With historical hand hygiene compliance rates typically in the 50% range, infection preventionists have tried multiple interventions that include a vast array of signs and messages in an attempt to change the behavior of health care workers. Can one word make a difference?
In a study slated for publication in an upcoming issue of Psychological Science , organizational behavioralists at the University of North Carolina in Chapel Hill hung different signs above alcohol gel dispensers and measured the frequency of hand hygiene.
A neutral sign said simply, “Gel in, wash out.” Another sign said, “Hand hygiene prevents you from catching diseases.” The clear winner was: “Hand hygiene prevents patients from catching diseases.”
Changing one word – “you” to “patients” – led to a 33% improvement in hand hygiene, says co-author David Hofmann, PhD, professor of organizational behavior at the university.
The sign speaks to the core imperative in medicine – “first do no harm,” says Hofmann. It also sidesteps
another common perception, he says. Health care workers often think they have good immunity and will not get
sick, he says.
“It’s difficult for them to think about an instance when they didn’t wash hands and that led them to get sick,”
he says. “There are factors that would lead them to be overconfident.”
Of course, simply putting up a new sign won’t solve the problem of hand hygiene compliance, Hofmann notes.
“Encouraging and improving hand hygiene is a complex problem to solve, as has been well shown in health care,”
he says. “We don’t expect, and our results don’t demonstrate, that if you change to patient-focused signs the problem will miraculously go away."
"We do find that changing to a patient-focused sign does have a significant effect on hand hygiene,” he says.
“For an organization trying to address this problem, this could be one aspect of that systematic approach.”
An unannounced inspector from the Centers for Medicare and Medicaid Services (CMS) walks into the hospital and summons the infection preventionist.
Looking down at a clipboard, he asks: “What were the last two hospital acquired infections that were serious preventable adverse events in the hospital, [meaning they caused] patient harm or death following development of the infection? What was done about each?”
Prepare now, because this is coming. Those questions and a slew of others are contained in a CMS draft document called “Acute Care Hospital Infection Control Tool for Surveyors” obtained by Hospital Infection Control & Prevention. The largest payer of health care in the country is rapidly developing a national inspection program for infection control in hospitals.
“We want to focus more on the bedside -- on the patients and procedures -- than has been done in the past,” says Daniel Schwartz, MD, MBA, chief medical officer of the CMS Survey and Certification Group. “We don’t want the surveyors sitting in a room scouring through policies and procedures for four to six hours.”
The draft survey for CMS inspectors is being trialed in 10 states, Washington D.C. and Puerto Rico. The tool will be refined as warranted based on the evaluation, with the final product expected to debut in all 50 states in October 2012. The CMS has created a survey tool for a sweeping assessment of infection prevention, using a patient tracer approach similar to the Joint Commission to follow key issues through the care process. The pressure is on, but infection preventionists who pivot toward this initiative by reviewing the CMS expectations -- and making hospital senior administration well aware of them -- are poised for empowerment.
For more on this important story see the December issue of Hospital Infection Control & Prevention.
In the latest in a remarkable surge of infection prevention initiatives, the Centers for Medicare and Medicaid Services (CMS) is partnering with the Centers for Disease Control and Prevention to prevent healthcare associated infections in dialysis facilities.
The initiative includes a new CMS requirement for dialysis facilities to submit three months of 2012 infection and antibiotic use data to CDC’s National Healthcare Safety Network (NHSN) in order to receive full Medicare payment. This is the first CMS/CDC data collaboration related to dialysis settings. However, the two agencies have been aligning patient safety efforts on multiple hospital quality measures.
In 2008 data, hemodialysis patients acquired some 37,000 central-line associated bloodstream infections (CLABSIs), the CDC reports. In addition, within the last decade there have been more than 30 outbreaks of hepatitis B and hepatitis C in non-hospital healthcare settings that include dialysis centers. The CDC is providing several new resources to dialysis facilities and patients to ensure smooth NHSN enrollment and improved quality care. These include a new dialysis safety web site including infection prevention recommendations, as well as step-by-step NHSN enrollment and training materials .
There are thousands of free standing dialysis centers in the U.S., owned primarily by the major corporate chains in the field. To a lesser degree, dialysis services are offered by or affiliated with hospitals. Hospital based IPs that fall in this category should prepare to begin reporting data, while the regulation for freestanding clinics would seem to provide a new opportunity for IP consultants.
“We have a dedicated dialysis unit so we are already looking at this new pay for reporting initiative as something we are clearly planning to comply with,” says Russ Olmsted, MPH, CIC, an infection preventionist at St. Joseph Mercy Health System in Ann Arbor, MI. “We actually already have our dialysis unit enrolled in NHSN and they are reporting.”
