The flu season that wasn't

It's official: CDC has proclaimed that the flu season that just ended was one of the mildest on record. See all the details here.

Photo: Eastern Connecticut State University

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.

Hospital shifts focus from Contact to Standard Precautions for MRSA and VRE: Costs decline and infections decrease

Since local factors can be dominant in infection prevention (e.g. size of hospital, number of ICUs or prevalence of MRSA on admission) it is important to acknowledge that one size doesn't always fit all, as far as use of Contact Precautions for MDRO control. At the 2012 APIC meeting in San Antonio Maureen Hodson, RN CIC, at HealthAlliance Hospital in Massachusetts presented her hospital's experience with shifting towards a stronger emphasis on Standard Precautions and away from Contact Precautions. Contact Precautions were limited to MRSA and VRE patients who present with uncontained secretions and ESBL, MDR-GNR and active C. difficile patients.

When comparing the 4-month intervention period to prior periods, costs for gowns and gloves declined by $20,000 and VRE infections declined while MRSA infections were unchanged (see table below).  It will be nice to see if this can be sustained and what the impact is on ESBL or C. difficile, but this approach makes a lot of sense.

Reference: Hodson et al, oral presentation #117, APIC 2012

Schadenfreude

Poor APIC! No sooner than they rolled out their new grand vision, healthcare without infection, the keynote speaker at their national meeting tells them it ain't gonna happen. Allan Morrison, a member of the reality based community an infectious diseases doctor, delivered the bad news to APIC. It's not the first time APIC's been rebuked in a plenary session of a national meeting, but this time it happened at their own meeting. Next time, they better make sure all speakers sign the zero pledge card before they let them on the stage.

Thanks, CDC laboratories!

I am on call this month for our clinical microbiology laboratory, so I spent part of yesterday afternoon squinting through a microscope and scratching my head (yes, at the same time). Another Iowa lab had sent us a slide and was asking our opinion regarding the identity of a parasitic form in section. After conferring briefly with a couple colleagues and our state lab, we sent several images to the CDC DPDx team. They responded less than four hours later (about 9 pm CDC time). In cases like this (which occur all day, every day, at hospitals around the country), patients may never know that CDC laboratorians were directly involved in establishing a diagnosis. And presumably, some of those patients will receive appropriate care based upon a correct diagnosis, and recover enough strength to vote for a candidate who wants to gut the CDC budget.

Read this report, recently submitted to a Senate committee, about the work of the CDC laboratories. Then consider contacting your own legislators to ask them to boost, not cut, essential public health and prevention funding.

Influenza for dummies

Here's a really cool video on influenza:

Daptomycin non-susceptible enterococcus

There was a time, way back in the 1990's, back before quinupristin/dalfopristin (1999), linezolid (2000) or daptomycin (2003), that we had to treat VRE with an antibiotic called chloramphenicol. You remember chloramphenicol and its association with reversible bone marrow suppression and fatal aplastic anemia. Even then, VRE developed resistance to chloramphenicol, but we didn't have many other options.

So, it was an exciting time a decade ago when we suddenly had three new treatment options for the always resistant enterococcus.  Those good times have passed us by quickly.  In a new study published in ARIC, Jeremy Storm (COI alert: an ID fellow in Dan's ID division) analyzed a case-series of daptomycin non-susceptible enterococci from a 6-year period (2005-2011) at the University of Iowa.  This is a case-series, so risk factors can't specifically be measured; however, 60% of the 25 patients had prior daptomycin exposure. I've pasted Table 3 below, so you can look at the resistance profile of the isolates. Hopefully, we won't have to dig out chloramphenicol anytime soon, but I'm brushing up on its dosing just in case.

If you need more depressing enterococcal news, you can also read about a high-prevalence (61 patients) of vanB containing E. faecium in a southwest Germany neonatal ICU.