Canada’s National Post newspaper recently issued a “superbug” alert, and advised readers to think twice about any hospital stay that could be avoided. Scare headlines like these are commonplace, and it’s possible they have pushed the healthcare industry beyond hand-wringing and into war against all hospital-acquired infections (HAIs).
New technology from Canada could emerge as the weapon of choice on one front in the fight – hand hygiene.
The tone of the World Health Organization (WHO) publication, "Prevention of Hospital-Acquired Infections – a Practical Guide,” is less fevered than the newspaper accounts, but is no less emphatic about the seriousness of HAIs – and “superbugs” in particular. These are the pathogenic organisms that resist antibiotics and antimicrobials. The outline offers clues to why the fight is so complex and difficult.
It explains that health care settings are environments where both infected persons and persons at increased risk of infection congregate. “Patients with infections or carriers of pathogenic microorganisms admitted to hospital are potential sources of infection for patients and staff,” according to the Guide, and patients “who become infected in the hospital are a further source of infection.” It notes that crowded conditions and the concentration of highly susceptible patients add to the problem, as well as frequent transfers of patients from one unit to another. Newborn infants, and patients in acute surgical wards, orthopedic and burn wards and in intensive care are particularly vulnerable. And the risk increases for elderly people, patients with underlying disease or those undergoing chemotherapy
In all of these places the pathogens can contaminate the air, objects, devices, and materials that touch susceptible body sites of the patients, the Guide notes.
It explains that many different bacteria, viruses, fungi and parasites can cause infection and that the likelihood of exposure leading to infection depends partly on the characteristics of the microorganisms, including resistance to antimicrobial agents, intrinsic virulence and the amount of infective material.
The best-known of the resistant microbes is the bacterium, Methicillin-resistant Staphylococcus aureus (MRSA). It is often undetected in carriers, who can include hospital personnel, because they can be symptom-free.
It’s a fight to the death in some cases. The Guide warns that infections acquired in health care settings are among the major causes of death and increased morbidity among hospitalized patients.
A campaign introduced by Johns Hopkins Hospital in Baltimore, Maryland, illustrates the many areas that must be battled simultaneously. Other campaigns around the United States also tackle the problem comprehensively.
Peter Doyle, Ph.D., CPE, a human factors engineer at Johns Hopkins, said the hospital has “rolled out an institution-wide infection campaign.” He described awareness of the importance of infection avoidance as the first step in the fight, and explained that the campaign emphasizes a commitment to follow five steps that are abbreviated by the acronym WIPES:
W – Wash/clean hands
I – Identify and isolate early
P – Precautions use (use gowns, gloves and masks)
E – Environments kept clean
S – Share the commitment, raise your hand
“The campaign features pictures of prominent hospital leaders and medical personnel showing their hand with fingers splayed and encouragement to follow the steps above,” he explained. “Campaign messages are displayed in public and clinical areas, and additional educational materials were distributed to all patient care units. To support the desired behavior, washing is facilitated by the availability of needed materials and Purell dispensers.” Purell promotes its product as an instant hand sanitizer.
He noted that Purell is not effective against C. difficile, so staff members are encouraged to wash as well. Hopkins also is a leader in moving to latex-free gloves, according to Dr. Doyle. He explained that the measure “not only protects patients with latex allergies, but encourages caregivers to use gloves more frequently because they prevent allergy reactions.”
In the March 3 National Post article with the “superbug” warning, Dr. Allison McGeer, the director of infection control at Mount Sinai Hospital in Toronto, observed that “being admitted to hospital is more dangerous than working in the most dangerous occupations such as forestry." She said the real news is that “superbugs are continuing to get worse.”
The Committee to Reduce Infection Deaths (RID) has issued similar advisories. One of several organizations in the United States that is pressing Washington to take a hand in the fight, it tracks the statistics. In an interview in February, 2007, Betsy McCaughey, Ph.D., an ex-lieutenant governor of New York and founder of RID, told The Ergonomics Report that in 1974 only 2 percent of Staphylococcus aureus infections were drug resistant. By 1995 that figure had shot up to 22 percent. By 2003, she said, it had reached 57 percent and now is over 60 percent.
The Difficulties of Compliance
Hospital rules like the WIPES regimen are clear and easily comprehensible, but several recent news stories suggest compliance with the first of the directives is patchy – at best. A hand-hygiene habit is proving difficult to establish.
