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         Clinical intelligence for supply chain leadership

 

INSIDE THE CURRENT ISSUE

October 2014

Infection Prevention

IP Update

‘Junk’ blood tests may offer life-saving information

Some 30 percent of all positive hospital blood culture samples are discarded every day because they’re "contaminated" — they reflect the presence of skin germs instead of specific disease-causing bacteria.

Rather than toss these compromised samples into the trash, clinicians may be able to use the resistance profiles of skin bacteria identified by these tests to treat patients with antibiotics appropriate to their ailment, Tel Aviv University researchers say. Dr. Gidi Stein and Dr. Danny Alon of TAU’s Sackler Faculty of Medicine and the Department of Internal Medicine B. at Beilinson Hospital, Rabin Medical Center, and Prof. Lilach Hadany and Uri Obolski of the Department of Molecular Biology and Ecology of Plants at TAU’s Faculty of Life Sciences conducted a retrospective study on more than 2,500 patients. Their test results demonstrate the unique diagnostic value of "erroneous" cultures.

The study showed the immediate effects on both public health questions and the treatment of individuals whose blood has been contaminated. The results were published in the Journal of Antimicrobial Chemotherapy.

The more resistant the skin germs, the higher the risk of the infecting bacteria to be resistant, the researchers found. "These results can certainly be used for on-site clinical decisions. Once a contaminated sample has been found to be highly resistant, it is likely that the blood-borne pathogens will have a similar resistance pattern. Thus antibiotic treatment may be better targeted for the actual pathogens," says Prof. Hadany.

In the study, the researchers processed the demographic information, hospital records, blood culture results, and date of death of all patients at the Rabin Medical Center with positive blood cultures from 2009-12. They found that out of 2,518 patients, 1,664 blood cultures drawn from 1,124 patients reflected the presence of a common skin contaminant, coagulase-negative staphylococci (CoNS). High overall CoNS resistance predicted high overall resistance of the bacteria causing disease or infection. Most importantly perhaps, highly resistant CoNS isolates were found to be associated with higher short-term mortality.

The researchers hope their conclusions will cause clinicians to pause before discarding contaminated blood test results.

According to the researchers, most hospital patients are treated at the outset with broad spectrum antibiotics. Days later, after initial test results are known, clinicians replace broad spectrum antibiotics with more precise narrow-spectrum antibiotics, which treat the specific bacteria identified by the blood sample.

It is well known that narrow spectrum antibiotics are better for the body because they target specific bacteria as opposed to an entire microenvironment. Moreover, broad spectrum antibiotics might result in altered bacterial environments of the skin and gastro-intestinal tract, promoting inflammation and the emergence of resistant pathogens.

 
 

A delicate balance

Gentler, more effective products and electronic monitoring increase
hand-hygiene compliance

by Susan Cantrell, ELS

Our first line of defense against infection is clean hands. It sounds so simple. Just wash your hands with soap and water or use an alcohol-based rub. How hard can that be? Unfortunately, it really is more complicated than that. Frequent hand cleansing is of paramount importance, but it carries its own hazards for healthcare workers (HCWs), which, in turn, creates hazards for their patients. Frequent cleansing of hands can cause raw, chapped, cracked skin that hurts. Damaged skin offers a multitude of hiding places for harmful bacteria that can be transmitted to patients during care.

There is a whole science that revolves around hand hygiene (HH) and skin care. That alone shows what an enormously important issue it is. Published scientific studies abound on HH, care of HCW skin, and their effects on compliance with HH guidelines. Industry takes that science, and often generates that science, and uses it to develop products that answer HCW needs.

Product development must address a number of issues. Hand-hygiene and skin-care products must be as gentle as possible while being as effective as possible. The products need to be easily accessible to HCWs and must be liked by HCWs or they are less likely to be used, which brings us to a closely related issue: compliance. Hand-hygiene–compliance products are able to perform on a considerably higher level than the so-called gold standard, direct observation. Direct observation has limitations. Monitoring technology is more accurate and capable of generating useful reports. Paul Alper, Vice President, Patient Safety Strategy, DebMed, Charlotte, NC, noted, "Most healthcare facilities continue to use the direct observation method, proven in study after published study to be inaccurate and overstated. To achieve accurate, reliable, and timely data, monitoring beyond direct observation is imperative. It’s also clear that improvement is needed, with the World Health Organization (WHO) reporting a compliance rate of HH among HCWs at less than 40 percent."

