pants policies and paranoia

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Pants, Policies and Paranoia Dr Stephanie Dancer, NHS Lanarkshire

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Page 1: Pants policies and paranoia

Pants, Policies and Paranoia

Dr Stephanie Dancer, NHS Lanarkshire

Page 3: Pants policies and paranoia

Pittet D et al, Lancet 2000

Page 4: Pants policies and paranoia

The global pursuit of clean hands

Slide courtesy of Dr I. Gould

Page 5: Pants policies and paranoia

The global pursuit of clean hands

• Pittet et al publish sentinel study, ‘Effectiveness of a hospital-wide programme to improve compliance with hand hygiene’, Lancet 2000

• Use alcohol gel: UK National Patient Safety Agency, 2004. ‘Patient safety alert: clean hands help saves lives’.

• WHO guidelines of hand hygiene in health care, Geneva 2005

• ‘Why healthcare workers don’t wash their hands: a behavioural explanation’, 2006

• ‘Five moments for hand hygiene’, WHO 2006

• Interventions to improve hand hygiene compliance in patient care, Cochrane Review 2007

• Educational interventions for prevention of HAI, Systematic Review 2008

Page 6: Pants policies and paranoia

Interventions to improve hand hygiene in the UK

Cardboard cut-outs; educational packages;

extra staff; more managers; hand-hygiene co-

ordinators; committees; audits; nice-smelling

soaps; UV detectors; antiseptic soaps, liquids

and gels; soft towels; signs; talking boxes; stick-

on gizmos; prominent hand-hygiene stations;

badges (for staff); badges (for patients); more

audits; notices; posters; e-mails; conferences;

screen savers; Matrons; labels; observers;

flyers; more audits; antiseptic containers

attached to beds; antiseptic containers in

pockets; reminder letters; feed-back; lectures;

coloured stickies; more audits; flashing signs;

cameras; violation letters; CCTV; more sinks;

floor artistry; rewards; covert audits; T-shirts;

lollipops; electronic detectors; laser beams;

spies beneath beds; sniffer dogs; psychological

counciling; brain washing; torture.... Photo: BBC

Page 7: Pants policies and paranoia
Page 8: Pants policies and paranoia

Dept. of Health Social Services 2007;

Dept. of Health Guidelines 2007;

Scottish Government Health 2008

• Bare-below-the-elbows

• No wristwatches

• No jewellery

• No ties

• No pens or scissors in outside pockets

• No white coats

• No leaving work in uniform

Page 9: Pants policies and paranoia

And now? ‘Zero Tolerance’.....................

Scottish Executive: Zero tolerance to non hand hygiene

compliance, 26th January 2009

The expression ‘Zero Tolerance’ imparts both the idea of tackling low-level

hygiene misdemeanours and of doing so in a particular way, namely

through aggressive, uncompromising law enforcement

Pollard C, ‘Zero tolerance: Policing a free society’, IEA Health & Welfare Unit, 1998

But……….if there are not enough sinks, staff, gel and/or beds, is poor

hand hygiene really our fault?

Goldmann D. System failure versus personal accountability – the case for clean

hands, New Engl J Med 2006

There should be a balance between the system

and an individual’s behaviour

Page 10: Pants policies and paranoia

Isn’t this ‘Zero Tolerance’?

‘’Hospital worker in disciplinary case over hygiene’’, Mail, Sept. 21st, 2010

Page 11: Pants policies and paranoia

Reviewing current evidence.....

concluded that there is a lack of

rigorous evidence linking specific

hand hygiene interventions with the

prevention of HCAIs

Backman et al, Am J Infect Control 2008

Patients are still at risk of infection in today’s hospitals despite huge

investment in promoting hand hygiene….there must be other factors

important for controlling infections that erode the benefits from

improved hand hygiene

Dancer SJ, Leader J Hosp Infect 2010

If there is little justification for ‘Zero Tolerance’,

then what is there for hand hygiene?

What is the evidence that cleaning hands stops patients

getting infections?