Experts say proper hand hygiene could reduce by half the number of hospital-acquired infections, according to the National Post article. Dr. McGeer explains that the amount of hand sanitizing required by health care workers is significant and needs to be done roughly 10 times an hour. That figure rises in neonatal intensive care units, where hand cleansing can take place 150 times in a 12-hour shift, she said.
A Globe and Mail article on hospital infections on March 3 pointed out that nothing has eluded those in infection control more than hand cleaning by hospital workers as they move from one patient to the next, referring to it as “a simple act too often ignored.” It cites studies showing that only 40 per cent of doctors, nurses and other health care workers properly wash their hands.
"We’ve really got to have a change in the way we think about hand hygiene," said Geoff Fernie, vice-president of research at Toronto Rehabilitation Institute, also known as Toronto Rehab. He explained in an interview with the Canadian national television network, CTV, that each year in Canada about 8,000 patients die from hospital-acquired infections. That’s about 22 patients a day. As many as half of those deaths can be attributed to poor hand cleaning, he said. "Worldwide, there are about 50,000 people a year being killed because of poor hand hygiene. It’s something we have to stop."
Efforts to get these numbers up include education programs, installation of hand sanitizers next to patient beds and dispatching roaming posses of infection-control workers throughout hospitals. According to an article in February in the Globe and Mail, coupons for doughnuts have been tried, as have flashy posters.
In almost every instance, according to CTV, hand-washing compliance usually rises initially but tends to slip back over time. That’s not because health workers don’t understand that hand hygiene can help stem the spread of MRSA, C. difficile, E. coli and strains of viral influenza, the report explains, but simply a matter of having a lot on their minds. "When you are busy, disinfecting your hands every time you have contact with a new patient is very difficult to sustain over time," says Veronique Boscart, a Toronto Rehab nurse and researcher told CTV.
Fernie sympathized. "A busy nurse will have to wash her hands 60-70 times an hour in a busy hour. So it’s not at all surprising that human beings would forget to do it sometimes. So we need to help them. It has to be automatic to cleanse your hands all the time. We’re helping remind when it needs to happen."
The reminder comes in the form of a device, developed by Fernie and other researchers at Toronto Rehab.
An electronic monitoring system running along a track on ward ceilings takes note of when a worker stops at a patient’s bed. It detects whether a health worker has washed his or her hands. If they haven’t, it signals a device on the lanyard carrying their identification tag to beep. A squeeze of hand gel sanitizer worn in a holster or taken from a wall dispenser, also equipped with a sensor, turns off the sound.
The device also keeps track of the compliance rate, which can then be downloaded to note handwashing history. Fernie said the data collection is not meant to be used by supervisors to monitor their staff, but rather a means of showing each worker if their handwashing hygiene is waning over time.
He believes the system will prevent hygiene compliance rates from dwindling over time. "Maybe, for the first time, we might be able to make a sustainable improvement in the rates of handwashing," he says.
"I was worried early on that there is an element of ‘Big Brother’-creepy element that you know where people are and what they are doing."
Dr. McGeer, who is on the team developing the system, told CTV that the health care workers who have tried it like it and so does she. "It lets me focus on the task I am doing with the patient, but it flags me when it wants me to do something that it doesn’t want me to think about," she explained.
The system will undergo further testing starting this summer in hospital settings. Over the next two years, two wards at St. Michael’s Hospital in Toronto and two at Toronto Rehab will be designated as test sites. Then, the research team plans to develop with a commercial partner. If all goes well, the system should be on the market in 2009 at an estimated cost of $300 per bed.
McGeer says she initially thought that sounded expensive when you calculate how many beds there are in a hospital. But she believes, it in the end, it will actually save hospitals money. "If it works to significantly improve hand hygiene, $300 is nothing. You don’t have to make a big difference in hospital-acquired infection rates to save a very large amount of money. So, if it reduces infections, it will make a dramatic difference in costs."
She said the system is about embedding the hand-washing habit – so people don’t have to think about it. She likened the device to seatbelt alarms. "Most of us don’t need the seatbelt alarms on," said Dr. McGeer. "But there was a period of time where seatbelt alarms were really useful."
Sources: National Post; Dr. Peter Doyle; WHO; Globe & Mail; CTV
This article originally appeared in The Ergonomics Report™ on 2008-03-15.