What’s needed: strong yet gentle products

Healthcare Purchasing News talked to representatives from some companies that offer HH and skin-care products to see how their products address the above-mentioned issues and more.

Ecolab hand sanitizer

Kim Lees, Marketing Director, Ecolab Healthcare, St. Paul, MN, explained how their product works to promote proper HH protocol while preserving skin health. "Ecolab offers a wide variety of HH products and dispensing options designed for use in a healthcare environment. Our HH products are designed to be gentle, yet effective, to support frequent hand-hygiene practices. Last year, we introduced Quik-Care Nourishing Foam, a new foam hand sanitizer with a clinically proven formula that uses essential nutrients to nourish the skin over time and enhance the skin’s natural repair process. An extended clinical study (BioScience Laboratories Inc., Study No. 120213-350, January 2013) confirmed skin is visibly less dry after 2 weeks of use. We also recently launched Daily Renewal Hand Cream, which was designed for daily use to help repair damaged skin and help maintain the skin’s natural protective function."

Lees talked about other advantages of Ecolab Healthcare’s HH and skin-care offering. "There are many instances when an HCW needs to perform hand hygiene and then dons gloves. Ecolab’s Express Gel Hand Sanitizer was designed to dry quickly for easier gloving. In panel testing, nurses found it significantly easier to glove after using Express Gel Hand Sanitizer compared to the leading gel hand sanitizer. In addition to easier gloving, the product is mild, 96 percent biobased, and formulated to help maintain skin moisture."

One common complaint from HCWs about HH products is that they don’t like how it feels on their hands, because of build-up. PDI offers a solution that keeps hands feeling clean while offering convenience and moisturization with aloe and vitamin E. Joe DeBelle, Director of Marketing for PDI Healthcare, PDI, Orangeburg, NY, talked about their product’s attributes. "Unlike gels and foams, Sani-Hands offers two benefits in one: First, the formulation has been proven to kill 99.99 percent of germs and bacteria; second, the wipe actually removes soil from the hands, leaving skin feeling clean."

The Sani-Hands family of products, from PDI, Inc.

"Newly released clinical guidelines will help foster the usage of wipes for HH," said DeBelle. "Recently, high-alcohol–based wipes have been included and accepted in a peer-reviewed, evidence-based guideline.1 This is an extremely positive change to clinical-practice guidelines for HH that affects not only recommendations for healthcare providers but, for the first time, patients and especially bed-bound patients. The Centers for Disease Control and Prevention (CDC) guidelines discuss the use of alcohol-containing hand wipes, offering a convenient option for bed-bound patients, first responders, and others who cannot easily get to sinks or wall-mounted dispensers. At PDI, we have introduced a unique offering with our Sani-Hands Bedside Pack, ideal for patients who cannot get out of bed to clean their hands. We have also integrated new educational icons to further support patient HH at the bedside."

DeBelle related two examples of scientific evidence supporting their product’s efficacy. "Sani-Hands has continuously shown to improve outcomes and compliance when implemented in healthcare facilities. In one study,2 Sani-Hands was introduced as part of a patient HH solution. Results showed bloodstream infections decreased over a 5-month period, 94 percent of patients reported cleaning their hands more often when given Sani-Hands, and 100 percent of patients felt their hands were cleaner after using Sani-Hands. When Sani-Hands was added to a long-term–care facility’s infection prevention program,3 it helped reduce HAIs and related costs: HAIs were reduced by 77 percent, antibiotic costs were reduced by $33,665, employee absenteeism was reduced by 41 percent, and acute-care transfers were reduced by 73 percent.

Dial Complete Antimicrobial Foaming Hand Soap

Henkel’s Dial Complete Antimicrobial Foaming Hand Soap was specifically formulated with healthcare workers in mind. Its patented technology allows 14X better germ kill than other antimicrobial soaps, and is proven effective against pathogens such as MRSA – both hospital and community-acquired, VRE and Streptococcus. Dial Complete foam is hypoallergenic and tested to be as gentle to the skin as water itself.

