Hospital adopts new technology to monitor hand-washing

Hospitals use various methods to monitor hand-washing by staff; some methods measure the volume of soap and disinfectant hand gel used while others employ "secret shoppers" to observe hand-washing activities. 

North Shore University Hospital in Manhasset, N.Y. is the first hospital to adopt a new video monitoring technology to track hand-washing.  The video monitor technology is made a by Arrowsight.  The technology relies on a network of sensors that monitor entrance activity around doors and a series of cameras mounted on ceilings above sinks and hand sanitizing stations both in and outside patient rooms.  Arrowsight employees monitor the footage to track whether staff wash their hands within 10 seconds of passing through the door.

The rates are published daily on large L.E.D. displays in the hallways and serve as a constant reminder to the staff.  The nurse manager also gets e-mail messages throughout the day with detailed information about hand-washing rates.

The new video monitoring technology was implemented in the surgical and medical intensive care units (ICUs).  ICUs typically have the lowest hand-washing rates because the staff there are the most harried due to large volume of patients and that most patients in ICUs are in serious medical conditions.  Since adopting the technology three years ago, both ICUs have achieved and sustained better results than before.  The medical ICU in particular, improved its hand-washing rates from 6.5% three years ago to over 80%.

Read the article in The New York Times

Abstract to North Shore's study published in Clinical Infectious Diseases

New York State publishes 4th HAI report

New York State published the 2010 Hospital Acquired Infection Rate report this week.   In 2005, New York became one of the first states to mandate reporting of HAIs to the state’s public health department.  In 2009 it became the first state to mandate reporting of inpatient adult and pediatric laboratory-confirmed C. difficile cases using the new NHSN reporting protocol.  Public reporting of HAIs began in 2005 and the first HAI report was published in 2007.  Over 170 hospitals in New York State reported their HAI rates.  The 2010 report found that since 2007, the rate of CLABSIs and SSIs has fallen 37% and 15% respectively, saving more than $15 million because of shorter hospital stays and preventing the need for additional treatment.  The decline in HAI rates can be attributed to better surveillance methods and higher adoption of best infection prevention practices at hospitals.

Full report

Marketing hand hygiene to the public – what works?

A recent study published in this month’s American Journal of Infection Control evaluated the effectiveness of hand hygiene posters placed in a hospital’s cafeteria.   The study was conducted over a 5 week period and had three phases which tracked hand hygiene compliance before, during, and after a poster has been placed next to the hand sanitizer stand.  The study found that hospital visitors used sanitizers significantly more frequently during and after the poster was put up than before, suggesting that the poster was effective at inducing people to change behavior. 

In the article’s conclusions, the author described key characteristics of the poster design.  The poster was large and highly visible to visitors, it had bright graphics, a persuasive message that highlights the benefits of hand hygiene, and offered practical advice.   Unpleasant images, passive training, and reminder messages were not included in the design.

To see the actual poster, please go to the article link

Strategies for Increasing Influenza Vaccine Acceptance by Employees

Face-Mask Mandate Improved Flu Vaccination Rates Among HCWs

An influenza vaccination campaign that included a face-mask mandate for all unvaccinated health care workers (HCWs) led to a vaccination compliance rate of 95 percent at Geisinger Medical Centers in Pennsylvania during 2009, researchers report in Infection Control and Hospital Epidemiology. "Establishing a tough and enforceable requirement that any unvaccinated individuals wear a mask for the entire flu season not only produced the vaccination compliance rates we wanted, but avoided unnecessary legal challenges and inspired an amazing amount of team spirit," said Dr. Lisa M. Esolen of Geisinger Health System. The analysis of the health system's vaccination campaign, implemented during the 2009-2010 flu season, included 12,363 HCWs employed at Geisinger Health System throughout the state. Unvaccinated employees were instructed to wear a surgical mask when they were within six feet of a patient during their shift. The campaign also included a vaccination effort that included increased vaccination hours, vaccination stations at HCW entrances and outside the cafeteria, and recruiting 150 "flu team captains" to decentralize vaccine supplies with vaccination kits. Compared with vaccination compliance rates of 47 percent in 2007 and 61 percent in 2008, vaccination compliance rates among HCWs were 95 percent during 2009 and 92 percent during 2010.

