By CS Copeland, PhD
Fueled by a recent study indicting medical errors as the third leading cause of death in the United States, renewed attention has been focused on preventing healthcare-associated harm to patients. Among the most common and preventable patient safety failures are healthcare-associated infections (HAIs). HAIs contribute to over 100,000 deaths in Europe each year and a similar number in the USA. The cost incurred by infections acquired in American hospitals is a staggering $20 billion. Worldwide, HAIs affect hundreds of millions of people, according to the WHO.
National Patient Safety Goals
The Joint Commission, a non-profit that accredits and certifies healthcare organizations worldwide, has responded to this crisis by publishing the National Patient Safety Goals. The National Patient Safety Goals are a set of specific goals for improving patient safety. Each goal includes the rationale substantiating its impact on patient safety and quality, and practical directives and guidelines to support the attainment of the goal.
The goal of reducing the risk of HAIs is largely focused on hand hygiene, consistent with the current hand hygiene guidelines from the CDC and WHO. To comply with the National Patient Safety Goal of reduced risk of HAIs, the Joint Commission recommends that healthcare organizations assess their compliance with the CDC and/or WHO guidelines “through a comprehensive program that provides a hand hygiene policy, fosters a culture of hand hygiene, and monitors compliance and provides feedback.” Following these guidelines for hand hygiene is one of the most powerful ways to reduce the transmission of infectious agents between staff and patients.
Why Do HAIs Persist?
Since Dr. Ignaz Semmelweiss provided us, in the 19th Century, the foundation for understanding that infections were being transmitted from patient to patient by doctors, there have been numerous studies about the microorganisms causing infectious disease and how they might be stopped. Over a century and a half of research, conducted after Semmelweiss’ clinical observations, continues to support his original recommendation: to reduce the risk of infections, physicians should wash their hands between patient contacts. By now, every healthcare worker should know this. So, how is it that HAIs due to poor hand hygiene are still prevalent in hospitals?
The answer is simple. HAIs persist because healthcare workers do not adhere to recommended handwashing practices. Handwashing rates among healthcare workers have hovered around 40%, with compliance worse among physicians and nurses’ assistants than nurses, and worse among male versus female healthcare workers. A number of conditions have also been associated with poor hand hygiene practices. These include:
Working in the ICU
Weekday (non-weekend) shifts
Understaffing/patient crowding/insufficient time
Healthcare workers feeling that hand hygiene interferes with the relationship with their patients
Gloves (belief that handwashing is unnecessary if gloves are worn)
Irritation/dryness from handwashing agents
Sinks inconvenient or lack of soap/paper towels
Belief that risk of acquiring an infection from a patient is low
Skepticism regarding the value of hand hygiene/disagreement with guidelines
Lack of knowledge of hand hygiene guidelines/protocols
Lack of institutional priority
Lack of role models
Forgetfulness (“not thinking about it”)
Obstacles to Meeting Hand Hygiene Standards
Some of the above conditions are more easily addressed than others. False beliefs, such as the belief that gloves obviate the need for handwashing, are relatively easy to address through education. Some conditions have clear solutions but require economic investment, such as installing more sinks and hiring more staff.
However, perhaps the most frustrating reasons for poor hygiene are those related to hospital operating culture, such as forgetfulness, skepticism about the need for hand hygiene and lack of role models. These factors tend to work together in a negative synergy: physicians who are skeptical about the value of hand hygiene create an environment that lacks good role models who could remind forgetful physicians to wash up—either through communication or by example.
Solutions to Help Meet Hand Hygiene Standards
Because lack of fastidious hand hygiene adherence and a myriad of reasons for noncompliance with hand hygiene programs, it is vital to institute consistent and persistent hand hygiene monitoring systems. Such systems work to increase hand hygiene compliance regardless of the reasons for non-compliance. Once a lack of compliance has been documented and reported through a monitoring program, the individuals involved can be mentored about their non-compliance and provided with additional support to improve.
The Joint Commission’s Hand Hygiene Recommendations and New Accreditation Requirements
While hand hygiene is one of the easiest and most powerful ways to reduce HAIs, the Joint Commission has listed four other specific subgoals and ways to address each. For every subgoal, the implementation of evidence-based practices is the primary and overarching recommendation. Another recommendation that weaves through all of the subgoals is the adoption of systems for monitoring and analyzing outcomes as steps are taken to achieve the subgoals. Of note, as of Jan. 1, 2018, the Joint Commission has escalated its hand hygiene compliance review process beyond simply having a hand hygiene policy in place. Join Commission reviewers are now observing and reporting actual missed hand hygiene events as a component of their survey process.
Preventing Infections With Multidrug-Resistant Organisms
The subgoal of preventing infections with multidrug-resistant organisms focuses on epidemiologically important organisms such as methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile (CDI), vancomycin-resistant enterococci (VRE), carbapenem-resistant Enterobacteriaceae (CRE), and other multidrug-resistant gram-negative bacteria.
Specific practices beyond hand hygiene are recommended for these microorganisms, such as implementing an alert system to let everyone in the hospital know when a patient with a multidrug-resistant infection has been admitted.
Prevention of Central Line-Associated Bloodstream Infections
Another subgoal is the prevention of central line-associated bloodstream infections. In addition to the general HAI-prevention recommendations, this goal also includes specific practices such as the use of alcoholic chlorhexidine antiseptics for skin preparation during central venous catheter insertion, use of a standardized protocol to disinfect catheter hubs and injection ports prior to injection, and removal of nonessential catheters.
Prevention of Surgical Site Infections
A third subgoal is the prevention of surgical site infections. In addition to education and monitoring, this subgoal presents specific recommendations for prophylaxis using antimicrobial agents as well as other specific practices, such as using a professionally endorsed method for hair removal.
Prevention of Indwelling Catheter-Associated Urinary Tract
A fourth subgoal is the prevention of indwelling catheter-associated urinary tract infections. In addition to education and monitoring, this subgoal also contains more specific recommendations, including the use of written standards for when a patient needs an indwelling catheter, limiting their use and duration as much as possible, using aseptic techniques for the insertion site and equipment, and being vigilant about hand hygiene before the procedure. In addition, catheters secured for unobstructed urine flow and urine samples should be collected for monitoring.
Preventing HAIs as a “Lifestyle Change”
Prevention of hospital associated infections must, above all, be a “lifestyle change” for a hospital. That is, the problem must be addressed as a system-wide, ongoing team effort to change to a healthier culture that prioritizes patient safety. Implementing a thoughtful, well-designed program is key to long-term success. This includes education not just on best practices, but on why these practices are important-- how much harm hospital associated infections can cause to patients and how easily they can be prevented. With support from a well-designed program, hospital culture can change, in a positive way that will prevent unnecessary hygiene-related morbidity in both the short and long term.
Dr. CS Copeland holds a BA in neuropsychology from the University of California at San Diego and a PhD in molecular and cellular biology from Tulane University, specializing in parasitology and virology, with postdoctoral research in molecular entomology and computational genomics.