Wringing Our Hands Over Infection Control

The solution to what appear to be paradoxical results in the cited study may be very simple. The authors of the Rupp paper used a hand hygiene product with insufficient antimicrobial activity, in other words, their product was insufficient at killing microorganisms on hands. We should keep in mind that it is not the ritual act of performing hand hygiene that prevents hospital infections, but instead the killing or elimination of microorganisms on hands that does so. Already good old Semmelweis 160 years ago showed very clearly that handwashing (which is now known to be insufficient at eliminating microorganisms from hands) was inferior to hand antisepsis with an agent that is now known to kill microorganisms on hands very effectively. If one uses a hand antiseptic with insufficient antimicrobial activity, then one has no advantage over traditional handwashing.

Matthias Maiwald 7:58PM April 01, 2008

It is terribly short-sighted to believe that hand washing and isolation are the most effective ways to fight the spread of MRSA.

Every day, otherwise healthy patients go into hospitals for regular treatment and end up with MRSA, C-Diff, VRE, or flu – despite being in a private room and having a caregiver with gloves and good hand washing.

So what else is going on?

There is no single answer. But one compelling clue is that two-thirds of hospital-acquired infection cases are now found in the general patient population, compared to just two percent 30 years ago.

One possibility may be that hospitals are overlooking and under-protecting their most widely-travelled employees.

Each day, housekeepers, transporters and their supervisors walk into hospital rooms without knowing infected patients have been there. So every day, people who cover the most ground in the hospital are inadvertently exposed to infection. Because these workers continue about their business without knowing they’ve been exposed, the risk of wider contamination is almost a certainty.

Inadvertent exposure occurs because of the way most hospitals communicate, or rather fail to communicate, isolation to staff. Many infection control nurses must still prepare “blocked” room lists by hand. Very often, those lists are outdated even before the nurses leave their offices.

By failing to alert environmental services and transport personnel in advance, hospitals deny them the opportunity to protect themselves from exposure and make them a walking vector for continued contagion.

Also, the need for terminal clean procedures is overlooked, so litters and wheelchairs go without antimicrobial wipe downs. And the infection chain continues.

Consider also that infected patients are taken for testing, sometimes two or three times daily. They are transferred to other units. They are eventually discharged. The people who move them and clean up after them are the ones most likely to be exposed without knowing it.

What can be done?

To protect both workers and patients throughout the hospital, patient flow technology is now available which automatically alerts staff of isolation conditions when a page goes out to clean a room. So workers not only know what they are facing, they know to bring the proper equipment for their own protection and optimal hygiene. That same technology, accessed via PDA, can give infection control nurses a mobile visual reference tool to help them assess isolation needs as they make clinical rounds.

This capability is even more vital now that a new strain, known as community-associated MRSA, is spreading outside the hospital. MRSA-CA has the potential of becoming more lethal since it is often misdiagnosed as the hospital-acquired version and treated with the wrong drugs, which could possibly increase its resistance.

In general, patient movement, or the lack of it, is emerging as an important factor in the spread of MRSA. Studies in Great Britain say the most crowded hospitals - with bed occupancy over 90% - had MRSA rates 42% higher than average. The studies concluded that “boarding” emergency patients in close proximity while they wait for inpatient rooms presents a risk of cross-infection.

With most of America’s 4,600 hospital EDs “at” or “over” critical capacity, these findings shouldn’t be ignored. But information technology has an important role to play here as well. Emergency room overcrowding is caused by log jams in patient traffic, due primarily to poor communications and conflicting priorities. Patient flow technology provides real-time information which can avoid those log jams, reducing or eliminating the need for boarding.

The British studies also found that overcrowding pressure denied hospital staff the time to thoroughly disinfect beds and surrounding areas. Improving patient flow can remove the “urgency” associated with overcrowded conditions, so those tasks can be completed in a reasonable time.

While isolation has reduced infection in some U.S. hospitals which also take extra precautions, like requiring workers to wear gloves and gowns for every contact, isolating patients can be extremely difficult in “overcrowded” hospitals.

