Infection Prevention, Hand Hygiene, and Social Change
Infection Prevention, Hand Hygiene, and Social Change
Editor's Note:
Elaine L. Larson, PhD, RN, Professor and Associate Dean of the Columbia University School of Nursing in New York, gave the Edward H. Kass Lecture at IDWeek 2012, in San Diego, California, on October 18, 2012. In her presentation, she focused on social changes that have an effect on infection prevention. Susan Yox, RN, EdD, of Medscape, followed up with Dr. Larson soon after the meeting ended to ask a bit more about this interesting topic.
Medscape: Dr. Larson, in your presentation at IDWeek, you talked about 3 social changes that affect infection prevention -- changes in reimbursement strategies, mandatory public reporting, and increased regulation -- and I'd like to ask you a little bit about each area. First, can you tell our readers a bit about the financial changes that have affected infection prevention?
Dr. Larson: Sure. I think most people are familiar with the changes in the Centers for Medicare & Medicaid Services (CMS) that occurred in October of 2008, denying payment for 10 healthcare-associated conditions, 3 of which are healthcare-associated infections -- some surgical site infections, vascular catheter-associated infections, and catheter-associated urinary tract infections. Of course, the rationale is that if these conditions are associated with being in the hospital, then CMS does not want to pay for things that could be potentially preventable. We hope that is a huge incentive to prevent such infections.
Medscape: Have there been results? Would you say that these changes in reimbursement are having a positive impact?
Dr. Larson: It's a little early, and studies are just beginning to come out. I'm not aware of a lot of evidence because, of course, the other possibility is that there could be untoward effects as well. For example, people might report fewer infections or take more cultures when patients come into the hospital or perhaps give antibiotics to prevent infections. We don't really know the impact yet or whether it is primarily positive or negative. It's going to be very important and interesting to find out. I'm sure that many people recall that, 15-20 years ago, during the last CMS changes, the hope was that incentives would reduce infections and the proportion of the gross national product that comes from healthcare, but that hasn't been very successful. We'll have to see what the impact of these new changes will be.
Medscape: Another area that you talked about was public reporting -- the movement towards hospitals being rated publicly on parameters such as postoperative infections. I'm wondering, again, if there is any evidence that public reporting is making a difference in infection prevention. I imagine it might be especially problematic to ascertain this because reporting varies from state to state and setting to setting.
Dr. Larson: I work with Dr. Pat Stone and her team here at Columbia, and we did a couple of national cross-sectional prevalence surveys of the presence of various evidence-based policies on infection. Between our first 2 surveys, and at the same time when public reporting was becoming common, we found a significant improvement in the number of hospitals that had evidence-based infection policies in place. We also found a significant reduction in the catheter-associated bloodstream infection rates and ventilator-associated pneumonia rates. Obviously you can't really say whether that's causal because a lot of other things were happening at the same time, but it's certainly promising. These changes were also at the same time as the new CMS regulations were coming into effect.
Medscape: Is public reporting expanding in healthcare? And what about other places besides hospitals -- long-term care, ambulatory surgery, and other outpatient settings?
Dr. Larson: Yes. Over a period of just 5-6 years, the number of states that have mandatory reporting has quadrupled, and right now in long-term care there are some states with mandatory reporting. The problem is the huge variation in the state laws about exactly what is reported and to whom. For example, the numbers and types of healthcare-associated infections that are required to be reported vary by state. Process measures, such as hand hygiene, also vary, and some of the states have public reporting vs reporting only to health departments. A few states have voluntary reporting and some have mandatory reporting. As you can see, it's really difficult to compare the impact across states. We're doing some work right now to analyze the difference in the public laws across states.
Medscape: I can see the problems! The other area that you spoke about at IDWeek was the increased regulation of research and institutional review boards (IRBs) and how that may affect infection prevention activities. I understand that when some of these infection prevention initiatives fall under the jurisdiction of these review boards that this might have the opposite effect than what is desired. Rather than encouraging infection prevention efforts, increased regulation often slows down or restricts these initiatives. Would you talk about that a little bit?
Dr. Larson: Absolutely. There's no question about that because I think that there's still a lot of confusion, not only among researchers and clinicians but even in the federal regulations and the Office of Human Research Protection (OHRP) about the difference between quality assurance and research. Much of what we do in infection prevention really has traditionally fallen under the rubric of quality assurance or quality assessment. Now, however, many initiatives fall between the lines -- is this really quality assessment or is it human subject research?