Another product that promotes skin nourishment and healing as it cleanses comes from 3M Health Care. Andrea Albrecht, Global Marketing Manager, 3M, St. Paul, MN, explained how their product works to maintain skin health while persistently killing pathogens. "3M developed 3M Avagard (chlorhexidine gluconate 1 percent solution and ethyl alcohol 61 percent w/w) Surgical and Healthcare Personnel Hand Antiseptic with Moisturizers as a fast and effective alternative to traditional soap and water and manual scrub methods. The unique formulation is 3 products in 1: alcohol for immediate antimicrobial kill, chlorhexidine gluconate for persistence, and an emollient-rich lotion base to help maintain skin integrity.4 This product can also be used as a healthcare-personnel hand antiseptic outside the operating room. The Avagard Surgical and Personnel Healthcare Antiseptic product is applied in a fraction of the time of traditional soap and water methods. In addition, its dual active formulation of alcohol and active levels of chlorhexidine gluconate provide cumulative and superior persistent antimicrobial activity as compared to products whose only active ingredient is alcohol."

Avagard from 3M

"3M also provides Avagard D (ethyl alcohol 61 percent w/w) Instant Hand Antiseptic with Moisturizers as a personnel-healthcare handwash option," continued Albrecht. "With the increased awareness and emphasis on sustained HH compliance, HCWs have been faced with a significant increase in HH opportunities. Avagard D Instant Hand Antiseptic has a unique, advanced, liquid-crystalline moisturizing formulation that helps prevent dryness and maintain skin integrity. Avagard D Instant Hand Antiseptic with Moisturizers has been shown to improve HH compliance when included as part of a multidimensional program, including use of a waterless hand rub, education, printed materials, and role modeling by key staff [A Multi-dimensional Intervention to Improve Hand-hygiene, 3M Internal Study LIMS 8554]."

3M makes available more information as well as continuing education for healthcare professionals, live webinars, and more at http://www.3M.com/IPEd.

Compliance-monitoring systems

Hand-hygiene compliance monitoring is more important than ever. Certainly it can contribute to a reduced rate of hospital-acquired infections (HAIs) and the suffering they cause patients, but it also can contribute to decreased costs. Since the Centers for Medicare and Medicaid Services no longer reimburses for HAIs, prevention is more important than ever. Dave Mackay, Vice President, Sales and Marketing, Healthcare, GOJO Industries Inc., Akron, OH, cited yet more advantages of electronic HH montoring systems. "The primary reason for implementing an electronic HH monitoring system is that it allows for the collection of robust data that is statistically significant, unbiased, and actionable. To improve HH, hospitals need the tools to measure it and the clinical education resources to interpret the data."

Traditionally, direct observation has been considered the gold standard for HH compliance measurement, but it is a very flawed method. No small consideration is the Hawthorne effect, which says that when people know they are being watched they perform better.

Hill-Rom's hand-hygiene compliance system

Sheeza Hussain, Director, Commercial Marketing, Hill-Rom, Cary, NC, talked about some of the shortcomings of the direct observation method. "Observation can drive increased compliance when observers, or ‘secret shoppers,’ are visible, but observers cannot be in place 24/7; therefore, compliance scores may be falsely inflated. In addition, observers typically document HH protocol compliance but do not alert to noncompliance."

Joel Cook, STANLEY Healthcare Solutions Director, Waltham, MA, added, "Customers are moving away from manual monitoring methods due to their labor-intensive nature and questionable effectiveness. Studies indicate that the Hawthorne effect is a real issue with monitoring HH manually, showing significantly elevated results when staff knows they are being monitored."

Hussain explained how Hill-Rom’s HH monitoring system works and described its role in proper HH protocol. "With the Hill-Rom solution, compliance is monitored 24/7, and caregivers are actively alerted to potential missed opportunities, giving them the ability to address missed opportunities in real time and potentially prevent the spread of infection. Hill-Rom’s HH compliance [system] uses locating technology to track HH events and records each visit to HH stations. Data can be viewed in real-time at the individual, unit, or hospital level to identify patterns in HH behavior and to facilitate continuous improvement. Hospital staff and visitors alike can be actively alerted to missed HH opportunities when entering and exiting the patient room through the use of an audio tone emitted by tags worn by each individual. No change to normal handwashing procedures is required to monitor visits to the HH stations effectively. The Joint Commission has asked hospitals to demonstrate the existence of HH protocols and demonstrate continuous improvement. With enterprise reporting, reports are generated to show the number of visits to HH stations, missed handwashing opportunities, and rates of visits and missed opportunities."

