Finding New Ways to Prevent Healthcare-Acquired Infections and Conditions
How a new approach to hand hygiene compliance monitoring can reduce infections, costs, and other preventable adverse events
Table of Contents
HAIs and HACs Continue to Increase – and They Need to be Prevented
Of all the patient safety challenges facing healthcare organizations today, the persistent increase of healthcare-acquired infections and conditions (HAIs and HACs) may be the most vexing. Despite all of the safety culture initiatives and awareness programs emphasizing infection control and hand hygiene, quality and safety leaders in all settings are still struggling with HAIs and HACs.
The incidence of HAIs is increasing as current infection control methods have not stopped preventable infections. A 2017 report published by Castlight Health and the Leapfrog Group shows HAIs rising across all five types examined in the survey: central line associated bloodstream infections (CLABSI), catheter associated urinary tract infections (CAUTI), surgical site infection after colon surgery (SSI: Colon), methicillin-resistant Staphylococcus aureus (MRSA), and Clostridium difficile (C. diff.).
HACs continue to contribute significantly to inpatient mortality and morbidity and excess operating costs
The Agency for Healthcare Quality and Research (AHRQ) reaches a similar conclusion in its 2017 report titled, “Estimating the Additional Hospital Inpatient Cost and Mortality Associated with Selected Hospital-Acquired Conditions,” including CLASBI, CAUTI, surgical site infections, and C. diff. – as well as falls, pressure ulcers and venous thromboembolism (VTE) – on its top 10 HACs list. AHRQ reports that HACs continue to cause a financial burden and contribute significantly to inpatient mortality and morbidity across the United States.
HAIs affect 5 to 10 percent of hospitalized patients in the U.S. per year, according to the Center for Disease Control and Prevention (CDC). About 1.7 million HAIs occur in U.S. hospitals each year, resulting in 99,000 deaths and an estimated $35 billion to $45 billion in healthcare costs in 2007 dollars, the CDC reports. The federal agency estimates the average annual patient cost to a hospital for HAIs to be $18,581 and indicates a potential savings of $5.7 billion to $6.8 billion if only 20 percent of HAIs could be prevented.
Direct patient care costs of HAIs and HACs are only the beginning
The cost of caring for patients afflicted by illnesses caused by HAIs and HACs lead to even more costs within the healthcare system: legal liabilities, reimbursement penalties, higher mortality rates, and more.
HAIs and HACs leave healthcare organizations vulnerable to medical liability claims. The cost of preventing and defending against these claims, including the practice of defensive medicine, has been estimated to be $55.6 billion in 2008, or 2.4 percent of total healthcare spending (Mello et al., 2010).
According to the AHRQ report, HACs have an adverse impact on patient mortality and healthcare organization financial margins. Table A shows the excess cost estimate and excess mortality estimate for the top 10 HACs.
CMS, The Joint Commission and consumers are holding healthcare organizations accountable
Healthcare organizations are being held accountable for poor health outcomes relating to HACs. The rising incidence of HACs has resulted in a 5 percent financial penalty on Medicare reimbursement for hospitals ranking in the worst-performing quartile on HACs. In addition, The Joint Commission’s accreditation process has changed its requirement for proof of compliance from simply having a hand hygiene policy in place and reporting observed data. In 2018, Joint Commission surveyors began reporting individual failures to perform hand hygiene in the process of direct patient care (The Joint Commission, 2017).
As consumers become more aware of the adverse impact of HAIs and HACs, they too are demanding accountability. For example, the Patient Safety Movement Foundation identifies HAIs as a challenge and has begun to give five-star rankings to hospitals committing to eliminating preventable deaths. The Joint Commission’s Quality Check program, Consumer Reports’ hospital ratings, and Medicare Hospital Compare all monitor hospital performance on preventing infections and publish results publicly. Increasing numbers of individuals have lost family and friends to HAIs, and they too demand action.
For too long, healthcare’s poor safety record has been accepted as normal when a similar record in industries such as air travel, auto-manufacturing, or food delivery would result in public outrage.
It’s time to act urgently and decisively
Healthcare organizations must innovate to assure compliance with hand hygiene and other patient safety initiatives that can decrease infection rates and associated costs. Methodologies currently used in most healthcare settings are simply costly and not completely effective. Healthcare leaders truly committed to a safety culture must implement systems that provide necessary information and insights for management to take preventive actions in real-time.
