Tag Archives: Hospital

Video monitors hospital handwashing with dramatic improvements in compliance; works for meat processing and dry cleaning too

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Tina Rosenberg of the New York Times writes that in the intensive care units at North Shore University Hospital in Manhasset, N.Y., two L.E.D. displays adorn the wall across from each nurses’ station. They show the hand hygiene rate achieved: last Friday in the surgical I.C.U., the weekly rate was 85 percent and the current shift had a rate of 91 percent. “Great Shift!!” the sign said. At the medical I.C.U. next door, the weekly rate was 81 percent, and the current shift 82 percent.

Those L.E.D. displays are very demanding — health care workers must clean their hands within 10 seconds of entering and exiting a patient’s room, or it doesn’t count. Three years ago, using the same criteria, the medical I.C.U.’s hand hygiene rate was appalling — it averaged 6.5 percent. But a video monitoring system that provides instant feedback on success has raised rates of handwashing or use of alcohol rubs to over 80 percent, and kept them there.

Hospitals do impossible things like heart surgery on a fetus, but they are apparently stymied by the task of getting health care workers to wash their hands. Most hospitals report compliance of around 40 percent — and that’s using a far more lax measure than North Shore uses.

How do hospitals even know their rates? Some hospitals track how much soap and alcohol gel gets used — a very rough measure. The current standard of care is to send around the hospital equivalent of secret shoppers — staff members who secretly observe their colleagues and record whether they wash their hands.

This has serious drawbacks: it is expensive and the results are distorted if health care workers figure out they’re being observed. One reason the North Shore staff was so shocked by the 6.5 percent hand-washing rate the video cameras found was that measured by the secret shoppers, the rate was 60 percent.

The North Shore study, published this week in the journal Clinical Infectious Diseases, is the first use of video in promoting hospital handwashing, and the first controlled study in a peer-reviewed journal of a high-tech effort to increase hand hygiene rates.

North Shore instead uses a video monitoring system made by a company called Arrowsight. Cameras on the ceiling are trained on the sinks and hand sanitizer dispensers just inside and outside patient rooms. (Patients are not photographed.) A monitor at each door tracks when someone enters or leaves the room — anyone passing through a door has 10 seconds to wash hands. Arrowsight employees in India monitor random snippets of tape and grade each event as pass or fail.

What makes the system function is not the videotaping alone — it’s the feedback.

The nurse manager gets an e-mail message three hours into the shift with detailed information about hand hygiene rates, and again at the end. The L.E.D. signs are a constant presence in both the surgical and medical I.C.U.s

This is Arrowsight’s first foray into health care. The company’s main business is meat: half the beef processing plants in America use its video system to monitor workers’ hygienic practices.

Adam Aronson, Arrowsight’s chief executive, said that at one plant cameras focused on a hand sanitizer dispenser right outside the bathroom. With monitoring and feedback, hand hygiene rates went from about 4 percent to over 95 percent, and the achievement was sustained.

At first Farber feared he wouldn’t be able to get approval; the conventional wisdom was that employees don’t like being videotaped. But then he thought about a recent experience at the dry cleaner: he had picked up some of his daughter’s clothes, but one of her suits was missing. He went back to the shop and told them the date and approximate time of his visit. They pulled up a video that indeed showed him leaving her suit behind. “If dry cleaners are doing that, we need to do that in the hospital,” he thought.

‘The dirty hand in the latex glove’ Handwashing issues in hospitals

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“Gloves give a false sense of security” is standard food safety banter when talking about the use of gloves in food service.

My version is, “It doesn’t matter whether someone making a sandwich or salad is wearing gloves or not if they pick their nose, explore their ear or scratch their butt and then continue to prepare food.”

A paper published in the journal Infection Control and Hospital Epidemiology "The Dirty Hand in the Latex Glove: A Study of Hand-Hygiene Compliance When Gloves Are Worn," takes up a similar issue in hospitals. The study was summarized by The Atlantic.

Problem: Gloves reduce germ transmission in situations where contact with body fluids is expected. Their use, however, is not a substitute for handwashing before and after patient contact, since germs can still get through latex and hands can be contaminated by "back spray" when gloves are removed.

Methodology: Researchers in the U.K. led by Sheldon Stoneof the Royal Free Hospital NHS Trust observed glove use and hand-hygiene practices involving 7,578 patient contacts in 56 intensive care units in 15 hospitals.