Some of the criteria that we used in the past to identify true research are no longer sufficient. For example, OHRP has actually said that just because you intend to publish findings doesn't necessarily mean that the initiative is categorized as research. That is one of the criteria we used to use. There are all kinds of papers out there now trying to differentiate and articulate the difference between quality assurance and research, but they are inconsistent, and I think we're all confused.
I chair 2 IRBs, and I usually advise people that if they're going to be doing something related to infection rates, even if individuals are not necessarily identified, that they should probably have an IRB review. One of the additional issues is that many journals now are insisting that authors make a statement that work has been reviewed by an ethics board. It's very interesting because after the talk at IDWeek a number of researchers came up to me and said, "This is our biggest challenge right now. Should we go through the IRB? When we do it takes weeks, sometimes months." Unfortunately, IRB review can be a serious deterrent.
Medscape: This certainly sounds like an area that needs further clarity if the goal is to make incremental improvements in infection prevention.
Dr. Larson: Absolutely, and it's an area I feel quite passionate about because I would love to provide more clarity to the people who ask me for advice, but even the federal publications are not very clear.
Medscape: I also attended your presentation at IDWeek on hand hygiene. Even though I have been a nurse a long time and handwashing is something that is pretty basic, it looks like there's still lots of room for improvement. I know you have done a good bit of research in this area, and I wonder if you can tell us about some of the most promising findings.
Dr. Larson: I think the most promising change in hand hygiene is some of the new electronic monitoring systems. As you know, the Joint Commission mandates that each hospital has a plan for monitoring hand hygiene and reporting rates, but the problem is that the way most people are doing it is still with direct observation. That's a terrible way to do it because it's very expensive and is subject to a huge amount of observer bias. Other concerns include the Hawthorne effect and the limitations of a direct observer, who can only observe 1 or 2 things at a time. It just doesn't work, and it's not very sustainable.
There are a variety of electronic monitoring systems out there that can actually monitor not only hand hygiene 24/7 across an entire institution but also prepare and provide reports that give feedback by dispenser, by day, and by unit in various ways. Some of them even provide information about individual differences in hand hygiene. I think the big incentive is that people respond well when they get feedback about their own performance, and the problem we've had is that we've been collecting data and then we haven't been doing anything with it. These new systems help us see a more efficient way to provide feedback to the clinician.
Medscape: What are the barriers that stop organizations from using these electronic monitoring devices? I'm guessing cost is one.
Dr. Larson: Most of these systems are costly, although direct observation is not cheap either. On the basis of research, it looks like hand hygiene observation costs about 66 cents per observation. You add that up and that approach costs thousands of dollars each year as well. Besides the upfront cost of electronic monitoring systems, I think even more important is that the systems are not really quite ready for primetime. Most of the systems are easy. Some of them just aren't quite to the point of beta testing where I would be comfortable in recommending that the investment be made. We want the systems to be as fail-safe as possible. I think institutions are a little reluctant to spend a lot of money for a system that has just one single use, and there may be other monitoring systems that come up that ultimately will be able to monitor other safety issues as well.
Medscape: I imagine there probably isn't a simple answer, but if you were making a recommendation to a hospital right now, would you suggest they stay with observers or would you suggest that it's time that they moved to one of these automated systems?
Dr. Larson: I would say that, if they are willing, this is a really good time to be in at the beginning and offer to be a test site for some of these new tools because a number of systems out there are being tested, and in general the test sites really help to configure the systems in the way that's relevant for them. But I'm not sure that I would recommend that places invest in a system until they are very, very clear that the kinks have been worked out. I would strongly urge people to get involved and test out these systems. It's kind of fun and it's not expensive. You're not taking a huge risk because it's pilot work.
Medscape: The other topic that concerns me is those people in hospitals and other healthcare settings beyond the doctors and nurses. It seems that most of the research focuses on physicians and nurses (for good reason), but what about all the visitors who come in and walk in and out of rooms and likely don't follow isolation precautions or don't wash their hands? Are we teaching them what to do? Are we monitoring to see if they're adherent?
Dr. Larson: Besides the visitors, there's also more attention now to the patient him or herself and how/what would facilitate patient hand hygiene because many of the infections that people get in the hospital are from organisms that they have on their skin when they come in. There is some evidence that other healthcare providers such as x-ray technicians or respiratory therapists are not so good at hand hygiene either. A nice thing about electronic monitoring systems is that you can monitor anybody who comes into the patient area. The problem with some of them is that you don't really have a denominator, so you may or may not know exactly who it is that's doing what, but I agree with you that we really need to focus on some of these other folks.