"Hill-Rom HH customers have tracked over 5 million HH events in the past year," said Hussain, who cited the experiences of two customers. "The largest hospital in a Mid-South state implemented a hospital-wide HH solution, and data has shown that this has more than doubled their HH compliance in less than a year. In addition, a 400-plus bed community teaching hospital in the northern United States implemented an HH solution from Hill-Rom; data demonstrates their compliance rates tripled in that same time period."

TeleTracking Technologies, Pittsburgh, PA, offers a real-time locating system (RTLS). Toni Morrison, RN, Product Manager, described it. "TeleTracking’s HH solution is RTLS-based. In conjunction with caregivers wearing badges, monitors are also mounted on gel and soap dispensers. Based on the industry gold standards set by WHO and other governing bodies, the TeleTracking system captures handwashing events pre- and postexposure to the patient and patient environment. The solution is a passive system that captures the events, while not interrupting the normal workflow of the caregivers. The system provides real-time feedback visible to the caregivers so that they have the ability to change behavior in real time, while providing robust reporting."

Hand hygiene monitoring system from TeleTracking

Morrison highlighted the importance of 24/7 monitoring, which is unlikely to occur with manual observation. "TeleTracking’s solutions work passively and around the clock. Twenty-four hour monitoring of all caregivers leads to better understanding of the trends, as well as the ability to identify potential contamination. Also, caregivers no longer must be pulled from staffing to perform manual observations, which are inherently flawed anyway because of the Hawthorne effect."

Morrison cited the experience of a facility that uses TeleTracking’s HH compliance-monitoring system. "New Cross Hospital, a 766-bed acute-care facility in Wolverhampton, UK, increased handwashing observations from 600 to 1.2 million in 1 month using RTLS monitoring technology from TeleTracking and has extended RTLS-enabled technology to automate almost all of its daily operating procedures enterprise-wide in what may be the world’s first ‘real-time hospital.’ The initiative won the prestigious ‘Patient Safety and Care Award’ for its use of RTLS to improve patient care."

Mackay explained how GOJO’s HH monitoring system works. "The GOJO SMARTLINK HH solution is built upon a state-of-the-art, electronic, compliance-monitoring platform, and includes clinician-based, on-site support; superior HH formulations; advanced technology dispensing systems; and technology that allows for, or accommodates, monitoring at a group, individual, role, and area level."

The primary components of the SMART­LINK solution include the following features:

  • GOJO SMARTLINK Activity Monitoring System (AMS) monitors soap- and sanitizer-dispenser activations and area entries and exits. The system accurately captures this data and estimates HH compliance at either a group or area level. It can be configured to monitor and measure HH compliance by facility, floor, unit, or room.

  • GOJO SMARTLINK and RTLS technology monitors and measures HH compliance at an individual level through RTLS-enabled employee badges. This system, which tracks person-specific movement and metrics, integrates with existing third-party RTLS systems.

  • GOJO SMARTLINK clinician-based support provides the organization with support from GOJO clinical team members. Our guides become part of the hospital’s infection prevention team and provide customized implementation, onsite audits, baseline measurements, and detailed improvement plans."

Sensors are inside GOJO and PURELL dispensers for accurate measurement.

Mackay also cited a customer experience. "GOJO conducted an independent research study at a Texas hospital to determine the impact on HH compliance rates when the hospital’s HH program included an electronic compliance-activity monitoring system. The technology used in the study was the GOJO SMARTLINK AMS. Results concluded that, during the study period (June to September 2012), there was a 92 percent increase in HH compliance rates when an electronic monitoring system was included as part of a HH program. This is just one example," said Mackay. "We are seeing significant improvements in many of our installations."

GOJO Industries makes available educational tools at http://www.gojo.com/united-states/market/healthcare/acute-care/resources/educational-tools.aspx. Also visit the GOJO Hand Hygiene Blog at http://www.gojo.com/united-states/blog.aspx.