The substantial number of CLABSIs among hemodialysis patients is also a problem for hospitals, as the infections are a major cause of admissions and readmissions. A primary prevention measure is the avoidance of central lines in favor of arteriovenous fistulas for dialysis patients.
“If a [dialysis] patient develops a bloodstream infection, inevitably they are going to be admitted to a nearby hospital,” Olmsted says. “The way I interpret this updated pay for reporting rule, if you didn’t have a dedicated dialysis unit in your hospital it should have minimal impact in terms of needing to report this. But certainly if you have a dialysis facility within your scope of service then there is a pretty significant incentive to go ahead and begin reporting this data if you are not already.”
The Biblical aphorism that lives on in modern translation to describe someone who does “not suffer fools gladly” usually infers an impatience with ignorance, particularly as it impedes true progress. Meet Stan Deresinski, MD, FACP, FIDSA, editor of one of our sister publications Infectious Disease Alert.
In a column in the current issue, the clinical professor of medicine at Stanford University, gives a thumbs up (with key caveat) to the latest Hollywood attempt to capture a global epidemic: "Contagion."
“The mutated virus causing the epidemic, called MEV-1 (it is unstated, but perhaps standing for "meningoencephalitis virus-1") is clearly modeled on the Nipah virus, which was first identified in Malaysia in 1988-1999 and whose natural host is a flying fox, a type of frugivorous bat,” Deresinski writes. “Nipah outbreaks in Asia have been associated with contact with pigs, but also with human-to-human transmission and with eating contaminated fruit and fruit juices, such as raw date palm juice. Clinical illness starts with influenza-like symptoms with, in some cases, progression to pneumonia and to encephalitis, often ushered in by seizures with progression to coma in 24-48 hours. There is no known effective treatment and no vaccine is available.”
As those in the field of infection control are well aware, infectious diseases and outbreaks in filmdom are typically given a few superpowers to move things along: “Let’s go, we’re not making Ben Hur here people! Where are all the extras on vents?”
Sure enough, Deresinski finds that the otherwise “amazingly realistic” science in the flick takes a similar liberty: “The initial spread of the virus is remarkably fast, probably unrealistically so,” he writes. “In addition, 57 versions of the vaccine are tested in primates before an effective one is developed. The vaccine undergoes unspecified further testing, is manufactured and distributed — all within a few months. This remarkable celerity may prove feasible at some time in the future, but not yet.”
Ok, Hollywood is generally getting on board with accuracy, but what about politicians? Not so much, Deresinski finds, blistering U.S. Rep Michelle Bachman’s (R-Minn) fact-free attack on the vaccine for human papillomavirus (HPV).
“HPV causes, among other malignancies, most of the more than 200,000 cervical cancers that occur in the world each year, most in developing countries where screening is not routinely performed,” Deresinski writes. “In the United States, where Pap screening is the rule, there are, nonetheless, 12,000 cases and 4,000 deaths each year. An effective preventive vaccine has been available for several years and is recommended for administration to girls beginning at age 11 years (and as early as age 9 years) — ideally before sexual debut, since HPV is the most prevalent sexually transmitted infection in the United States and the vaccine does not protect against existing infection. The quadrivalent vaccine also protects against genital warts and recently received approved for use in males as young as 9 years of age. Importantly, the vaccine, which does not contain live virus, has an impressive safety record.1
“Despite this safety record, Rep. Bachman, a graduate of the Oral Roberts School of Law, in a recent Republican candidates' debate, called the vaccine `dangerous’ and spoke of the `poor innocent little girls’ upon whom it was inflicted,” he continues. “The following day she went on to relay an unsubstantiated story about a girl who `became mentally retarded’ after receiving the vaccine. Associated statements by her and some of her fellow candidates also contained the implication that any public health mandate constituted an unconstitutional denial of freedom. As an apparently charter member of the seemingly expanding cult of `denialism’ — the rejection of science and its methods and of objective reality itself — perhaps these statements should have been expected. They, nonetheless, have the potential to cause enormous damage by causing individuals to reject the vaccine for themselves or their children. Will the denialists take responsibility for the resultant deaths?”
Wow, what a great moral question. And don’t forget this vaccine has an emerging role in protecting boys as well from oral cancers. But I won’t even go near an assessment of the possible audience reactions if the debate moderator asked Bachman and other HPV critics: “Aren’t you resistant to this HPV vaccine because you fear it will encourage earlier sexual activity? Experts say that is not the case, but even if it was is that not a better alternative to your child acquiring cancer?”