Most Hand Hygiene Programs Lack Compliance Needed to Reduce Infections
The World Health Organization (WHO) identifies hand hygiene as a simple, low-cost action to prevent the spread of HAIs, as germs are spread by people’s actions. “There is convincing evidence that improved hand hygiene through multimodal implementation strategies can reduce infection rates,” WHO’s 2009 report states. “Failure to perform appropriate hand hygiene is considered the leading cause of HAIs and spread of multidrug-resistant organisms.”
The problem, however, in today’s busy healthcare facilities is hand hygiene compliance.
Among healthcare workers, compliance rates with hand hygiene standards average below 50%, according to the Centers for Disease Control and Prevention.
Source: Centers of Disease Control and Prevention (2017)
Studies show that on average, healthcare providers clean their hands less than half of the times that they should (CDC, 2017; Erasmus, et al., 2010). While hand hygiene compliance under 50 percent is insufficient, there is recent evidence showing that the average compliance rate is even lower (McLaws et al., 2018; Eiamsitrakoon et al., 2013; Pan S-C, et al., 2013).
The connection between proper hand hygiene and HAI prevention is proven
This low compliance is bad news considering the connection between proper hand hygiene and HAI prevention. As many as 65 to 70 percent of cases of CABSI and CAUTI and 55 percent of cases of surgical-site infections and ventilator-associated pneumonia may be preventable with current evidence-based strategies including proper hand hygiene (Umscheid, et al., 2011).
A study conducted in Michigan hospitals where an evidence-based intervention including hand washing was implemented, achieved up to a 66% reduction in catheter-related bloodstream infections (Pronovost et al., 2006).
Another study quantified the contamination found on the hands of healthcare workers during critical moments of care in a wound care center. Healthcare workers there had at least one healthcare-associated pathogen on their hands during 28.3 percent of all patient care encounters. Hands sampled before a clean or aseptic procedure and after body fluid exposure risk were each contaminated in 17.4 percent of instances. The pathogens included MRSA, C. diff., vancomycin-resistant Enterococcus, and multidrug-resistant Acinetobacter species (Bingham et al., 2016).
Healthcare organizations leading themselves to believe that their hand hygiene compliance is higher than what they can prove and sustain are creating a false sense of security rather than truly addressing the problem.
Direct Observation of Hand Hygiene:
Some Advantages and Some Disadvantages
The direct human observation of hand hygiene was adopted by the World Health Organization as the gold standard in 2009 for monitoring compliance. This standard was crafted assuming observers have the ability to witness a care provider perform hand hygiene in the “five moments”: washing hands 1) before touching a patient, 2) before clean/aseptic procedures, 3) after body fluid exposure/risk, 4) after touching a patient, and 5) after touching patient surroundings.
Direct observation also gives observers the opportunity to intervene if hand washing opportunities are missed and to provide just-in-time coaching to care providers.
Compliance drops off when care providers are not observed
However, when care providers are not being observed, compliance drops off, due to the Hawthorne effect. Simply put, the Hawthorne effect – the alteration of behavior by the subjects of the study due to their awareness of being observed – greatly increases estimated hand hygiene compliance rates. Studies show the overestimation to be as high as 300 percent since compliance drops off significantly when healthcare workers are not directly observed, and most hand hygiene events are not directly observed (Hagel et al., 2015; Srigley et al., 2014).
The once-considered gold standard of direct observation has lately been found by researchers and experts to have other significant disadvantages (Boyce, 2017; Gould et al., 2017). These disadvantages were previously mentioned by the WHO (2009). Both Boyce and Gould note that for direct observation to be valid, healthcare organizations must invest considerable time and expense for the adequate training and periodic validation of observers, who in turn, must devote considerable time repeatedly observing caregivers in multiple clinical areas. Healthcare organizations often have difficulty achieving an adequate number of observations, especially on night and weekend shifts. This is a costly process to ensure ongoing effectiveness.
