then, we all thought this was a death sentence for Magic, like it was for so many before him. Magic's role in changing the conversation probably saved his life and certainly saved many other lives. Thanks Magic.

Personal note:  My med-school friend's (Laura Jana) mother, Dr. June Osborn, was the chair of the National Commission on AIDS and played a significant role in getting Magic appointed to Commission and assisted Magic as he framed his message.  At the time she said "there is no question in my mind that Magic Johnson has achieved a breakthrough that will result in a fundamental sea change. I have been frantic to get the message across to children and youth, and I know damn well that I can't do it. He can." June has been a wonderful mentor to me over the years and I'm proud to know someone, such as June, who has made such an important public health contribution.

There must be a pony in here somewhere...

Before mandatory reporting and pay-for-performance, and before zero became the only acceptable infection rate, it was OK to have somewhat subjective, imperfect definitions for healthcare associated infections. No longer!

Never fear…HICPAC has working groups now grappling with three different definitions: for CLABSI, VAP and SSI (full disclosure: I’m a member of these working groups). Here are just a few desired attributes of any newly-modified HAI definition:

• Must have excellent performance characteristics (most importantly, nearly 100% specificity) when compared with gold standards (note: gold standards do not yet exist).
• Must consist of only objective measures that can be collected by all NHSN participating hospitals, and that are amenable to electronic reporting and easy validation.
• Must demonstrate excellent concordance with clinical definitions of infection, so as not to lose credibility with frontline clinicians (note: because of the subjectivity of clinical definitions, this attribute is not consistent with the attribute above).
• Must not be subject to “gaming”, even by the most creative hospitals (note: even supposedly “objective” measures, like culture and antibiotic use data, are subject to practice changes in response to pressure to reduce HAI rates).
• Must not result in public or political perception that modifications were made in an attempt to lower HAI rates (i.e. “define our way to zero”).

So, keeping these in mind, feel free to submit any suggested changes to current definitions, in the comments section!

The Affect Heuristic

Source: XKCD.com

We've discussed conflicts of interest and bias frequently, particularly in regards to guidelines.  Bob Centor has a nice post today that discusses the affect heuristic and how it might impact clinical guidelines.

The affect heuristic suggests that a good feeling or emotion towards a situation (i.e., positive affect) would result in a person having a lower risk perception and higher benefit perception than supported by an unbiased look at the data. I think this is closely related to confirmation bias, which we have written about frequently, as well.

His recommendation for selection of guideline panels - choose strong methodologists who are non-experts - is one worth pondering.

Disgust and Infection Prevention

That's disgusting! (source: wikipedia)

Just came across this great article in the journal Philosophical Transactions for the Royal Society B, titled "Why Disgust Matters." In the paper Valerie Curtis of the London School of Hygiene and Tropical Medicine argues that the human feeling of "disgust" evolved to motivate infectious disease avoidance. She suggests that a better understanding of disgust could be harnessed to combat the behavioural causes of infectious and chronic disease such as diarrheal disease, influenza and even smoking.

You could imagine that more knowledge around "disgust" or what motivates good behavior (covering your face when you sneeze or washing your hands) could greatly improve infection prevention in hospitals.

Curtis V, Phil. Trans. R. Soc. B 12 December 2011 vol. 366 no. 1583 3478-3490 (abstract) (full text)

Related BBC Article by Health Reporter Philippa Roxby

Conflicting Results in Clinical Trials: the APC Example

Dan posted last week on activated protein C (Xigris) being withdrawn from the market.  David Rind (Evidence in Medicine blog) has posted his thoughts on what might have been behind the initial positive study in 2001 and subsequent negative studies.  It is worth a read.

David Rind: APC and Conflicting Trials (10/29/2011)

Odds and ends

Here are a few odds and ends that I've been mulling over--some related to infection prevention, some tangentially related, and some, well not at all.

• A new paper in the International Journal of Obesity looks to see whether response to influenza vaccine is impacted by obesity. This is important since during the H1N1 pandemic obesity was found to be a risk factor for morbidity and mortality. Interestingly, in this study of nearly 500 participants the investigators found that antibody production is not affected by BMI, but as BMI increases there is a significant decrease in antibody detected at 12 months. The implications of this paper could be huge given the increasing prevalence of obesity in the US.
• I just read Steven Berk's recently published book, Anatomy of a Kidnapping, on a quick trip to Vermont. Berk is an infectious diseases physician and medical school dean, who was kidnapped at gunpoint from his home in 2005. He writes that equanimity helped him to stay cool through the entire ordeal. Though this may have saved his life, I think it robbed some of the emotion from his prose, and I was left with little connection to what should have been a very compelling story. And if I were not on a plane without anything else to read, I would have closed the book for sure when he articulates his view that individuals should be allowed to purchase and own assault weapons.
• Coldplay's new album, Mylo Xyloto, is simply amazing. I can't quit listening to it. It's already setting records for the rate (there's a tie to epidemiology!) of digital downloads it's receiving.
• Dick Wenzel, the most famous hospital epidemiologist since Semmelweis, has in his "retirement"  published a novel and danced the tango for charity. This week he will debut in VCU's production of the musical Grease. He plays the DJ, Vince Fontaine. He still has a day job, too--this week he's attending on the Transplant ID Service.