1. Gee J, et al. Monitoring the safety of quadrivalent human papillomavirus vaccine: Findings from the Vaccine Safety Datalink. Vaccine 2011 Sep 9; Epub ahead of print. http://www.ncbi.nlm.nih.gov/pubmed/21907257
[caption id="attachment_545" align="alignleft" width="150" caption="New Year's Day at 6 a.m.!"][/caption]
The Joint Commission's new National Patient Safety Goal (NPSG) on preventing indwelling catheter-associated urinary tract infections — which emphasizes prompt removal of unnecessary devices and surveillance for CAUTIs — is effective January 1, 2012 for hospitals.
Though there has been some historical tendency to dismiss these as relatively low priority infections, the Centers for Disease Control and Prevention cited a staggering annual mortality figure in a recently posted surveillance document, stating that "more than 13,000 deaths are associated with UTIs."1,2
"The urinary tract is the most common site of healthcare-associated infection, accounting for more than 30% of infections reported by acute care hospitals," the CDC reports. "Virtually all healthcare- associated urinary tract infections are caused by instrumentation of the urinary tract. CAUTI can lead to such complications as cystitis, pyelonephritis, gram-negative bacteremia, prostatitis, epididymitis, and orchitis in males and, less commonly, endocarditis, vertebral osteomyelitis, septic arthritis, endophthalmitis, and meningitis in all patients. Complications associated with CAUTI cause discomfort to the patient, prolonged hospital stay, and increased cost and mortality."
Indeed catheter use in and of itself is associated with negative outcomes other than infection, including nonbacterial urethral inflammation, urethral strictures and mechanical trauma, the Joint Commission notes. "The length of time that a catheter is in place contributes to infection, so limiting catheter use and duration are important to preventing infection," the Joint Commission recently stressed.3
More than a quarter of the patients with an indwelling urinary catheter for two to 10 days will develop bacteriuria, and a quarter of these will develop a CAUTI. Approximately 450,000 CAUTIs occur annually in hospitals, the Joint Commission reported, citing estimates of the excess cost per case of $1,200 to more than $2,700 and a total annual cost of some $400 million.4-8 Moreover, the Centers for Medicare & Medicaid Services (CMS) lists CAUTIs among the healthcare associated infections targeted for non-reimbursement.
"The healthcare-associated conditions that CMS will not cover are high cost or high volume or both; result in the assignment of a case to a diagnosis-related group (DRG) that has a higher payment when present as a secondary diagnosis; and could reasonably have been prevented through the application of evidence-based guidelines," the Joint Commission states.
CAUTI surveillance may be targeted to areas with a high volume of patients using indwelling catheters, the Joint Commission states. High-volume areas should be identified through the hospital's risk assessment as required in IC.01.03.01. In that regard, what if your risk assessment reveals CAUTIs are not an issue at your hospital? The Joint Commission recently answered that question (see Q&A, below) providing clarification that included this statement:
"This new NPSG has a phase-in period during 2012, during which surveyors will be ensuring that hospitals are planning and preparing for full implementation in 2013. Starting in January 2013, a hospital that has decided, based on its risk assessment, that CAUTI surveillance is not indicated should be prepared to discuss this decision with its survey team and provide a clear rationale. Even if surveillance is not performed, the insertion and management requirements of the goal must still be implemented."
According to the Joint Commission, NPSG.07.06.01 requires hospital infection control programs to "implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections. (Evidence-based guidelines for CAUTI include the "Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals": The CAUTI patient safety goal is not applicable to pediatric populations. "Research resulting in evidence-based practices was conducted with adults, and there is not consensus that these practices apply to children," the Joint Commission notes.
1. Centers for Disease Control and Prevention. Available at: http://ow.ly/70gUU
2. Klevens RM, Edward JR, et al. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Reports 2007;122:160-166.
3. Joint Commission. R3 Report. “Catheter-associated urinary tract infections: Issue 2, September 28, 2011, available at: http://ow.ly/709mW
4. Saint S., Chenoweth C.E.: Biofilms and catheter-associated urinary tract infections. Infect Dis Clin North Am: 2003; 17(2):411-432
5. Johnson J.R., et al. Prevention of catheter-associated urinary tract infection with a silver-oxide-coated urinary catheter: clinical and microbiologic correlation. Jrl Infect Dis 1990;62(5):1145-1150.