Direct observation often depends upon an insufficient sample size leading to statistical invalidity
Boyce and Gould add that compliance rates determined by direct observation often have an insufficient sample size. Due to the time required for direct observation, only a very small fraction of hand hygiene opportunities can be observed, from which massive and inaccurate extrapolations sometimes are generated. Studies estimate that only 1.2 to 3.5 percent of hand hygiene opportunities are captured via direct observation because of the tremendous number that occur, according to the Electronic Hand Hygiene Compliance Organization. For example, in an acute-care hospital with 1,000 beds, more than 171 million hand hygiene opportunities occur per year in inpatient and emergency areas (Boyce, 2017).
In addition, variations in how observers are trained and validated and how they conduct observations can clearly affect compliance rates. “Unintentional observer bias, as well as the Hawthorne effect, is likely when observations on a nursing unit are made by nurses who routinely work on the unit, rather than by non-unit observers. The distance of the observer from the healthcare provider being observed, the location of the observer on the unit, the
level of activity on the unit, the duration of each observational session, and even the time of day when observations are made can influence compliance rates,” Boyce states. Perhaps the most serious criticism of direct observation is that the presence of observers can potentially influence caregivers’ usual behavior and therefore reduce the validity of the findings (Gould et al., 2017).
In McCalla et al. (2017), researchers come to the conclusion that “it may be impossible to obtain a true measure of compliance through human observation. Because observers are unlikely to be utilized during the hospital’s full hours of operation, no institution can determine whether results from limited human observation will accurately reflect actual handwashing compliance in the 24 hours a day, seven days a week healthcare setting.”
In sum, there is a growing consensus that direct observation is flawed primarily because it cannot produce a true measure of hand hygiene performance. However, there is also a lingering perception that direct observation is the only process available. That is changing.
Automated Monitoring Systems Can Monitor 24/7 and Produce Useful, Actionable Data
Automated hand hygiene monitoring systems using electronic and computerized technology have been introduced into the marketplace. These systems can monitor hand hygiene performance 24/7 on all shifts without observer bias or the Hawthorne effect and gather significantly more data than direct observation. These systems can summarize large amounts of data quickly and provide actionable feedback through customizable reports made available on individual care provider, shift, unit and organizational levels. Another advantage is the limited personnel resources they require once implemented compared to direct observation strategies (Boyce, 2017).
These automated systems represent the latest technological advancement within the evolution of solutions designed to address HAIs and HACs. After creating awareness of the importance of hand hygiene and other preventive measures, healthcare organizations proceed along a continuum of actions they can embed into the safety culture and measure; most organizations start with simple compliance reminders and advance to direct observation programs followed by more sophisticated automated systems.
Ellingson et al. (2014) recommends exploring automated systems as an adjunct to or as a replacement of direct observation. Boyce points out that since many automated systems use the entering and exiting of patient rooms as proxies for hand washing moments 1, 4 and 5, combining automated monitoring with observational methods in a multimodal strategy may provide the best information.
As healthcare facilities invest in and implement these systems, many other organizations wait to see the impact these systems will have on hand hygiene compliance and HAI rate reduction.
Automated systems have improved compliance and reduced infection rates
The results of various studies have been promising. Michael et al. (2017) reports that an automated system with immediate feedback caused a rapid and sustained improvement in compliance. For example, one unit improved from 54 percent compliance over 12 months based on 88 direct observations to 98 percent compliance over 12 weeks based on 140,000 automated observations.
Another study of an electronic system shows an increase of hand hygiene compliance of 25.5 percent, a decrease of healthcare-associated MRSA infections of 42 percent from baseline, and a savings of $434,000 over the study timeframe (Kelly et al., 2016). The results also demonstrate how continual feedback from the data led to staff engagement and sustained improvement. “Across the entire hospital, periods of improved hand hygiene compliance led to lower infection rates,” the authors state. “We believe the monitoring system aided nursing leadership’s ability to drive change and improve staff performance, by providing real-time reliable (compliance) data. Continuing feedback allowed for ongoing conversation with frontline nursing staff, and unit-level data allowed for unit-level solutions because staff engagement with the data led to strategic decisions, which resulted in consistent, sustained improvement in hand hygiene performance.”
Vitalacy wristband providing immediate hand hygiene feedback
Boyce explains that electronic compliance monitoring systems currently fall into three major categories: 1) activity monitoring systems that monitor dispenser use and the entry and exit of individuals into a patient room, 2) systems that include the wearing of electronic badges or sensors by healthcare providers, and 3) camera-based systems that determine compliance rates by visual review of videos. In addition, Kelly (2016) and Azim (2016) described a badge-less electronic system that captured hand hygiene events from dispensers and transmitted data via a radio frequency network to a cloud-based database.