From "Face-Mask Mandate Improved Flu Vaccination Rates Among HCWs"
Pediatric Supersite (06/22/2011)

Crying Wolf about Infectious Diseases

A well-known public health expert is often asked to be a keynote speaker at infection management seminars. I happened to hear him present at two different infection control gatherings about a year apart. They were both emotional speeches about the modern day dangers cause us all to face. During the first speech he talked about how he lay awake nights worrying about his daughters and their survival chances in a world of anthrax. In the next speech he talked about how he lay awake nights worrying about his daughters and their survival chances in an age of Avian Flu. Clearly he was talking about the disastrous infection of the moment.

So what’s wrong with this picture? Link to the following for the answer: https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEizUPpvyapWBM4hS0DJJWynXROBCE5uwFcf9uGbW1NNkPyb5MDX4AibMR9dR2oht5i6XLnZCgTcz1PMWfgVaqk1LtEjfx0yKGu-EeOesFWd9eVg-c3Sfz00ZED4s_1tqGkDV-KzWNCfWA4/s1600/sky+falling+in+cartoon.jpg.

I believe that the public and healthcare providers are suffering from a disaster fatigue. There are too many infections to worry about them all. Worse yet, many of the dire scenarios painted by the media (with the help of some public health officials) have not occurred. It is becoming more and more difficult to know what is real and what to do about it

At the same time the public has come to view health care facilities as death houses where patients are discharged in worse condition than when they were admitted. Public reporting has reinforced this perception. I think that the fact that reporting is legally required is more frightening than the actual contents of the reports. If it must be reported, it must be really bad.

Certainly, there are serious infections occurring in various places throughout the world. The recent E. coli outbreak was a sobering event. Our job as IPs is to place these events in perspective and to help people understand their personal risks of contracting a serious infectious disease.

When everyone was worried about avian flu I was asked to make several presentations about it. I used humor to try to deflate the audience’s anxiety. I showed pictures of houses built above duck ponds and asked “Does this look like your house?”

I showed pictures of people taking dead geese to market on the backs of mopeds, etc.

I think my efforts were successful in bringing listeners back to reality where they could plan rationally.

The humor was not intended to make light of the issue. Rather it was intended to reduce the level of anxiety in the audience so that we could discuss the actual threats and possible responses.

I think it is important to use a variety of techniques balance the scales of concern. In some cases stories about personal concerns are appropriate. But we must consider ourselves to be Panic Preventionists as well as Infection Preventionists. This is no easy challenge to bring people back to earthly sights when everyone else is screaming “Watch out for the birds”!

The future of the flu vaccine?

Flu vaccines today have two major problems: they need to be administered every year, and are only effective against a small subset of flu strains.  Basically, the vaccine makers make an educated guess about which will be the most prominent strains in a given year, and then manufacture the vaccine based on that prediction.  Since different strains become prevalent in different years, this means that each new vaccine must be given when it’s developed each year. 

Damian Ekiert and Ian Wilson, along with Robert Friesen and Jaap Goudsmit from Crucell (a Dutch biopharmaceutical company), recently published a paper in Science Express that details their efforts to prevent and treat influenza infection using antibodies, which would avoid the problems of traditional flu vaccines. 

The project was started several years ago, when Goudsmit and other researchers at Crucell discovered an antibody that bound to a functionally important structure on the flu virus which exists in many different strains.  The antibody, CR6261, worked to both prevent and treat infections by about 50% of influenza viruses, including H1 viruses.  Crucell is about to begin early clinical trials of CR6261, according to the Scripps Research Institute.

To complement this, Crucell’s team began to search for another similar antibody that would be effective against other flu viruses, including H3 and H7 subtypes.  They discovered CR8020, an antibody which binds close to the viral membrane.  CR8020 appears to work by preventing the conformational changes that occur when a flu virus is taken up by a host cell, thereby blocking the release of the virus DNA into the host. 

As Ekiert et al. note in the publication, influenza A viruses responsible for human pandemics have come from very different strains.  In accordance with this, a near-universal therapy for influenza should protect against all these strains, if possible.  Though it is unknown how the antibodies will fare in clinical trials, a mixture of antibodies such as CR6261 and CD8020 is a potentially promising treatment for people who have contracted the flu.  Despite the challenges in developing the antibody mixture into a vaccine, there is now more hope that a “universal” vaccine can be developed.