6. Riley D.K., et al: A large, randomized clinical trial of a silver-impregnated urinary catheter: Lack of efficacy and staphylococcal superinfection. Am Jrl Med 1995: 98(4):349-356
7. Rebmann T., Greene, L.R. Preventing catheter-associated urinary tract infections: An executive summary of the Association for Professionals in Infection Control and Epidemiology, Inc. Elimination Guide. AJIC 2010; 38(8):644-646.
8. Fuchs, M.A., et al: Evaluation of an evidence-based, nurse-driven checklist to prevent hospital-acquired catheter-associated urinary tract infections in intensive care units. Jrl Nurs Care Qual, 2011;26(2):101-109
HIV/AIDS mortality data highlight disparities between states, suggesting differences in HIV treatment and care, a new study shows.1
Investigators compared HIV/AIDS data from 37 states that have collected confidential HIV reporting data for most of the past decade. They found geographic disparities in HIV mortality.
“We combined data from two national sources,” says David Hanna, MS, a doctoral student in epidemiology at Johns Hopkins Bloomberg School of Public Health in Baltimore, MD.
“The first source was the national HIV/AIDS reporting system maintained by the Centers for Disease Control and Prevention,” he says. “The other data source is the national vital statistics system maintained by the National Center for Health Statistics, which contains data for all reported deaths in the country.”
With data from 2001 to 2007, researchers calculated mortality rates due to HIV and AIDS, finding out what the HIV death rate was in the state’s general population, calculated as HIV death rate per 100,000 population person-years. Then they looked more specifically at the mortality rate among only HIV-positive populations, describing this as the HIV case-fatality rate per 1,000 HIV-infected person years.
“We collaborated with the CDC to generate this information,” Hanna says.
When investigators charted the conventional HIV death rate and compared it with the HIV case-fatality rate among HIV-infected populations, they found that the Southeast was dominant in both measures. States like Mississippi, North Carolina, Tennessee, Louisiana, Georgia, South Carolina, and Florida were ranked in the top 10 on both lists. For instance, Florida has the highest HIV death rate with 12.5 HIV deaths per 100,000 population, and it has the 10th highest HIV case-fatality rate with 24.2 HIV deaths per 1,000 HIV-infected person years.1
Louisiana ranks second in both measures with 11.2 HIV deaths per 100,000 person-years and 32.5 HIV deaths per 1,000 HIV-infected person years.1
New York and New Jersey rank third and fifth in the conventional HIV death rate, but their rankings fall to 30th and 15th when it comes to HIV deaths per 1,000 HIV-infected person years.1
“We know that New York has a relatively high number of residents infected with HIV, and consequently a high number of deaths due to the sheer size of its HIV population,” Hanna explains.
“However, when we calculated the HIV case-fatality rate to take into account the number of deaths occurring among HIV-infected people only, we found that at 14.7 per 1,000, New York’s rate is quite low,” he adds. “This suggests that the risk of death for those with HIV is lower in New York state than in many other states.”
It might also suggest that New York does a good job at identifying new HIV infections and getting people into care, although the epidemiological findings can only suggest this as a possibility.
“Then, let’s look at South Carolina, which has a conventional death rate ranking of sixth out of 37 states -- with 8.6 deaths per 100,000 person years,” Hanna says.
“Similarly, the state’s case-fatality rate ranks at seventh out of 37 states, with 25.2 deaths per 1,000 person-years” he says. “So with respect to South Carolina, HIV mortality appears relatively high regardless of the metric used.”
As national public health policymakers address the HIV epidemic and disparities, they should keep in mind geographic disparities, Hanna suggests.
“Ultimately, we’re trying to identify factors that policymakers can understand to help them formulate strategies to improve the health of people with HIV,” he adds.
“Race and transmission risk are important, but we want to show there are other factors that should be taken into consideration, like geography,” Hanna says. “States provide different environments with respect to health insurance, prescription drug coverage, and other economic factors, and these cannot be ignored.”
1. Hanna DB, Selik RM, Tang T, et al. Disparities among states in HIV-related mortality in persons with HIV infection, 37 U.S. states, 2001-2007. AIDS. 2011;[Epub ahead of print.]
Growing anti-regulatory pressure in a down economy – to say nothing of presidential politics as an election year looms-- are making it exceeding difficult for the Occupational Safety and Health Administration (OSHA) to advance its controversial proposed infectious disease standard to protect health care workers.