What all these electronic monitoring systems have in common is that they are “capable of capturing 100 percent of hand hygiene events, not a statistically insignificant sample, as is the case with direct observation,” Apler (2016) explains. “Observer bias and the Hawthorne effect are thus eliminated.”
Personal feedback empowers care providers
Son et al., (2011) raises another key advantage of electronic systems, saying that they empower healthcare providers within a group or unit with “the responsibility to identify their own obstacles and barriers to proper hand hygiene, create action plans to remove them,
and establish their own goals that can lead to sustainable improvement over time. . . They allow for tracking and reporting on an individual healthcare worker’s performance, so they can receive personal feedback . . . Most importantly, electronic monitoring systems tell the truth, better enable accountability, and can drive real performance improvement from an honest baseline. Accurate, reliable, timely, and actionable data is the key benefit.”
Vitalacy's real-time web analytics
Automated systems do present their own challenges, however. Given the required learning curve, they require an upfront investment of capital, resources and time, as well as a maintenance plan to ensure system continuity (Edmisten et al., 2017). Acceptance of automated systems by care providers is influenced by concerns over privacy and how compliance data will be handled by administrators (Boyce, 2017).
Automated compliance systems: Five steps to organizational buy-in
Every healthcare executive dealing with patient safety challenges must deal with the realities of organizational culture, the philosophy of stakeholders in the organization in regard to patient safety, and budget. Many find themselves facing a daunting task with command of too few resources to attack a well-known but poorly documented problem.
Most likely, their present tools are highly manual and people oriented and, therefore, expensive, unreliable and inconsistent. Yet, they know the financial stakes are getting much higher with the advent of HAC penalties and value-based payment. They see margins decaying and must consider how patient safety innovations can help them stay ahead of changes to reimbursement that have created new financial and operational risks.
A challenge for leadership is to get beyond lip service associated with quality and safety and to take a deeper dive into patient safety systems that leverage contemporary technology and best practices. Since manual processes are deeply engrained in many healthcare settings, informing stakeholders about the shortcomings of these processes can be politically charged.
Any new approach will work only if it becomes a seamless and meaningful part of an organization’s safety culture. There must be a willingness to imbed technology into the clinical workflow and use the data to reinforce a cultural shift.
Create a pilot project and gather actionable data. Many healthcare organizations get the ball rolling through a pilot project that can gather actionable data leading to better compliance and reduced HAIs and HACs. Know your pre-project baseline compliance and infection rates and their associated costs. Make your case by producing, introducing and using credible data demonstrating improvement.
Set goals and gain leadership support. Make clear throughout the organization the patient safety goals the project is designed to achieve. Gain the visible support of clinical, operational and financial leadership behind the goals and the project.
Take a multidisciplinary approach. Coordinate all departments whose participation and buy-in will be essential for successful implementation. While support from the C suite is important, only gaining buy-in from frontline providers will assure the project’s success.
Collaborate. Gain and use direct input from frontline providers who will use the automated system. Help them integrate the automated monitoring seamlessly into their workflow. Compare compliance results from unit to unit and discuss and find solutions to ongoing challenges. Share success stories and best practices during the rollout and beyond.
Find champions. Because they find themselves at the frontline in the war against HACs, nurses and nursing leadership are often among the first to voice concerns and find solutions. Champions need to be identified and energized among physicians and other healthcare professionals as well.
Vitalacy Applies New Workflow Tracking Methods to Reduce HAIs and HACs
The Vitalacy system is an automated solution that combines Internet of Things (IoT) technology with artificial intelligence (AI) to provide a continual, real-time platform that tracks caregiver workflow. These capabilities enable healthcare organizations to monitor care provider activities that, if performed consistently, can reduce HAIs and HACs.
By creating this patient “safety sphere,” Vitalacy provides a consistent and durable location-based workflow tracking system that helps healthcare organizations achieve better compliance results and patient safety.