Frankly, visitors are of less concern to me because in general -- this isn't always true -- they tend to stick around the patients that they're visiting, and it's likely that the patient and their visitors are sharing common flora already, particularly if visitors are family members. And it is likely they are not doing a lot of intimate touching (direct caregiving), but that is not always the case. Certainly in pediatric units, for example, the parents and other members of the family are often doing a lot of care. I don't think we can focus only on doctors and nurses, but we have shown that nurses are by far doing most of the touching of patients.
Medscape: Are there other questions I may have missed?
Dr. Larson: I think we've covered some interesting topics and I really believe that we're at the tipping point of some new and exciting innovations in monitoring and providing people with feedback regarding hand hygiene. My belief is that healthcare workers really want to do the right thing, but sometimes they're just not conscious of what they are doing. By providing them with information in a respectful and helpful way about how they're doing, they're going to want to do better.
Medscape: I agree. I'm also imagining a number of folks would be really interested in how you became so involved in infection prevention throughout your career. Do you have any advice for those clinicians at the beginning of their career who might find this an interesting area?
Dr. Larson: I started becoming interested in infection prevention when I was a clinical nurse specialist in the intensive care unit (ICU) and I got involved in a project with a colleague from epidemiology. The hospital where I worked was building a new surgical ICU. The old ICU was like the traditional 6-bed unit with 1 nursing station in the center and basically no separation between the 6 beds. There were 2 or 3 sinks in the entire unit and 1 of them was always occupied by a dialysis machine. We were interested in the impact of the architectural change in the new unit.
The hospital was building a new unit that was 12 beds, and it had each bed separated into separate rooms. We were interested in the impact of the architectural change on infection rates. We studied the old unit and the new unit each for a year, and while we observed we noticed that hand hygiene was not very common. It wasn't something that we had actually planned to look at, but we saw this serendipitously, and that's when I got interested in hand hygiene. In the new unit, even though there were isolation rooms and sinks all over the place, there was no change in infection rates, and there was also no change in hand hygiene rates.
We published that paper many years ago, in 1981, in the American Journal of Medicine, and that got me passionate about the role of the healthcare provider in transmitting infections. It's just been a really, really exciting career. I would love to encourage young physicians, nurses, and other clinicians to consider infection control as a career. Many of us are getting older and we want some young people to come along and help us out here!
Editor's Note:
Elaine L. Larson, PhD, RN, Professor and Associate Dean of the Columbia University School of Nursing in New York, gave the Edward H. Kass Lecture at IDWeek 2012, in San Diego, California, on October 18, 2012. In her presentation, she focused on social changes that have an effect on infection prevention. Susan Yox, RN, EdD, of Medscape, followed up with Dr. Larson soon after the meeting ended to ask a bit more about this interesting topic.
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Elaine L. Larson, PhD, RN |
Medscape: Dr. Larson, in your presentation at IDWeek, you talked about 3 social changes that affect infection prevention -- changes in reimbursement strategies, mandatory public reporting, and increased regulation -- and I'd like to ask you a little bit about each area. First, can you tell our readers a bit about the financial changes that have affected infection prevention?
Dr. Larson: Sure. I think most people are familiar with the changes in the Centers for Medicare & Medicaid Services (CMS) that occurred in October of 2008, denying payment for 10 healthcare-associated conditions, 3 of which are healthcare-associated infections -- some surgical site infections, vascular catheter-associated infections, and catheter-associated urinary tract infections. Of course, the rationale is that if these conditions are associated with being in the hospital, then CMS does not want to pay for things that could be potentially preventable. We hope that is a huge incentive to prevent such infections.
Medscape: Have there been results? Would you say that these changes in reimbursement are having a positive impact?
Dr. Larson: It's a little early, and studies are just beginning to come out. I'm not aware of a lot of evidence because, of course, the other possibility is that there could be untoward effects as well. For example, people might report fewer infections or take more cultures when patients come into the hospital or perhaps give antibiotics to prevent infections. We don't really know the impact yet or whether it is primarily positive or negative. It's going to be very important and interesting to find out. I'm sure that many people recall that, 15-20 years ago, during the last CMS changes, the hope was that incentives would reduce infections and the proportion of the gross national product that comes from healthcare, but that hasn't been very successful. We'll have to see what the impact of these new changes will be.
Medscape: Another area that you talked about was public reporting -- the movement towards hospitals being rated publicly on parameters such as postoperative infections. I'm wondering, again, if there is any evidence that public reporting is making a difference in infection prevention. I imagine it might be especially problematic to ascertain this because reporting varies from state to state and setting to setting.