Results: Gloves were used in just over a quarter of the patient contacts and were absent in 141 of 669 high-risk contacts. Use of gloves was strongly associated with poor hand hygiene as well. While only half of those who didn’t wear gloves washed their hands before and after coming into contact with a patient, the rate for those who wore gloves was even lower at just 41.4 percent.

Conclusion: Hand hygiene is a serious problem in hospitals. Healthcare workers who wear gloves may be relying too much on their ability to prevent transmission, as they clean their hands before and after patient contact much less frequently.

Implication: This failure of basic hand hygiene could be contributing to the spread of infection, the researchers say in a statement. Hand-hygiene campaigns should consider placing greater emphasis on the World Health Organization’s indications for glove use.

Handwashing motivator: Study shows posters can help increase hand hygiene practices

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A study by Kansas State University shows posters can make a difference when it comes to hand hygiene in a health care setting.

The research, based on observations of more than 5,000 patrons at a hospital-based cafeteria, shows that an evidence-based informational poster can increase attempts at hand hygiene. The study appears in the current issue of the American Journal of Infection Control, and was funded by One Health Kansas, a project supported by the Kansas Health Foundation.

The research team included K-State’s Katie Filion, a December 2010 master’s graduate in biomedical science; Kate KuKanich, assistant professor of clinical sciences; Megan Hardigree, a 2008 master’s graduate in kinesiology; and Doug Powell, professor of food safety. Also on the team was Ben Chapman, assistant professor in the department of 4-H youth development and family and consumer sciences at North Carolina State University.

Hand hygiene is important before meals, especially in a hospital cafeteria where patrons may have had recent contact with infectious agents, KuKanich said.

"Few interventions to improve hand hygiene have had measurable success. This study was designed to use a poster intervention to encourage hand hygiene among health care workers and hospital visitors upon entry to a hospital cafeteria," she said.

Over a five-week period, a poster intervention with an accessible hand-sanitizer unit was deployed to improve hand hygiene at the entrance to a hospital cafeteria. An anonymous researcher was able to observe hand hygiene attempts from the adjacent dining area. The study included baseline, intervention and follow-up phases, with each consisting of three randomized days of observation for three hours at lunchtime.

Gains were modest, Powell said. During the 27 hours of observation, 5,551 participants were observed, with hand hygiene attempts increasing from 3.16 per cent to 6.17 per cent.

Hand washing compliance efforts have focused on increasing availability of proper tools for hand hygiene, education and training, and use of prompts such as visual reminders or peer pressure and the presence of others, according to Powell and KuKanich.

"Hand hygiene is still the best way to prevent the spread of infectious diseases. Unfortunately, many of us don’t wash our hands as often as we should," KuKanich said.

"Those ‘Employees Must Wash Hands’ signs in bathrooms may not be the most effective reminder," Powell said. "While improvements in this study were modest, we have set an evaluation framework to work with informational posters that use more graphical messages and reminders that use a shock-and-shame approach."

An abstract of "Observation-based evaluation of hand hygiene practices and the effects of an intervention at a public hospital cafeteria" is available at http://www.ajicjournal.org/article/S0196-6553%2810%2900986-7/abstract
 

Operations cancelled as UK hospital staff hit by food poisoning at party

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Patients about to go into surgery at Poole Hospital were left angry after being told to get dressed and go home because staff had fallen ill after a party.

One woman told the Daily Echo about her experience.

“We had all got into our nighties and dressing gowns when they told us our ops had been cancelled. They were making another date because all the doctors and anaesthetists went out for a party, had a good drink and some got food poisoning. Everyone was disgusted.”

The hospital’s director of nursing and patient safety Martin Smits confirmed a “number of staff” became unwell after an event in a non-clinical part of the hospital on Thursday, July 21.
 

Going into hospital far riskier than flying: WHO

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Who’s the last person most people see before dying? A doctor. So stay out of hospitals and you may live longer.

The World Health Organization said today millions of people die each year from medical errors and infections linked to health care and going into hospital is far riskier than flying.

"If you were admitted to hospital tomorrow in any country… your chances of being subjected to an error in your care would be something like 1 in 10. Your chances of dying due to an error in health care would be 1 in 300," Liam Donaldson, the WHO’s newly appointed envoy for patient safety, told a news briefing.