Page 12: Pants policies and paranoia

What about bare-below-the-elbows?

149 medics were randomised into 2 groups;

One group was BBE and the other was not;

All medics had their hand washing

technique evaluated using fluorescent gel

‘Bare below the elbows’ and quality of handwashing: a randomized comparison study. J Hosp Infect 2009

There was no significant difference in the overall

percentage area missed after handwashing

The group wearing white coats did miss

significantly more of the wrist area

Being bare below the elbows improves wrist

washing

Do patients acquire hospital organisms from a

doctor’s unwashed wrists?

Page 13: Pants policies and paranoia

Alan Johnson

cleans his hands

during a visit to St

Mary's Hospital in

London

Photo: Telegraph, 23 Sept 2008

Looking the part………..

That’s what it’s about

Page 14: Pants policies and paranoia

Hand hygiene rates improved dramatically after

introducing hand gel into two ICU’s, but there were NO

changes in the rates of device-associated infection, or

infections due to multi-resistant pathogens or C.difficile

Rupp ME et al, ICHE 2008

Introducing alcohol hand antiseptic into a hospital reduced

VRE but had no effect on MRSA Larson et al, Behav Med 2000; Lai et al 1CHE, 2006

Excessive use of hand hygiene products is not an efficient

way of reducing infections in low-prevalence wards

Herud et al, AmJIC 2008

Are there benefits in using alcohol gel?

Hand hygiene compliance and consumption of alcohol gel does

not correlate with pathogen transmission in ICU

Eckmanns et al, JHI 2006

Page 15: Pants policies and paranoia

Does hand hygiene compliance and consumption of alcohol

gel correlate with pathogen transmission in ICU’s?

Eckmanns et al, JHI 2006

Page 16: Pants policies and paranoia

Does alcohol gel aid in the

control of C.difficile?

No effect! (Boyce et al, ICHE, 2006)

Norovirus?

Probably not (Lages et al, JHI, 2008)

Acinetobacter?

Left wondering....

(Edwards et al, JMM 2007; Pittet et al, LID, 2008)

Alcohol enhances the pathogenicity of clinical CNS

(Milisaviljevic et al, AmJIC 2008)

....and vulnerable people drink it (24dash.com, 2008)

Page 17: Pants policies and paranoia

S.aureus bacteraemia, HPA 2009

Have hand hygiene interventions had any effect on MRSA?

Page 18: Pants policies and paranoia

Yes! No! Maybe...........

MRSA rates are down

BUT – these rates are based upon bacteraemias. How do we know that total

MRSA acquisitions are down? No one is counting these.

MRSA bacteraemias surely have reponded to enhanced screening, topical

clearance strategies and intravascular catheter care bundles; but not necessarily

increased hand hygiene.

What a pity meticillin-SUSCEPTIBLE S.aureus bacteraemia rates have

barely changed.

If enhanced hand hygiene is responsible for the decrease in MRSA rates, then

why have MSSA rates stayed the same, or even gone up?

What about C.difficile?

HPS Weekly Report 6/10/10; Dancer SJ, J Hosp Infect 2010; Dancer et al, ECCMID 2010;

S.aureus bacteraemia, HPA 2010; Orthopaedic SSI 2004-9, HPA 2009

Page 19: Pants policies and paranoia

Ceftriaxone consumption and cases of C.difficile in a hospital over a two

year period

0

10

20

30

40

50

60

70

80

90

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Months Dec 2007-Dec 2009

DD

D's

1000p

t/o

cc.b

ds

0

0.5

1

1.5

2

2.5

3

3.5

Cases C

.dif

ficil

e/1

000p

t/o

cc.b

ds

Ceftriaxone consumption No. of cases of C.difficile

Ceftriaxone consumption and cases of C.difficile in a

hospital over a two year period

Page 20: Pants policies and paranoia

Overall compliance for hand

disinfection was 22% from

nearly 600 opportunities for

hand hygiene Kim PW et al, AmJIC 2003

Staff are too busy!