When implemented to track hand hygiene compliance, the Vitalacy system reminds caregivers to wash their hands at the right place and at the right time. When deployed with a feature that facilitates purposeful nurse rounding, the system can help prevent HACs such as falls, pressure ulcers, and VTE. Danaf et al. 2018 identified 26 high-performing hospitals in the staff responsiveness and/or nurse communication domains of the Hospital Consumer Assessment of Health Providers and Systems (HCAHSP) survey; 96 percent of these hospitals reported proactive nurse rounding as their main rounding intervention to help discover and address the needs of hospitalized patients in a timely fashion.
Sensors make it possible to track every hand hygiene opportunity – and the quality of each hand wash
The Vitalacy system tracks individual, unit, and organizational hand hygiene performance through sensors installed in dispensers and in wristbands worn by healthcare providers. Location beacons installed in patient rooms monitor hand hygiene opportunities, and a gateway sends all the data to a cloud database. A reporting system accessible via a mobile app and the web shows how often, how long, and how well individuals are washing their hands and provides feedback and reminders for hand hygiene.
The ability to track the quality of each hand wash is a primary differentiator of the Vitalacy system. AI sensors within the wristband monitor hand movements during the hand wash. When the care providers wash their hands, these observational data are fed into a proprietary algorithm that identifies the proper hand washing sequence and enables the wristband to provide feedback to its wearer on how to improve hand-washing technique.
The dispenser sensors track how often and for how long the dispensers are used and how much soap or sanitizer is dispensed. Strategically positioned, the sensors make it possible to assure that no hand hygiene opportunity goes unfulfilled, tracking every patient room entry and exit along with wash frequencies. Enabled by IoT, the sensors measure and report dispenser use, provide dispenser refill reminders, and offer customized management reports including graphic “heat maps” for each dispenser location. Simple to implement, the AI and IoT functionalities can be integrated fully into existing manual or automated dispensers.
Real-time reminders drive up caregiver compliance and help reduce HAIs and HACs
Providing real-time reminders at the point of service is a pivotal step in increasing and sustaining patient safety and hand hygiene compliance. Communicating with each other via low-power Bluetooth technology, the patented dispenser sensors and wristbands work together at the point of service to remind caregivers and drive up compliance rates.
Healthcare organizations using the Vitalacy systems can view and analyze five different kinds of reports: 1) compliance by individual and unit over time, 2) location tracking showing the movement of staff throughout the day, 3) shift reports showing the times care providers worked, 4) dispenser management with a map showing dispenser use; this report helps to place dispensers in the best locations, and 5) nurse rounding, which shows the amount of time care providers spend in each room and how many providers visited a patient’s room over a certain timeframe.
Example Vitalacy hand hygiene e-mail report
A Case Study: Improving Compliance and Reducing Infections
In early 2017, the Vitalacy system was implemented in about half the medical and surgical beds in an academic medical center with a higher-than-average HAI rate; this rate was high despite the medical center reporting direct observation hand hygiene compliance rates of more than 90 percent on 1,500 direct observations per quarter.
Immediately after implementation, Vitalacy’s automated hand hygiene compliance tracking found that the actual hand compliance was about 30 percent when healthcare providers did not receive vibration alerts on their wristbands. After activating the wristband alerts, the compliance rate increased to more than 70 percent over the course of about one week.
Compliance up, infections down
As of publication of this document, hand hygiene compliance stood at more than 70 percent based on about 225,000 observations per quarter. Infection incidence decreased both on the monitored units and medical center-wide for two consecutive quarters. From the January 2017 implementation through September 2018, Vitalacy has reported on more than 1.17 million hand hygiene observations. Due to these initial results, the medical center is expanding the project to all patient care units.
Multidisciplinary work group provides an engagement opportunity leading to better compliance
Realizing the potential impact of the real-time feedback system, Vitalacy collaborated with care providers to overcome objections to participation and compliance. By creating a multidisciplinary work group, the onsite Vitalacy team quickly found solutions to increase the care providers’ willingness to wear the tracking devices, such as reducing the frequency of charging the devices and developing a badge option that can be clipped on a shirt collar or sleeve instead of wearing the wristband. The feedback also led to changes in the patterns and frequency of vibration reminders.
The work groups also created the opportunity for broad multidisciplinary participation from as many departments as possible – for example, each patient care unit, infection control, facilities management, environmental services, nursing management, and more.