This compared with a risk of dying in an air crash of about 1 in 10 million passengers, according to Donaldson, formerly England’s chief medical officer.

More than 50 percent of acquired infections can be prevented if health care workers clean their hands with soap and water or an alcohol-based handrub before treating patients.

Risk comparisons are also risky.
 

Checklist culture to reduce risk

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Tina Rosenberg of the New York Times follows up her ‘machines that go ping’ piece about hi-tech handwashing compliance techniques with a low-tech approach that seems ridiculously successful: checklists.

“In 2003, the Michigan Health and Hospital Association began an experiment to see if its members could bring down the rate of infection in central line catheters — one of the deadliest types of hospital-acquired infections.

“The intensive care units at nearly every hospital in Michigan participated — 103 I.C.U.’s. What they had to do was use a five-point checklist to prevent infection when inserting the catheters. The steps were: Wash hands. Cover the patient with sterile drapes. Clean the skin with chlorhexidine antiseptic. Do not insert catheters into the groin area. Remove catheters as soon as they are no longer needed.

“A paper in the New England Journal of Medicine by Peter Pronovost, the Johns Hopkins University doctor who designed the checklist, set out the results.

“’Within 3 months after implementation, the median rate of infection was 0, a rate sustained throughout the remaining 15 months of follow-up. All types of participating hospitals realized a similar improvement.’”

“Atul Gawande wrote about the checklist in The New Yorker, and went on to write a book called “The Checklist Manifesto.” In his article, he talks about how the checklist makes each step explicit and helps harried doctors and nurses to remember all of them. …

“The checklist itself probably isn’t useful for routine hand-washing — there would be only one item on it. What is useful is borrowing the way the checklist replaces a culture of “no questions” with a culture of “patient safety comes first and it is part of my job to speak up.”

“One very valuable source for ways to improve hand-washing rates comes from the health care industry’s Joint Commission Center for Transforming Healthcare Hand Hygiene Project. The project worked with eight hospitals to implement pilot programs designed to raise hand-washing rates in different ways. A solution that helped almost everywhere was to streamline workflow to make it easier and more automatic to wash hands: for example, to put sinks in the same place in every room, with a table to put down items the nurse might be carrying. Keep supplies in every room so nurses don’t have to go in and out to get them.

But the project also found, as many readers suggested, that hospital managers needed to elevate hand-washing as a priority, stress its importance, and hold all hospital workers accountable. Accountability requires knowing the hand-washing rates of different units and people, which is why the technological systems I wrote about on Tuesday can be important. But data only matters if it is used. Once hospitals can know their workers’ hand-washing rates, they need to use the information for coaching and to create incentives — both negative and positive.”
 

Food trial goes wrong at hospital; 10 sick

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An investigation is under way at a U.K. hospital after 10 staff who took part in a food trial were struck down with illness.

Eight of the catering team at Raigmore Hospital in Inverness received treatment in the accident and emergency department.

The workers were testing a new food product aimed at patients with swallowing difficulties, such as stroke victims and dementia sufferers.

Symptoms ranged from temporary loss of vision to facial inflammation. None of the staff was detained in hospital and all are now back at work. No patients were affected and the kitchens were not shut down. It is believed that the illness was not food-related, a spokeswoman for NHS Highland said. The food packaging is the suspected source of the illnesses.

A source, who wished to remain anonymous, said: "Some had lost their vision because their eyes were so swollen, they couldn’t open them. It must have been frightening."

"I am surprised the kitchen was not closed down for a while to find out what was going on," the source added.

Raigmore has 577 beds and employs around 3,200 staff. The catering department has 60 staff who provide 2,500 meals a day to patients, staff and visitors.

Sanitizers suck for petting zoos, hospitals?

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What’s better, washing with soap and water and drying with paper towel, or using a sanitizer?

About 10 years ago the consensus was leaning toward sanitizers because of convenience and mobility. But new studies questioning the effectiveness of various sanitizers means handwashing has become fashionable yet again.

Are sanitizers better than nothing? Probably, in places like hospitals, but not so much on farms where organic matter – dirt and poop – rapidly reduce the effectiveness of sanitizers.

In the wake of an outbreak of cryptosporidium linked to a live lambing event in Wales that has sickened at least 13, the U.K. Health Protection Agency (HPA) has warned anyone who is visiting an open farm over the Easter weekend not to rely on sanitizing hand gels or wipes to protect themselves or their children against germs that may be present in animal dirt around the farm.