Dancer et al, AmJIC 2007; Hugonnet et al, Crit Care

Med 2007; Erasmus et al, ICHE 2010

Overcrowding & understaffing

The effects of hand hygiene are

eroded if the environment is

heavily contaminated…..

Why isn’t hand hygiene having an effect?

Farr et al, LID 2001

Beggs et al, BMC Infect Dis 2008;

Clements et al, LID 2008

Page 21: Pants policies and paranoia

People are dirty b*****s

Only 43% of mothers wash their hands after changing a

dirty nappy Curtis V et al, Soc Sci Med 2003

28% commuters have faecal bacteria

on their hands

34% male and 56% female members of the

public wash their hands after using public toilets

Jumaa & Hately, BMJ 1999

Compliance with hand hygiene after toilet visits was

84% for ECCMID attendees, 75% for men in public

toilets and 46% for hospital staff!

Van der Vegt & Voss, JHI 2009

Americans Don’t Alter Hygiene Amid Swine Flu Threat

Bradley Corp., USA Sept. 2009

Judah et al, Epidem Infect 2010

Page 22: Pants policies and paranoia

Scheithauer et al, J Hosp Infect in press 2010

Healthcare Workers are more concerned about protecting

themselves than protecting their patients

Page 23: Pants policies and paranoia

…beliefs about the importance of self-protection are the main

reasons for performing hand hygiene

Whitby et al, ICHE 2006; Erasmus V et al, ICHE 2009; Dancer SJ, ICHE 2010

Where’s the REAL risk?

Activities such as handling curtains or

patient’s notes do not register as ‘dirty’, yet

they could pose more of an infection risk

than removal of a bed pan, because staff

are more likely to clean their hands after

performing the latter.

Contamination of hospital

curtains with healthcare

associated pathogens.

Trillis et al, ICHE 2008

Page 24: Pants policies and paranoia

Photo courtesy of Clean Path Solutions, LLC, Nevada USA

Dancer, J Hosp Infect 2010; Burnett E, J Hosp Infect 2010

‘I wonder what’s on his hands....his white coat......his stethoscope.......’

SHOULD I REMIND HIM TO WASH HIS HANDS?

Page 25: Pants policies and paranoia

Jang et al: Staff physician: ‘If … someone is upset and they’re crying

and they want human contact, you can’t say, just a second I’m going

to wash my hands.’

Bye bye social niceties

Bye bye friendly touch

Jang et al, J Hosp Infect in press 2010

Page 26: Pants policies and paranoia

On the state of public health:

Annual report, Chief Medical Officer 2006

Dept of Health, London.

The CMO stated that hand

hygiene is a major priority and

quoted examples of poor practice

by doctors and nurses.

But overuse of NHS facilities is a

critical factor in controlling

infection – so why are increasing

bed occupancy rates, increased

turnover and lack of isolation

facilities not mentioned?

Richardson NBG. What about reducing turnover? BMJ 2007; 335: 221

Page 27: Pants policies and paranoia

Bed occupancy, turnover intervals and MRSA rates Cunningham et al, Br J Nursing 2006

Page 28: Pants policies and paranoia

Overcrowding of wards and staff shortages

contribute to hospital infections. One in 10

patients admitted to hospital in Britain acquires

an infection and the threat from MRSA and

Clostridium difficile is the direct result of efforts to

reduce beds and increase efficiency.

In England, the number of hospital beds has

been cut by more than 25 per cent since 1981

but patient numbers have soared. Over 70% of

NHS trusts exceeded the Government's target

bed occupancy rate of 82%.

