Watching the Hospital Hand-Washing Watchers
Thanks to fellow blogger Bob Wachter, a hospitalist at the University of California, San Francisco Medical Center, for taking note on his blog, Wachter's World, of a story in yesterday's ModernHealthcare.com about a development that very well might solve the low rate of hand-washing by hospital caregivers. Because the solution involves video monitoring, however, it raises a question or two of its own.
I've blogged here and here and here about the need for all healthcare workers to scrub their hands or use a hand sanitizer before touching or approaching patients. Rather surprisingly, no one can say with authority how much the number or rate of hospital-acquired infections would drop if hand-washing compliance shot up, but certainly it would be significant, considering the room for improvement. Because of all the attention recently devoted to hand-washing, Wachter writes, "many hospitals, including my own, have seen hand-cleansing rates skyrocket, from previously mortifying levels of 20 to 30 percent to merely embarrassing rates of 60 to 80 percent."
Nothing seems to be work that well, even though many hospitals go to great lengths—such as enlisting staff members to keep a record of the hand-washing diligence of their fellow employees. That's a tactic that has always puzzled me. Does anybody think no one knows who or where the observers are? They can't be completely out of sight, or they wouldn't be able to observe. If they're just sort of hanging around, that's a tough act to pull off. From the statistics, they are not especially successful.
A few years ago, Wachter proposed at a UCSF quality meeting that video cameras be installed to observe hand-washing compliance in ICUs, where the sickest patients are especially vulnerable to infection. The reaction, he writes: " 'We can't do that,' came the shocked reply. I never got an answer to the 'why not?' question."
Now, Arrowsight Medical, a division of a company in Mt. Kisco, N.Y., that already offers video monitoring in food-processing plants and other operations, is pushing to do the same in hospitals. One large eastern hospital, which Arrowsight spokesman Neil Vineberg would not name, has put cameras in its ICUs and is collecting hand-washing information that will be described in a future study. (Staffers are aware of the project and know about the cameras.) In a previous small-scale installation at an outpatient surgery center in Georgia, says Vineberg, compliance jumped within three months from 30 percent to more than 90 percent.
The system is more sophisticated than a battery of videocams connected to a remote site. That would require an army of bored observers staring nonstop at flickering screens, stirred to action only by "gotcha!" moments when a hapless doctor or nurse walked past the Purell dispenser. Instead, sensors are deployed at the doorways of patient rooms and elsewhere. They get tripped when someone comes in, and they turn on the videorecorder for a short time. "Auditors," as Arrowsight calls them, then look at each entry and enter the corresponding time-stamped data. You can watch a promotional video on YouTube.
"[I]t is natural to be slightly repelled by this concept," writes Wachter, whose entry is headed "Big Brother Arrives." Arrowsight insists that its system will be used to educate caregivers and modify their behavior, not to punish noncompliant types. "Yeah, sure," writes Wachter.
Vineberg notes that in the hospital where the system is going through a tryout, the data fed back to the hospital consist only of the rate of compliance for each patient room during one shift. Nurse managers receive the data the next day at the latest and can see which rooms need improvement. No one, not even the hospital's top administrators, is allowed to see the videos. That's reassuring.
Video monitoring seems inevitable. "So, get used to it," writes Wachter. "Who knows, it might even save a few lives."
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The installation of surveillance cameras to keep an eye on doctors' handwashing habits would be a final vindication of Ignaz Semmelweis, (July 1, 1818 – August 13, 1865). This Hungarian physician came to be called the "saviour of mothers" as a result of discovering, by 1847, that the incidence of puerperal fever, also known as childbed fever, could be drastically cut by use of hand washing standards in obstetrical clinics.
In Austria in 1847, doctors sometimes dissected cadavers, then went on to deliver babies without changing their coats or washing their hands! Up to about a third of mothers who had given birth consequently died from puerperal fever, also known as childbed fever.
Semmelweis introduced hand washing with chlorinated lime solutions for interns who had performed autopsies. This immediately reduced the incidence of fatal puerperal fever from about 10 percent (range 5–30 percent) to about 1–2 percent.
Semmelweis' hypothesis, that cleanliness was essential, was largely ignored, rejected or ridiculed at the time. He was dismissed from the hospital and harassed by the medical community in Vienna, which eventually forced him to move to Budapest.
Semmelweis was outraged by the indifference of the medical profession and began writing open and increasingly angry letters to prominent European obstetricians, at times denouncing them as irresponsible murderers. His contemporaries, including his wife, believed he was losing his mind and he was in 1865 committed to an asylum (mental institution). Semmelweis died there only 14 days later, possibly after being severely beaten by guards.
Semmelweis' practice only earned widespread acceptance years after his death. He is considered a pioneer of antiseptic procedures.
Watching the Hospital Handwashing Watchers
MultiCare Health System implemented a hand hygiene program in 2006, modeled after the “Partners in Your Care” program from the University of Pennsylvania. We measure all the soap and gel used each month on each unit. Using the PIYC formula, we obtain a rate for each unit. The benchmark, also from PIYC, is 72 hand hygiene episodes per occupied bed day; for ICU it is 144 and for ambulatory, 6 per patient visit. The percentage of compliance is graphed and sent to the manager of each unit to share with staff and the graph posted in the staff lounge. Our CEO personally calls each manager if they are not at 90%, asking what she can do to remove barriers and help them get to at least 90%. We have some areas that are well above 100%, meaning that they exceeded the 72, 144 or 6 hand hygiene episodes per occupied bed day. We also do visual monitoring during tracer rounds by Quality Management and Infection Prevention staff. This has confirmed our high levels of compliance. All four of our hospitals have been surveyed by Joint Commission this year, none of them received a hand hygiene finding.
For 2007 and thus far in 2008, we have a sustained level of over 90% for the organization. We credit this to having the right product in the right places, staff education and support from the top. We have seen decreases in infections across the board. We can’t attribute all of them to improved hand hygiene as we have several other initiatives in progress at the same time. The point is, hand hygiene compliance CAN be achieved without cameras, armed guards etc. It is a culture change within the organization, supported from the top, with easy access to a good product.
Marcia Patrick
Director, Infection Prevention and Control
MultiCare Health System
Tacoma, WA
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U.S. News's Avery Comarow has been editor of the America's Best Hospitals annual rankings since they first appeared in 1990. His reporting on clinical medicine, from the latest cholesterol guidelines to robotic surgery, has been driven by the question: What does this mean to patients? And that is the perspective he brings to his observations and commentaries on the increasing number of programs by hospitals and other healthcare providers to improve care and patient safety.