Although the risk of becoming unwell is very low in light of the millions of farm visits every year there are, on average, around three outbreaks of gastrointestinal disease which are linked to visits to petting farms. The route of infection in these outbreaks is generally through contact with germs from animal droppings. These germs can be ingested when people, especially children, put their fingers in their mouths.

To reduce the risk of illness, both adults and children should thoroughly wash their hands using soap and water after they have handled animals or touched surfaces at the farm and always before eating or drinking. Hand gels can’t remove contamination in the manner that soap and water can.

Research published by the HPA of a review of 55 outbreaks of intestinal disease linked to petting farms between 1992 and 2009 showed that one of the risk factors associated with illness was the reliance on hand gels instead of handwashing. Over the 17 year period of the study, 1,328 people were reported to have fallen ill following a farm visit, of whom 113 were hospitalised. Illness ranged from mild through to severe diarrhoea and occasionally more serious conditions.

Over half of the 55 outbreaks in the study, 30 (55 per cent) were caused by E. coli O157 (VTEC O157) and a further 23 (42 per cent) were caused by cryptosporidium. The remaining two (three per cent) outbreaks were caused by a type of salmonella.
Other risk factors noted in the research are which have been linked to outbreaks include bottle feeding lambs and thumb sucking by children. The full research paper can be found in Emerging Infectious Diseases 2010 Gormley et al. ‘Transmission of Cryptosporidium spp. at petting farms, England and Wales’ http://www.cdc.gov/ncidod/eid/

Hand gels have their use in areas which are generally clean, for example offices or hospitals, but are not effective in killing bugs such as E. coli or cryptosporidium which can be found in animal droppings and on contaminated surfaces around farms.

Except there may be some BS in the cleanest offices.

The U.S. Food and Drug Administration (FDA) reported yesterday that some hand sanitizers and antiseptic products come with claims that they can prevent MRSA (methicillin-resistant Staphylococcus aureus) infections.

Don’t believe them. These statements are unproven, says FDA.

“Staphylococcus aureus itself is a very aggressive organism,” says Edward Cox, M.D., M.P.H., director of FDA’s Office of Antimicrobial Products. “It’s often associated with patients in hospitals who have weakened immune systems, but the bacterium can also cause significant skin infections and abscesses in a normal, healthy person. And it can get into the bloodstream and, less frequently, may involve the heart valve, which is very difficult to treat.”

But this antibiotic-resistant strain is even more difficult to treat. “With MRSA, a number of the antibiotic drugs we typically used often don’t work, so we lose treatment options we used to rely upon,” says Cox.

FDA is cracking down on companies that break federal law by promoting their products as preventing MRSA infections and other diseases without agency review and approval.

“Consumers are being misled if they think these products you can buy in a drug store or from other places will protect them from a potentially deadly infection,” says Deborah Autor, compliance director at FDA’s Center for Drug Evaluation and Research.

FDA wants consumers to watch out for unproven product claims, too—whether they buy a product from a retail store or through the Internet.

Examples of unproven claims found on product labels are
* kills over 99.9% of MRSA
* helps prevent skin infections caused by MRSA and other germs
* is effective against a broad spectrum of pathogens, including MRSA

One company claims that its hand sanitizing lotion prevents infection from the bacterium E. coli and the H1N1 flu virus. And another firm claims its “patented formulation of essential plant oils” kills the bacterium Salmonella. These claims are also unproven and, therefore, illegal.

“FDA has not approved any products claiming to prevent infection from MRSA, E. coli, Salmonella, or H1N1 flu, which a consumer can just walk into a store and buy” says Autor. “These products give consumers a false sense of protection.”

Are the sick and dying really the critical control point for disease transmission in a hospital?

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Maureen Dowd of the New York Times wrote last week about how her brother went into the hospital with pneumonia, quickly contracted four other infections in the intensive care unit, and sadly, died.

Anguished, I asked a young doctor why this was happening. Wearing a white lab coat and blue tie, he did a show-and-tell. He leaned over Michael and let his tie brush my sedated brother’s hospital gown.

“It could be anything,” he said. “It could be my tie spreading germs.”

I was dumbfounded. “Then why do you wear a tie?” I asked. He shrugged and left for rounds.