Clements et al, Lancet Infectious Diseases 2008

Crowded wards 'add to patient infection risks'

Page 29: Pants policies and paranoia

Microbial load in the environment....is associated

with bed occupancy rates

S.aureus & MRSA are found

on lockers, overbed tables

and beds; finding these at any

site was significantly

associated with higher aerobic

colony counts from that site

(p=0.001) as well as bed

occupancy rates

Dancer SJ et al, IJEHR 2008

‘Priority should be given to improving the

cleaning of sites around the patient's

bedside. These are the sites that are both

frequently contaminated and frequently

touched, thereby making them important

for transferring bacteria to patients.’ Peter Obee, PhD thesis, 2009

Page 30: Pants policies and paranoia

There is a heavy bioburden on all hand-touch sites

Microbes can survive on surfaces for months. X denotes tested surfaces

Hayden et al, SHEA 2004

Page 31: Pants policies and paranoia

What’s on YOUR hands??!

Even if you keep your hands clean ALL THE TIME, any benefits from

hand hygiene are eroded if there is MRSA or C.difficile on the very

next surface you touch

Bobulsky G et al, CID 2007; Farr et al, LID 2001

Page 32: Pants policies and paranoia

When are the hands of healthcare

workers positive for MRSA?

Creamer et al, JHI, 2010

5% fingertips from 500 HCWs were MRSA positive;

6% after clinical contact; 7% after environmental

contact; and 4% after no specific contact.

MRSA was recovered on 3% occasions after using

alcohol rub; 6% after 4% chlorhexidine; 3% after

hand washing with soap & water; and 5% with NO

hand hygiene.

What is the point in continually asking

HCWs to clean their hands, if it is

inevitable that they are going to touch

something in the environment?

Page 33: Pants policies and paranoia

MRSA and VRE in this room are picked up by attendant staff –

and also by the next patient Boyce et al, ICHE 1997; Huang et al, Arch Intern Med 2006; Drees et al, ICHE 2008; Hayden et al, ICHE 2008

It’s just as easy to pick up organisms after touching a patient's

environment as it is by touching the patient

Page 34: Pants policies and paranoia

Date Specimen site Environment PFGE profile

24.7.06 Foot 15e§

10.8.06 Nose 15b/15z/15-71

18.8.06 *Foot 16-237/16-296

21.8.06 Groin 15h/15-133

21.8.06 Nose 15a§

23.8.06 Nose 15e§

23.8.06 Groin 15h/15-133

26.8.06 Groin 16-237/16-296

31.8.06 Nose 15a§

08.9.06 Nose 15d/15-74

21.9.06 *Groin 15b/15z/15-71

25.9.06 Computer 15-73§

06.10.6 Patient notes 15-73§

11.10.06 Overbed table 15-73§

13.10.96 Throat 15a§

18.10.06 Heel 15b/15z/15-71

07.11.06 Hoist 16-237/16-296

07.11.06 Door handle 16-237/16-296

27.11.06 Throat 15b/15z/15-71

13.2.07 Hoist 15a

13.2.07 Bedside locker 15a§

13.2.07 Desk 15e/15-121

14.2.07 *Arm 15b/15z/15-71

18.2.07 *Catheter line 15b/15z/15-71

19.2.07 Bed frame 15e/15-121

19.2.07 Overbed table 15b

21.2.07 *Throat 16-98/16-118

08.3.07 Bed frame 15a

22.6.07 Bed frame 15e/15-121

27.6.07 Hoist 15d/15-74/15-304

04.7.07 Desk 15b/15z/15-71

12.7.07 *Throat 15z/15-71/15-119

21.7.07 BP stand 15b§

23.8.07 Nose 15aDancer et al, BMC Med 2009

Table to show the

molecular relationships

between patient and

environmental strains of

MRSA on one surgical

ward over a one year

period

Page 36: Pants policies and paranoia

A room with a view

Over half (58%) of clinical staff touched the patient;

Most frequently handled equipment inside: IV drip (27%) & BP stand (13%);

outside: computer (25%), notes trolley (23%) and telephone (22%).

Monitoring the sequence of hand-touch events highlighted potential microbial

transmission pathways.

Since hand hygiene compliance is so low, should we not

target high risk sites for cleaning?

Cross-transmission audit of

surfaces, clinical equipment and

patient: Who touches what?

We undertook 40x30 minutes covert audit of

entries into a side-room on a medical ward.

