Monday, May 23, 2011

Better Hand-Washing Through Technology -
Tina Rosenberg writes in The New York Times

Why can’t hospitals get health care workers to wash their hands?

... Virtually all of them have alcohol-rub dispensers, hundreds of them, in the hallways. Using one takes a few seconds. Yet health care workers fail to wash hands a good percentage of the times they should. Doctors are particularly bad.

A health care worker’s hands are the main route infections take to move from one patient to another. One recent study of several intensive care units — where the patients most vulnerable to infection reside — showed that hands were washed on only one quarter of the necessary occasions.

It’s not that hospitals are ignoring the problem — indeed, they are implementing all kinds of strategies to promote hand-washing. Nevertheless, it is rare to find a hospital that has been able to keep the hand-washing rate above 50 percent.
There is a new technological fix available that — when accompanied by other changes — may be key to reducing dangerous infections.

... 2 million patients in America acquire an infection in the hospital every year — about one in 20 patients — and 100,000 people die of them. This is the fourth leading cause of death in America.... Hand-washing rates in other wealthy countries are not much different.

Hospital-acquired infections cost the American health care system between $30 and $40 billion annually. Simple division puts the rough average cost of treating of a hospital-acquired infection at $15,000 to $20,000. One study that gathered data from other studies found the average cost of treating an infection with MRSA, a staph bacteria resistant to many antibiotics, is $47,000.

There are several reasons, however, that hospital hand-washing rates may be about to improve. One reason is that hospitals have a strong financial incentive to reduce infections. In 2008, hospitals were told that Medicare would no longer reimburse them for the cost of treating preventable hospital-acquired conditions it calls “never events,” which includes many kinds of hospital-acquired infections. The new health care reform bill instructs states to do the same with Medicaid. Many insurance companies also now refuse to pay for never events. This tends to concentrate the minds of hospital executives.

Another powerful incentive to prevent infection is the rise of superbugs, like MRSA, that are increasingly resistant to our arsenal of antibiotics. Infections are getting more and more deadly....

Patients are also more knowledgeable about hospital infections and more empowered. Hospitals are increasingly required to report their incidence of hospital-acquired infections, and those results will be posted online. ...
It will be very difficult to improve compliance unless hospitals can tell who is and isn’t cleaning hands, and in what circumstances. Individual doctors and nurses need to know their own hand-washing rates.
Until now, hospitals have had two ways to measure hand-washing. One is by monitoring how often each soap or alcohol gel dispenser needs to be refilled. By tracking how much product a unit uses, you can get a rough idea of how much hand-washing is going on. The limits here are obvious: there is no way to tell who is washing hands and when.

The method currently considered the gold standard is using human observers: nurses or other health care workers who roam halls and patient rooms with a clipboard, recording who does and doesn’t wash hands. Sometimes they’re like secret shoppers and sometimes they’re announced.

This system, too, is woeful. Spending health care workers’ time in observing is expensive. And they can monitor only a small sample of health care workers. A recent study at the University of Iowa to test whether observers should stand still or move around found that moving more was better, but the real news was this: “All observation schedules capture at best 3.5% and at worst 1.2% of all daily opportunities” for handwashing.

When the monitors are announced, it’s bound to inflate compliance, in part because their presence reminds workers to wash hands. ...

In the last year or two, several new ways to promote hand-washing – all things that beep – have made their debut: HyGreen, BioVigil, Patient Care Technology System’s Amelior 360 and Proventix’s nGage are some of them, but there are others. Some are spinoffs of systems widely used to track hospital equipment (this is how hospitals can find a wheelchair when it is needed). All employ new technology that can detect alcohol — which in hospitals is a component not only of rubbing gel but also soap.

They work like this: every health care worker wears an electronic badge. When she washes her hands or uses alcohol rub, a sensor at the sink or dispenser or her own badge smells the alcohol and registers that she has washed her hands. Another sensor near the patient detects when her badge enters a room or the perimeter around a patient that the hospital sets. If that badge shows that her hands were recently washed, it displays a green light or something else the patient can see. If she hasn’t washed, her hands, the badge says so and emits a signal to remind her to do so. The sensor also sends this information to a central data base. Information about the hand-washing practices of a particular unit, shift or individual is instantly available.

Do they work? It is early yet — these systems are largely in the pilot phase or in use in only a handful of hospitals. But several different studies have shown that they greatly improve hand-washing compliance. There is some evidence that the systems are associated with a drop in infections. Proventix claims its nGage system saw a 22 percent drop in infection in the units where it was used in a seven-month trial, while elsewhere in the hospital the drop during that time was only 4 percent.

Miami Children’s Hospital said that during the time it used the HyGreen system in its oncology unit, the unit had a whopping 89 percent drop in infections. Deise Granado-Villar, chief medical officer, said that the gains have been maintained eight months later. ...

The drawback to these systems is that they are much more expensive than other measures hospitals have tried. ... These systems are brand new and their price is likely to drop substantially, but right now they are expensive — Amelior, for example, costs $1,500 to $2,000 per hospital bed to install. Most offer hospitals the option to buy a system or lease it.

Hospital-acquired infections are so expensive, however, that a system that proves effective will pay for itself in the first year. “It paid for itself with the avoidance of one infection,” Granado-Villar said of the HyGreen system. “It cost $50,000 to implement, which can be the cost of one infection today.” An article in the journal Infection Control and Hospital Epidemiology found that if a hospital improved hand-washing rates by 5 percent, it would save $1,000 per bed each year in averted MRSA infections alone – and MRSA infections make up only 8 percent of all hospital-acquired infections.
by Tina Rosenberg
The New York Times
April 25, 2011

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