The STANLEY Healthcare hand-hygiene solution uses a real-time location system.

STANLEY Healthcare also offers an RTLS HH compliance solution. "The STANLEY Healthcare HH solution uses an RTLS and incorporates an embedded device within soap, gel, or foam dispensers," explained Cook. "The dispenser causes the staff badge, worn by each healthcare provider or other staff member, to transmit an ‘event,’ with which the system automatically logs and reports HH compliance across a unit, floor, or entire facility. Because STANLEY uses an RTLS, reports show whether the user is entering, inside, or leaving a patient room when they wash; therefore, we create an accurate log of when and where each HH event occurred, by individual, role, time-of-day, or other measurement, generating an automatic calculation of HH compliance, 24/7. Using our sophisticated business analytics, customers are positioned to understand compliance gaps, improve staff education, assess the need for process improvement or optimal placement of dispensers, and properly support the drive to reduce HAIs.

"The central objective for customers deploying an automated HH solution is to reduce HAIs," said Cook. "Among many other features, our compliance dashboards are being used at nurses stations to remind staff in real time of the importance of HH and see how they are doing as compared to their peers. We’ve even noticed that they are competing with each other to have the best scores."

DebMed’s GMS, electronic hand-hygiene
compliance-monitoring system

Another electronic option is from DebMed. Alper described its attributes. "One of the strongest assets of DebMed’s GMS [group monitoring system] is that it measures at the group, ward, [or] unit level . . . as opposed to requiring employees to wear a badge and being tracked as individuals. It is not punitive and helps create a ‘just’ safety culture, meaning everyone feels safe to talk about improvement and the change that’s needed to make this happen. This offers a more team-driven approach to improve compliance. It draws on an evidence-based, statistically valid algorithm, which determines how many times HCWs should have performed HH, based on unit-specific census and patient-to-nurse ratio, to derive an accurate and reliable compliance rate."

"Electronic group monitoring has been found to be as effective as video monitoring in ensuring HH compliance within hospitals and health systems, according to researchers from Greenville Health System, Greenville, SC, who published their findings in the American Journal of Infection Control5 and presented [them] at the 2013 Infection Prevention Society Annual Conference in London and at the 2012 International Consortium on Prevention and Infection Control in Geneva. The study utilized the DebMed GMS and measured HH compliance over a 15-month period three ways: electronically, video capture, and direct observation. The study showed the DebMed GMS and videotaped methods were about equivalent but that direct observation of HH compliance overstated compliance by an average of 33 percent, likely due to the Hawthorne effect. For example, [an] article published in BMJ Quality & Safety Online6 cited a 300 percent increase in hallway hand washes per hour among healthcare staff when a visible auditor was in the area. This study contributes to the proof of electronic HH monitoring as a most accurate measurement, as behavior is most likely to be naturally habitual and accurate, rather than influenced by environmental encouragement such as awareness of an auditor."


References

1. Ellingson K, Haas JP, Aiello AE, et al. Strategies to prevent healthcare-associated infections through hand hygiene. Infect Control Hosp Epidemiol. 2014;35(8):937-960.

2. Misuraca J, Brooksbank N, Potak A, et al. Using evidence-based strategies to reduce blood stream infection rates on a hematology-oncology inpatient unit. Presented at the 35th Annual Oncology Nursing Society Congress; San Diego, CA; 2010. Abstract #4601.

3. Schandel JM, Thomas KS. Project: clean sweep reducing healthcare-associated infections, employee absenteeism, healthcare cost and hospital readmissions in a long term care facility. Presented at the Association for Professionals in Infection Control and Epidemiology Annual Conference; New Orleans, LA; 2010. Abstract #8-080.

4. Larson EL, Aiello AE, Bastyr J, et.al. Assessment of two hand hygiene regimens for intensive care unit personnel. Crit Care Med 2001;29(5):944-951.

5. Ward MA, Schweizer ML, Polgreen PM, et al. Automated and electronically assisted hand hygiene monitoring systems: a systematic review. Am J Infect Control. 2014;42(5):472-478.

6. Srigley JA, Furness CD, Baker GR, et al. Quantification of the Hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system: a retrospective cohort study. BMJ Qual Saf 2014:Jul 7. [Epub ahead of print]