Overall compliance with hand hygiene among

clinical staff before and after entry was 25%

(38/154)

Smith et al, in preparation, 2010

Page 37: Pants policies and paranoia

What is the evidence for cleaning as a viable control

mechanism for hospital-acquired infections ?

BBC website, 2008

We introduced one additional cleaner into

two matched wards from Monday to Friday,

with each ward receiving enhanced

cleaning for six months in a cross-over

design;

Enhanced cleaning was associated with a

33% reduction in levels of microbial

contamination at hand-touch sites;

The number of new MRSA infections

decreased from 9 to 4, despite higher bed

occupancies and MRSA colonisation

pressures (p=0.032: 95% CI 7.7%, 92.3%).

Dancer et al, BMC Med, 2009

Page 38: Pants policies and paranoia

Total aerobic colony count from ten hand-touch sites on two

matched surgical wards

0

20

40

60

80

100

120

140

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

Weeks

To

tal A

CC

Ward A Ward B Dancer et al, BMC Med, 2009

Total aerobic colony counts (ACC) from ten hand-touch

sites on two surgical wards; the study cleaner moved

from Ward A to Ward B at week 13.

NB. Middle 6 months of study

Page 39: Pants policies and paranoia

=

The Hand-Touch equation

Hand

Hand-touch site

WHY is all the emphasis on cleaning hands and not

on cleaning the things that they touch?

‘Zero tolerance’ should exclude inadequate cleaning in our hospitals

Page 40: Pants policies and paranoia

Antibiotic

Pressures

Berntsen et al,

NEJM 1960; Cheng

et al, JHI 2008

Hands (whose?)

Environment

including air

Patients (infected and/or

colonised)

DYNAMIC TRANSMISSION CYCLE

OF HOSPITAL PATHOGENS

Page 41: Pants policies and paranoia

Could patients’ hands constitute

a missing link? Banfield & Kerr, J Hosp Infect 2005

Figure from Pittet et al, Lancet Infect Dis 2006

What is the impact of systematic patients’ hands disinfection on

MRSA infection rates? Gagne et al, J Hosp Infect 2010

Page 42: Pants policies and paranoia

Distribution of S.aureus in general

population and nasal carriers

Wertheim et al, Lancet Infect Dis, 2005; Dancer S, Lancet Infect Dis 2008

General Population: S.aureus nasal (+):

Page 43: Pants policies and paranoia

The ‘Cloud Adult’ – sort of

Courtesy of the American Association for the Advancement of Science

Page 44: Pants policies and paranoia

Let’s screen everyone for MRSA! Is it ethical to subject a population to mass screening, given the low

prevalence and the relatively high rate of false positive tests? (Millar M, J Hosp Infect & BMJ 2009)

Is it ethical to screen every patient coming into hospital when we do

not routinely screen healthcare staff?

Is it sufficient to only screen the nose rather than include other sites

known to be common staphylococcal reservoirs?

How good is mupirocin nasal cream for eliminating carriage? Is there a risk that we might encourage resistance to mupirocin?

Can the laboratories cope with the extra workload?

Do our hospitals have the infection control infrastructure to

cope with an increase in newly identified MRSA patients?

Dancer SJ, Considering the introduction of universal MRSA screening, J Hosp Infect, 2008

Page 45: Pants policies and paranoia

A universal, rapid MRSA admission

screening strategy did NOT reduce

nosocomial MRSA infection in a surgical

department with endemic MRSA ……

Harbarth S et al, JAMA 2008

Page 46: Pants policies and paranoia

S. aureus dispersal from nasal & perineal carriers

Solberg, Acta Med Scand Sppl.1965

Page 48: Pants policies and paranoia
Page 49: Pants policies and paranoia

Bacterial contamination of

white coats......

Stethoscopes, pens,

cuffs, ties, rings,

watches, and so on

Let’s get rid of them!

Page 50: Pants policies and paranoia

What’s wrong with ties?

Steinlechner et al, Microbes on ties: do they correlate with wound infection?