Dr. Larson: I work with Dr. Pat Stone and her team here at Columbia, and we did a couple of national cross-sectional prevalence surveys of the presence of various evidence-based policies on infection. Between our first 2 surveys, and at the same time when public reporting was becoming common, we found a significant improvement in the number of hospitals that had evidence-based infection policies in place. We also found a significant reduction in the catheter-associated bloodstream infection rates and ventilator-associated pneumonia rates. Obviously you can't really say whether that's causal because a lot of other things were happening at the same time, but it's certainly promising. These changes were also at the same time as the new CMS regulations were coming into effect.
Medscape: Is public reporting expanding in healthcare? And what about other places besides hospitals -- long-term care, ambulatory surgery, and other outpatient settings?
Dr. Larson: Yes. Over a period of just 5-6 years, the number of states that have mandatory reporting has quadrupled, and right now in long-term care there are some states with mandatory reporting. The problem is the huge variation in the state laws about exactly what is reported and to whom. For example, the numbers and types of healthcare-associated infections that are required to be reported vary by state. Process measures, such as hand hygiene, also vary, and some of the states have public reporting vs reporting only to health departments. A few states have voluntary reporting and some have mandatory reporting. As you can see, it's really difficult to compare the impact across states. We're doing some work right now to analyze the difference in the public laws across states.
Medscape: I can see the problems! The other area that you spoke about at IDWeek was the increased regulation of research and institutional review boards (IRBs) and how that may affect infection prevention activities. I understand that when some of these infection prevention initiatives fall under the jurisdiction of these review boards that this might have the opposite effect than what is desired. Rather than encouraging infection prevention efforts, increased regulation often slows down or restricts these initiatives. Would you talk about that a little bit?
Dr. Larson: Absolutely. There's no question about that because I think that there's still a lot of confusion, not only among researchers and clinicians but even in the federal regulations and the Office of Human Research Protection (OHRP) about the difference between quality assurance and research. Much of what we do in infection prevention really has traditionally fallen under the rubric of quality assurance or quality assessment. Now, however, many initiatives fall between the lines -- is this really quality assessment or is it human subject research?
Some of the criteria that we used in the past to identify true research are no longer sufficient. For example, OHRP has actually said that just because you intend to publish findings doesn't necessarily mean that the initiative is categorized as research. That is one of the criteria we used to use. There are all kinds of papers out there now trying to differentiate and articulate the difference between quality assurance and research, but they are inconsistent, and I think we're all confused.
I chair 2 IRBs, and I usually advise people that if they're going to be doing something related to infection rates, even if individuals are not necessarily identified, that they should probably have an IRB review. One of the additional issues is that many journals now are insisting that authors make a statement that work has been reviewed by an ethics board. It's very interesting because after the talk at IDWeek a number of researchers came up to me and said, "This is our biggest challenge right now. Should we go through the IRB? When we do it takes weeks, sometimes months." Unfortunately, IRB review can be a serious deterrent.
Medscape: This certainly sounds like an area that needs further clarity if the goal is to make incremental improvements in infection prevention.
Dr. Larson: Absolutely, and it's an area I feel quite passionate about because I would love to provide more clarity to the people who ask me for advice, but even the federal publications are not very clear.
Medscape: I also attended your presentation at IDWeek on hand hygiene. Even though I have been a nurse a long time and handwashing is something that is pretty basic, it looks like there's still lots of room for improvement. I know you have done a good bit of research in this area, and I wonder if you can tell us about some of the most promising findings.
Dr. Larson: I think the most promising change in hand hygiene is some of the new electronic monitoring systems. As you know, the Joint Commission mandates that each hospital has a plan for monitoring hand hygiene and reporting rates, but the problem is that the way most people are doing it is still with direct observation. That's a terrible way to do it because it's very expensive and is subject to a huge amount of observer bias. Other concerns include the Hawthorne effect and the limitations of a direct observer, who can only observe 1 or 2 things at a time. It just doesn't work, and it's not very sustainable.
There are a variety of electronic monitoring systems out there that can actually monitor not only hand hygiene 24/7 across an entire institution but also prepare and provide reports that give feedback by dispenser, by day, and by unit in various ways. Some of them even provide information about individual differences in hand hygiene. I think the big incentive is that people respond well when they get feedback about their own performance, and the problem we've had is that we've been collecting data and then we haven't been doing anything with it. These new systems help us see a more efficient way to provide feedback to the clinician.
Medscape: What are the barriers that stop organizations from using these electronic monitoring devices? I'm guessing cost is one.