Without real-time knowledge of bed status throughout the institution, non-infected patients can be mismatched with infected ones. However, those “mismatches” can now be largely avoided because of improvements in patient flow processes, combined with advanced patient flow technology. These advances allow for more flexibility in making room assignments and blocking access to rooms with infected patients.

About 30 percent of hospitals are already using information technology to track and manage hospital-acquired MRSA. Another 50 percent are actively considering it. These include automatic surveillance systems, rapid-testing devices, and computer systems which allow hospitals to pull data from bedside monitors, lab-test results and more to identify problem areas quickly.

The fight will take more than a single solution. The very presence of MSRA disproves the theory that there is a silver bullet for infection. It’s going to take a great deal of effort on many fronts. Communicating information about isolation in real-time, reducing overcrowding and smoothing out the patient flow process are powerful weapons in the war against MRSA that hospitals cannot afford to ignore.

Patients with hospital-acquired infections are seven times as likely to die as the average patient. In 2005, nearly one in five of the 94,000 hospital-acquired MRSA cases was fatal. Deaths that experts say were largely preventable.

Anthony Sanzo, CEO, TeleTracking Technologies of PA 3:22PM February 19, 2008

I read with great interest the report on the Hand Hygiene Study that was carried out at the University of Nebraska Medical Center under the direction of Dr. Mark Rupp (reported in Infection Control and Hospital Epidemiology, January 2008).

Hand hygiene compliance was reported to increase from 38 to 70 %. At first glance, it is surprising that the infection rate did not decrease. Most hand washing study reports, back to Semmelweiss (1846), indicate a decrease in infection rates when hand washing compliance is markedly increased. However, this may not always be the case when ‘waterless’ hand sanitizers are substituted for hand washing. A thorough review of the literature is needed regarding this subject.

There may be a reason why the use of ‘waterless’ hand sanitizers, in some studies, have been found to be ineffective in reducing infection rates. That is, an insufficient amount of ‘waterless’ hand sanitizer was dispensed to the hands of health care workers. The clinical studies that were carried out to justify the approval of use of ‘waterless’ hand sanitizers for inclusion in the FDA OTC Tentative Final Monograph for Over - the Counter Health – care Antiseptic Drug Products 59 Federal Register 31402 (June 17, 1994) were carried out using 3 – 5 mL of the product repeatedly applied to hands. We have tested the amount of ‘waterless’ hand sanitizer delivered from dispensers in various hospitals as well as the volume of sanitizer delivered from bottles and other containers of ‘waterless’ hand sanitizers. It has been found that as little as 0.33 mL is being delivered from some dispensers. The average volume delivered is about 1.5 mL – which is 50% below the lowest level of testing in the studies mentioned above.

Thus, ‘waterless’ hand sanitizers may do more harm than good – if health care workers falsely believe that their hands are properly sanitized when they are not. I believe that monitoring the amount of ‘waterless’ hand sanitizer being applied to the hands should be part of a hand hygiene monitoring program. The amount applied should conform to the effective amount as published in the FDA OTC Tentative Final Monograph (1994).

Gene Pittz of NV 7:10PM February 13, 2008

Dear Mr. Comarow: The comments that you have posted are very meaningful, especially those from Michael in Maryland.

An honest and conscientious effort by hospital administrators and their boards to control these infections will get the job done. However, the old song keeps being sung;.."it is too costly ". Well, considering that the health care industry often fails to correct its flaws, perhaps a public outcry by an organization such as the AARP with thirty seven million members can make things happen. I am so convinced that such an organization providing consumers with the tools to evaluate the healthcare providers of this country could rattle the market share of many health care centers and lets face it, market share trumps everything in the competitive healthcare arena. Patient empowerment has to come in the form of an active, collaborative effort mandating a patient bill of rights( that does more than decorate the walls of hospital elevators) and real bedside advocacy. Producing more and more brochures to hand out to patients as they enter the hospital falls way short of the mark and offers nothing more than a "wink and a nod" towards patient safety and quality of care.

Dr. Robert B. Schultz of FL 3:04PM February 08, 2008