Ann R C Surg Engl, 2002

Page 51: Pants policies and paranoia

About three-quarters of watches from 100 staff

were colonised with skin bacteria, with retrieval

of just one pathogen (S.aureus) from one watch

only. The group concluded that wristwatches are

unlikely to be common sources of healthcare-

associated infections

A more recent study suggests that the risk of

bacterial contamination on the hands of watch

wearers originates from manipulation of the

watch, but not necessarily from the wearing of it

What’s wrong with wristwatches?

Bhusal et al, AmJIC 2009; Jeans et al, JHI 2009

Page 52: Pants policies and paranoia

What items of attire do patients perceive as

an infection risk?

Ardolino et al, J Hosp Infect, 2009

75

62

50 49

3734

31 2925 24

0

10

20

30

40

50

60

70

80

Items

% of patients

Items perceived as an infection risk

Nose ring

Bracelet

Wrist watch

Engagement ring

Earrings

Long sleeves

Neck tie

Wedding ring

Necklace

Bow tie

Page 53: Pants policies and paranoia

This?

Or this?

Shelton et al, J Hosp Infect, 2009

If we can’t wear white coats and ties, what do we

wear instead?

Page 54: Pants policies and paranoia

Goodbye white coats……………….

Page 55: Pants policies and paranoia

Cartoon from Private Eye, 2007

Page 56: Pants policies and paranoia

‘.......... no-evidence knee jerk interventions such as bare-

below-the-elbows, no watches, even hand hygiene - imply

that staff, visitors and even patients themselves are

responsible for ...... hospital infections

Hospitals actually need more space, beds, isolation

rooms, nurses and cleaners - not targets, clipoards or a

culture of blame. And yes, we want laundries back on site,

with clean coats (white), uniforms and linen for everyone

who needs it, every day.

The problem is, all this costs money, and it costs a lot

more than a few bottles of alcohol gel, posters and

dictatorial fingers pointing at healthcare staff.’

Letter, BMA News Review Sept 2008

Magos A et al, A cheap sound bite, BMJ 2007

Page 57: Pants policies and paranoia

Sunday Telegraph, November 29th 2009

Page 58: Pants policies and paranoia

Conclusion There is little if no evidence for the recent policies imposed

upon healthcare staff in the name of infection control

The interventions that would really make a difference cost

a lot of money and are difficult to implement

Zero tolerance is a politician’s mandate to reassure the

electorate on hygiene behaviour in our hospitals; BUT, if

we ever get the system right, the focus will be on personal

accountability

If you are a hospital employee, then you have NO CHOICE

but to comply with these policies……..so,

Be seen to keep your hands clean

Page 59: Pants policies and paranoia

Acknowledgements

• ICN’s Pia Kirkpatrick and

Christina Coulombe

(for info)

• Mike Stewart and staff in the

Hairmyres microbiology lab

(for support)

• BMA (ditto)

• Miss N. Sturgeon, Scottish

Health Minister

(for good intentions)

Please note that the views expressed in this presentation will not necessarily be

representative of the views of the Hospital Infection Society nor NHS Lanarkshire

Page 60: Pants policies and paranoia

They didn’t wash their hands..........

Page 61: Pants policies and paranoia
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…..a politician’s mandate to reassure the electorate on hygiene

behaviour in our hospitals. Commentators and others latch on to this

term because it is seen as the latest fashionable label to prescribe the

solution to all our hygiene problems

…..a simplistic, short-term quick-fit fix, which will not, and cannot, reach

into the heart of the infection control problems in our hospitals

‘….zero tolerance is no more than one fundamental principle of several that need

to be carefully and sensitively woven together if infection control is to work well’

What is Zero tolerance?

Pollard C, IEA Health & Welfare Unit 1998;

Dancer S, 2009; Goldmann D, N Engl J Med, 2006

However, BEWARE! We need to get the system right, and when we do, the focus

will be personal accountability AND THE CHARGE WILL BE VIOLATION!

Page 63: Pants policies and paranoia