Dr. Larson: Most of these systems are costly, although direct observation is not cheap either. On the basis of research, it looks like hand hygiene observation costs about 66 cents per observation. You add that up and that approach costs thousands of dollars each year as well. Besides the upfront cost of electronic monitoring systems, I think even more important is that the systems are not really quite ready for primetime. Most of the systems are easy. Some of them just aren't quite to the point of beta testing where I would be comfortable in recommending that the investment be made. We want the systems to be as fail-safe as possible. I think institutions are a little reluctant to spend a lot of money for a system that has just one single use, and there may be other monitoring systems that come up that ultimately will be able to monitor other safety issues as well.
Medscape: I imagine there probably isn't a simple answer, but if you were making a recommendation to a hospital right now, would you suggest they stay with observers or would you suggest that it's time that they moved to one of these automated systems?
Dr. Larson: I would say that, if they are willing, this is a really good time to be in at the beginning and offer to be a test site for some of these new tools because a number of systems out there are being tested, and in general the test sites really help to configure the systems in the way that's relevant for them. But I'm not sure that I would recommend that places invest in a system until they are very, very clear that the kinks have been worked out. I would strongly urge people to get involved and test out these systems. It's kind of fun and it's not expensive. You're not taking a huge risk because it's pilot work.
Medscape: The other topic that concerns me is those people in hospitals and other healthcare settings beyond the doctors and nurses. It seems that most of the research focuses on physicians and nurses (for good reason), but what about all the visitors who come in and walk in and out of rooms and likely don't follow isolation precautions or don't wash their hands? Are we teaching them what to do? Are we monitoring to see if they're adherent?
Dr. Larson: Besides the visitors, there's also more attention now to the patient him or herself and how/what would facilitate patient hand hygiene because many of the infections that people get in the hospital are from organisms that they have on their skin when they come in. There is some evidence that other healthcare providers such as x-ray technicians or respiratory therapists are not so good at hand hygiene either. A nice thing about electronic monitoring systems is that you can monitor anybody who comes into the patient area. The problem with some of them is that you don't really have a denominator, so you may or may not know exactly who it is that's doing what, but I agree with you that we really need to focus on some of these other folks.
Frankly, visitors are of less concern to me because in general -- this isn't always true -- they tend to stick around the patients that they're visiting, and it's likely that the patient and their visitors are sharing common flora already, particularly if visitors are family members. And it is likely they are not doing a lot of intimate touching (direct caregiving), but that is not always the case. Certainly in pediatric units, for example, the parents and other members of the family are often doing a lot of care. I don't think we can focus only on doctors and nurses, but we have shown that nurses are by far doing most of the touching of patients.
Medscape: Are there other questions I may have missed?
Dr. Larson: I think we've covered some interesting topics and I really believe that we're at the tipping point of some new and exciting innovations in monitoring and providing people with feedback regarding hand hygiene. My belief is that healthcare workers really want to do the right thing, but sometimes they're just not conscious of what they are doing. By providing them with information in a respectful and helpful way about how they're doing, they're going to want to do better.
Medscape: I agree. I'm also imagining a number of folks would be really interested in how you became so involved in infection prevention throughout your career. Do you have any advice for those clinicians at the beginning of their career who might find this an interesting area?
Dr. Larson: I started becoming interested in infection prevention when I was a clinical nurse specialist in the intensive care unit (ICU) and I got involved in a project with a colleague from epidemiology. The hospital where I worked was building a new surgical ICU. The old ICU was like the traditional 6-bed unit with 1 nursing station in the center and basically no separation between the 6 beds. There were 2 or 3 sinks in the entire unit and 1 of them was always occupied by a dialysis machine. We were interested in the impact of the architectural change in the new unit.
The hospital was building a new unit that was 12 beds, and it had each bed separated into separate rooms. We were interested in the impact of the architectural change on infection rates. We studied the old unit and the new unit each for a year, and while we observed we noticed that hand hygiene was not very common. It wasn't something that we had actually planned to look at, but we saw this serendipitously, and that's when I got interested in hand hygiene. In the new unit, even though there were isolation rooms and sinks all over the place, there was no change in infection rates, and there was also no change in hand hygiene rates.
We published that paper many years ago, in 1981, in the American Journal of Medicine, and that got me passionate about the role of the healthcare provider in transmitting infections. It's just been a really, really exciting career. I would love to encourage young physicians, nurses, and other clinicians to consider infection control as a career. Many of us are getting older and we want some young people to come along and help us out here!
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