Science Express paper: http://www.sciencemag.org/content/early/2011/07/06/science.1204839

Infection Control Today article: http://www.infectioncontroltoday.com/news/2011/07/discovery-of-natural-antibody-brings-universal-flu-vaccine-a-step-closer.aspx

Reasons to question Consumer Report’s report on hospital performance

Consumer Reports published new hospital ratings recently. One of the key measures in the report was CLABSI and SSI rates. The report obtained CLABSI and SSI rates from states with mandatory reporting and from the independent reporting agency, the Leapfrog Group.

One conclusion in the report is that large teaching hospitals perform poorly in preventing CLABSIs. According to the report, 3 teaching hospitals got the lowest rating in preventing CLABSIs and 64 teaching hospitals got the second lowest rating.

APIC has issued a letter to the infection prevention community to bring attention to the findings in this report. APIC pointed to several reasons why findings from the report may not tell the whole story. Patient demographics vary widely between teaching hospitals and small community hospitals. Many teaching hospitals serve as Level 1 trauma centers that treat patients with more serious illness than those treated at community hospitals. Patients with serious illnesses have a higher risk of becoming infected than others. Another reason that the report may not be reliable is due to the robustness of the infection prevention program in place at each institution examined. Hospitals with strong infection prevention practices may identify more cases of HAIs than hospitals without good practices. As a result the facility that actively tracks HAIs may appear to have worse rates than those which do track HAIs closely.

While APIC encourages the public to use the information to initiate conversations with healthcare providers to learn more about a hospital’s infection prevention program, the organization emphasizes that the public should not base their decisions and opinions solely on this report.

Link to Consumer Reports' Hospital Rating

Article on teaching hospitals having worse HAI rates than other hospitals

Handwashing and the Law of Diminishing Returns

IPs spend a lot of time monitoring and educating about handwashing. There are continuous debates about what the consequences should be for staff who are “caught” not washing their hands. One question that rarely is raised in Infection Control Committee meetings is whether there is an upper limit beyond which hand hygiene will no longer play a major role in HAI prevention. The answer can have profound effects on the amount of time and energy devoted to this one particular part of the IP role.

Two recent articles have questioned the relationship between increasing handwashing compliance and reduction of health care infections. Biggs, Shepherd and Kerr (2008) performed a mathematical analysis of the transmission of Staph by healthcare workers’ hands that became contaminated by patient contact. They concluded that a compliance levels (or imperfect hand hygiene) <50% were sufficient to stop outbreaks. They also concluded that the rate of increase in hand hygiene compliance was not associated with a similar decrease in infection transmission

Silvestri, Petros, Sarginson, et al (2005) conducted a literature review of 9 studies that looked at the relationship between hand hygiene compliance levels and actual infection rates. They concluded that [poor] handwashing can only account for 40% of transmission in intensive care units.

Why do these studies make sense in a time when hand washing is the first commandment of health care delivery? Both the literature and everyday observation provide some answers. First, glove use is becoming a universal practice. There are few studies that test how much hand contamination occurs with the use of gloves. Second, think of all of the environmental surfaces and healthcare equipment becomes contaminated and is used without cleaning. Stethoscopes, phones (both patient and clinician), bath basins, computer screens and on and on have been found to be contaminated. How effective are clean and gloved hands if contaminated equipment is used between patients without cleaning in between. I recently conducted a study in which we found that pens became contaminated within a single work shift. How many staff take pens into patients rooms, mark dressings and put the pen back into a pocket?

I think the time has come to take a harder look at housekeeping surfaces. I have found that most housekeepers want to do a good job but are hampered by a workload that allows only the most cursory of cleaning. It is about time that we stopped using precious resources on hand hygiene compliance and use them to provide more housekeepers with better equipment.

Beggs, C.B, Shepherd, S.J., and Kerr, K.G. (2008). Increasing the frequency of

handwashing by healthcare workers does not lead to commensurate reductions

in staphylococcal infections in a hospital ward. British Medical Journal of

Infectious Disease,8, 114. Available at: http:/www.biomedcentral.com/1471-

2334/8/114.

Silvestri, L., Petros, A.J., Sarginson, R.E., de la Cal, M.A.,Murray, A.E. and Saene, H.K.

(2005). Handwashing in the intensive care unit: a big measure with modest effects.

Journal of Hospital Infections, 59(3), 172 – 179.