A couple years later, I read reports about how neckties and lab coats worn by doctors and clinical workers were suspected as carriers of deadly germs. Infections kill 100,000 patients in hospitals and other clinics in the U.S. every year.

A 2004 study of New York City doctors and clinicians discovered that their ties were contagious with at least one type of infectious microbe. Four years ago, the British National health system initiated a “bare below the elbow” dress code barring ties, lab coats, jewelry on the hands and wrists, and long fingernails.

The Centers for Disease Control and Prevention says that health care workers, even doctors and nurses, have a “poor” record of obeying hand-washing rules.

A report in the April issue of Health Affairs indicated that one out of every three people suffer a mistake during a hospital stay.

Commenting on the new report on hospital errors, CNN’s senior medical correspondent, Elizabeth Cohen, instructed viewers to “ask doctors and nurses to wash their hands” if they haven’t.

“They sometimes will actually give you a hard time, believe it or not,” she said, “and they say, ‘My gloves are on. I’m clean.’ ‘Well, I didn’t see you put those gloves on. What if you put those on with dirty hands?’ ”

I called Cohen, the author of “The Empowered Patient,” to ask her the best way to confront those taking care of you or family members. She said that you have to get over the “waiter spitting in your soup scenario,” that the medical professionals will somehow avenge themselves, by giving less attention, if you insult them.

Dr. Peter Pronovost of Johns Hopkins has been able to prove in a national program that you can curb infections and reduce mortality rates in I.C.U.’s by adhering to checklists, creating accountability and fostering a culture where patients, their families and even nurses and residents feel freer to challenge doctors.

We’ve had some success using a mixture of shock and shame – shock being gross photos, shame being social embarrassment – in hospital, teaching and food service environments.

Yesterday, several letter writers voiced their views.

Steven Kussin, a gastroenterologist, is the author of the forthcoming book “Doctor, Your Patient Will See You Now” wrote that asking, “Did you wash your hands?” is not the way to start off the conversation. Doctors or staff members who respond “no” are guilty of a grave medical lapse. If they didn’t wash and then lie to you, they’re also guilty of a grave ethical lapse. Either way, the question raises their defenses and their hackles. Instead, if you didn’t witness a hand-washing ritual, then assume it didn’t happen. You’ll probably be right. Physician hand-washing compliance runs about 33 percent.

When they, or anyone, approach your bedside, give them notice of your intent. Hold out a bottle of sanitizer with a big smile. As you squirt them say: “I know how busy you are, and I am sure you’ve already done this a million times a day. But I’m terrified of those infections I’ve been reading about. I hope you’re O.K. with this.”

Theresa Merrill Anovick of Ridgewood, N.J.,writes, “I send back food in restaurants all the time, and never let a doctor shake my hand until I see him wash his in front of me! Do I get a lot of attitude and resistance? Absolutely. That’s O.K.; then I know that this is not the doctor I want caring for me.”

But is it really up to the sick and dying to enforce basic sanitation?
 

Engineering safety: Hands-free faucets may harbor more bacteria than old kind

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Those hands-free electronic water faucets that seem to be in every public bathroom may not be that great at keeping us germ free after all.

A study of newly installed fixtures at Johns Hopkins Hospital showed the faucets were more likely to be contaminated with a common and hazardous bacteria than the old fashioned faucets with separate handles for hot and cold water.

Dr. Lisa Maragakis, senior study investigator, said in a statement and reported by the Baltimore Sun,

“Newer is not necessarily better when it comes to infection control in hospitals, especially when it comes to warding off potential hazards from water-borne bacteria, such as Legionella species. New devices, even faucets, however well intentioned in their make-up and purpose, have the potential for unintended consequences, which is why constant surveillance is needed.”

The results will be presented April 2 at the Society for Health Care Epidemiology’s annual meeting.

The new faucets did cut daily water use by more than half, said Maragakis, director of hospital epidemiology and infection control at Hopkins Hospital and an assistant professor at the Johns Hopkins University School of Medicine. But, for example, they also had Legionella growing in half of the water samples from 20 faucets near patient rooms. That compares with 15 percent of the cultures from 20 of the old faucets in the same patient care areas.

The Hopkins researchers had aimed to determine how often the new faucets had to be treated to protect vulnerable patients when they discovered the higher rates of bacteria. They’ve notified other hospitals and plan to work with manufacturers to remedy the problem.