Mobile app creates fun competition between units
The team used the work group as an opportunity to introduce care providers to the mobile app that showed them, on a daily basis, their compliance rate compared to other individuals and units. “This started a fun competition between them,” remembers Tal Cohen, Vitalacy’s Vice President of Engineering. “They started to compare themselves to each other, which increased the awareness of hand hygiene and made the product more user-friendly."
The pushback from staff at first came from their concerns that the monitoring might lead to punitive measures, said Janel Nour-Omid, Vitalacy’s Vice President of Product and Marketing. “They didn't particularly like being watched which is completely understandable. It's human nature to react in that way. And that's when we decided to introduce the mobile apps to empower them with their own data.”
Responding to care provider feedback and introducing the mobile app helped the Vitalacy team increase buy-in, participation and engagement with the new system.
Vitalacy mobile app
Project champion pushes project forward to increase compliance and decrease infections
As part of this process, one of the nurse managers volunteered to be the project’s champion, and “she took the whole project under her wing,” Nour-Omid said. Cohen stated that “she pushed the project forward. The success of a project is determined not just by the technology, but by the cooperation of the staff and leaders.”
Refining the technology and, more importantly, engaging the staff significantly increased participation and compliance. “And that’s where we saw a decrease in infection rates,” Nour-Omid said.
Trial results showing increase in hand hygiene compliance.
Suggestions from care providers lead to further Vitalacy innovations
The caregivers at the medical center provided feedback and ideas that helped Vitalacy to develop ways to evolve and enhance its system. Noting that the Vitalacy system can track the movement of caregivers through their work day, the project champion asked if the system could track when and for how long caregivers interacted with patients. Her question rose from a concern about the high fall rate at the medical center due to severely immunocompromised end-stage cancer patients at high risk for falls and other complications.
Other innovations stemming from staff suggestions include an infrared thermal sensor installed above a patient bed that can alert staff when a patient at risk for a fall sits up and a wristband for immunosuppressed patients that can detect pulse and temperature, since a change in either reading must be addressed immediately in these types of patients. Another suggestion was to develop brochures about the Vitalacy system for patients, so they could be aware that the wristbands and sensors were implemented by the institution for their safety.
This question led to the development of Vitalacy’s purposeful nurse rounding data module, which was implemented for the first time at this medical center. The module identifies which staff member completed rounding in each room, at what time, and for how long. By viewing activity by staff and room, managers can ensure that care providers get alerts when patients have not been visited as necessary; this information also helps managers to identify high- and low-performing staff to target education and training. The timing and frequency of visits can be set for each patient and adjusted to alert for higher-risk patients.
Reducing HAIs and HACs is a Personal Mission for Vitalacy
Finding solutions to these problems is very personal for Vitalacy Chairman and CEO Bahram Nour-Omid, who has lost family members to HAIs. The issue of HAIs was first brought to Bahram’s attention when his wife experienced the death of her father due to hospital-acquired pneumonia when he was admitted for kidney stone treatment. Some time later, he met Nancy Conrad, the wife of astronaut Pete Conrad, who was the third man on the moon and who went into space four times – on Gemini 5 and 11, Apollo 12 and Skylab. “He was obviously, by any standards, a courageous man, a risk taker, someone who could calculate risks,” Bahram stated. Nancy told him how one day, Conrad hurt himself in a motorcycle accident, and even though his injuries were not serious, he died soon afterwards of a hospital-acquired condition.
“We are able to send a man to the moon, yet somehow not able to control infections in hospitals,” Bahram remembers thinking at the time. More recently, the HAI problem hit closer to home for Bahram, when his mother passed away from an infection after a brain operation. “This problem was hitting me from so many directions. That’s what inspired me to step in and try to solve the problem.” A long-time technology entrepreneur, he invested his own money to found Vitalacy, a company that’s dedicated to finding patient safety improvement solutions targeting healthcare-acquired conditions.
Vitalacy continually fine tunes its public narrative. The company discovered that the Institute for Healthcare Improvement, in its 2018 monograph about behavior change in the healthcare environment, wrote: “…to reach a higher level of performance and reliability, improvement teams and healthcare organizations will need to create the conditions for people to advance and sustain improvement.”
This statement provides a succinct and accurate description of the core beliefs of the Vitalacy team. We are in the business of providing the data that affects change.
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