As we previously reported inHospital Infection Control & Prevention, OSHA is considering a proposed rule that would address airborne, droplet and contact transmission in health care settings. Occupational infections during the SARS epidemic and the H1N1 pandemic spurred the agency interest, though many infection preventionists immediately came out against the idea. The general concern is that flexible and evolving Centers for Disease Control and Prevention guidelines are better designed to address a moving target like infectious diseases than rigid OSHA standards. The issue is reminiscent of OSHA’s previous failed attempt to create a standard to protect health care workers from tuberculosis.
"While the agency learned a great deal from the previously proposed tuberculosis rule, the agency is considering the current infectious disease activity in the larger context of standard and transmission-based precautions rather than on a disease-by-disease basis," OSHA stated.
While the infectious disease proposed rule is in its early stages, OSHA initiatives that were much closer to finalization have also be stalled out by the current economic and political climate. For example, a recordkeeping rule that would add a column to the OSHA 300 log for musculoskeletal disorders (MSDs) seemed on a fast-track in 2010, with implementation scheduled for 2011. However, it became mired in an unusually lengthy review in the Office of Management and Budget, and OSHA withdrew the rule. The agency gathered more comments and was expected to reissue it in time for the rule to become effective in 2012. It remains in limbo.
OSHA administrator David Michaels, MD, MPH, has said that issuing an Injury and Illness Prevention Program standard (I2P2), requiring employers to have a program to address workplace hazards, is his top priority. A draft version was due by June 2011, according to the agency’s regulatory agenda. But again, no sign of I2P2 has emerged.
“I’ve been amazed at the extent to which OSHA’s agenda has been affected,” says Brad Hammock, an attorney with Jackson Lewis in Reston, VA, who specializes in occupational health law and was counsel for safety standards at OSHA from 2005 to 2008.
“There’s never one thing that causes a delay in a regulatory initiative by OSHA. There are things that go on behind the scenes that have nothing to do with politics. It could be something as simple as difficult technical issues with a rule. But I suspect it’s a combination of a lot of things [including politics],” he says.
Republicans have put OSHA in their sights as they criticize “job-killing” regulations. “We’re coming up to an election year. Jobs are the top issue in the upcoming election and a dominant theme has been government creating an atmosphere where jobs can be created. OSHA has been an easy whipping boy, like the EPA [Environmental Protection Agency], for that theme,” says Eric J. Conn, an attorney who heads the OSHA group at Epstein Becker and Green in Washington, DC.
A staggering succession of hepatitis outbreaks has steeled the general perception that infection prevention programs in ambulatory care settings leave a lot to be desired.
Inspections by the Occupational Safety and Health Administration (OSHA) confirm these fears, even as the number of surgeries performed in ambulatory care centers (ASCs) continues to rise. In the past four years, OSHA has increased inspections in these settings, fining ASCs and physician offices for violations of its Bloodborne Pathogen Standard. In fact, such violations make up the majority of OSHA medical facility citations in recent years, according to a two-part series of articles published in the journal of the Association for Operating Room Nurses (AORN).
The authors found that the most frequent causes of bloodborne pathogen violations were outdated or nonexistent exposure control plans, poor documentation, the failure to use safety devices and the lack of free training during working hours. The violations that merited the largest fines dealt with failure to immediately remove personal protective equipment (PPE) penetrated with body fluids; failure to use safety devices; and the failure to provide workers with a free Hepatitis B vaccination and follow up.
“Compliance with the Bloodborne Pathogen Standard may seem complex; however, it is the key to providing a safe workplace for both the health care employee and patient,” writes Pamela Dembski Hart, BS, MT(ASCP), CHSP, principal of Healthcare Accreditation Resources of Boston, in the two-part series, “Complying With the Bloodborne Pathogen Standard: Protecting Health Care Workers and Patients,” and “Compliance: the Key to Bloodborne Pathogen Safety.”
OSHA adopted the mandatory Bloodborne Pathogen Standard approximately 20 years ago in order to protect health care workers from exposure to blood, body fluids and infectious material. In the last decade more than 130,000 U.S. patients served at ASCs were notified of potential exposure to HBV, HCV and HIV due to unsafe injection practices and lapses in infection control. Facilities should develop and exposure control plans that determine safety risks and describe work practice controls, Hart recommends. ASC managers should solicit input from all employees to prevent needle sticks and sharps contamination and identify employees’ exposure risks.
Hospital Infection Control & Prevention has been the leading source for news and comment on health care epidemiology for 38 years. With the HICprevent blog site we extend our coverage and commentary on this dynamic field, opening a new dialogue with infection preventionists, health care epidemiologists and others seeking solutions to one of the most vexing problems in patient safety: health care associated infections. HICprevent welcomes your comments, questions, tips and strategies for infection prevention.