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KSR Publishing, Inc.
Copyright © 2016

         Clinical intelligence for supply chain leadership



March 2015

Infection Prevention

IP Update

CDC reports progress in infection control in U.S. hospitals

Progress has been made in the effort to eliminate infections that commonly threaten hospital patients, including a 46 percent decrease in central line-associated bloodstream infections (CLABSI) between 2008 and 2013, according to a report released by the Centers for Disease Control and Prevention.

However, additional work is needed to continue to improve patient safety. CDC’s Healthcare-Associated Infections (HAI) progress report is a snapshot of how each state and the country are doing in eliminating six infection types that hospitals are required to report to CDC. For the first time, this year’s HAI progress report includes state-specific data about hospital lab-identified methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections and Clostridium difficile (C. difficile) infections (deadly diarrhea). 

The annual National and State Healthcare-associated Infection Progress Report  summarizes data submitted to CDC’s National Healthcare Safety Network (NHSN), the nation’s healthcare-associated infection tracking system, which is used by more than 14,500 healthcare facilities across all 50 states, Washington, D.C., and Puerto Rico.

Healthcare-associated infections are a major, yet often preventable, threat to patient safety. On any given day, approximately one in 25 U.S. patients has at least one infection contracted during the course of their hospital care, demonstrating the need for improved infection control in U.S. healthcare facilities.

The majority of C. difficile infections and MRSA infections develop in the community or are diagnosed in healthcare settings other than hospitals. Other recent reports on infections caused by germs such as MRSA and C. difficile suggest that infections in hospitalized patients only account for about one-third of all the healthcare-associated infections.

On the national level, the report found a:

•  46 percent decrease in central line-associated bloodstream infections (CLABSI) between 2008 and 2013. A central line-associated bloodstream infection occurs when a tube is placed in a large vein and either not put in correctly or not kept clean.

•  19 percent decrease in surgical site infections (SSI) related to the 10 select procedures tracked in the report between 2008 and 2013. When germs get into the surgical wound, patients can get a surgical site infection involving the skin, organs, or implanted material.

•  6 percent increase in catheter-associated urinary tract infections (CAUTI) since 2009; initial data from 2014 seem to indicate that these infections have started to decrease. When a urinary catheter is either not put in correctly, not kept clean, or left in a patient for too long.

•  8 percent decrease in MRSA bloodstream infections between 2011 and 2013.

•  10 percent decrease in C. difficile infections between 2011 and 2013. 

Research shows that when healthcare facilities, care teams, and individual doctors and nurses, are aware of infection control problems and take specific steps to prevent them, rates of targeted HAIs can decrease dramatically.


Hand hygiene, like germs, should be ever-present

by Susan Cantrell, ELS

Hand washing has long been recognized as the most important, data-proven method of reducing transmission of all types of pathogens in health care; yet, hand-hygiene (HH) compliance is still low. Some estimates put compliance at an abysmal 50 percent. There is work to be done, but improvement cannot be accomplished without reliable measurement.

The first step is to establish a baseline, noted Cheryl Littau, Ph.D., Senior Staff Scientist, Ecolab Healthcare, St. Paul, MN. "Tracking HH events and reporting outcomes gives hospitals a baseline and ongoing data to help them more effectively train their staff to perform HH at all necessary opportunities."

Sue Boeker, Infection Preventionist at Greenville Hospital System, using a DebMed GMS dispenser

A variety of HH measurement systems are available. The gold standard is direct observation, and it is still widely employed, but direct observation has inherent weaknesses that can result in skewed data. Heather McLarney, Vice President of Marketing, DebMed, North America, Charlotte, NC, said, "There are many flaws with direct observation, the primary method used to track compliance, and it provides inaccurate data. The bottom line is that you can’t improve what you can’t reliably measure, and HH can be reliably measured with the use of an electronic HH monitoring system."

Sheeza Hussain, Director, Commercial Marketing, Hill-Rom Inc., Batesville, IN, added, "The Joint Commission has asked hospitals to demonstrate the existence of HH protocols and continuous improvement. An electronic monitoring system can help actively monitor compliance and provide the reports needed to drive HH compliance. Improved HH compliance has a direct tie to a reduction in infections."

Real-time monitoring solutions

A free web-based tool, the Targeted Solutions Tool (TST), is available to Joint Commission-accredited organizations. The TST system is a direct-observation method, but it is more powerful than the standard method. Just-in-time coaching by specially trained staff search for root causes of, and contributing factors to, noncompliance and actively intervene when HH failures are observed, in real-time. Healthcare workers are then educated on proper compliance, and collected data is used for root-cause analysis and solutions across all shifts to increase staff awareness and reinforce behavior.

Erin DuPree

"The TST observation approach is more robust than the typical secret-shopper observation approach. The TST includes the identification and frequency of contributing factors that lead to noncompliance, in addition to the overall HH compliance rate," said Erin S. DuPree, MD, Vice President and Chief Medical Officer of The Joint Commission Center for Transforming Healthcare, an affiliate of The Joint Commission. "Hand-hygiene performance is measured with both secret shoppers and just-in-time coaches collecting data. These data collectors are trained in a consistent manner and must pass an assessment to ensure accurate and reliable data collection."

DuPree also referred to challenges in measuring HH compliance. "The major challenge in measuring adherence to HH is ensuring accuracy and reliability of data," she said. "In addition to measuring HH compliance, it is important to measure the contributing factors for noncompliance. The contributing factors are different from one healthcare facility to the next, even from one unit to the next in the same healthcare facility, and each contributing factor requires its own unique solution.

"The TST provides healthcare facilities with real-time analysis, including tracking HH compliance rates and the identification of contributing factors from highest to lowest frequency. Data can be stratified by healthcare worker role and shift. The data can be analyzed at a project-level, facility-level, or system-level."

For more information, DuPree recommended two recently published articles on the development of the TST surveillance and improvement system.1,2 Access these articles at http://www.jointcommission.org/sustaining_and_spreading_

Dave Mackay, Vice President, Sales and Marketing, Healthcare, GOJO Industries, Akron, OH, emphasized the need for unbiased data. "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 and act on the data. The GOJO SMARTLINK solution provides both and complements the traditional method of direct observation. In addition, our systems are upgradable, can measure at either the individual or group level, and can integrate with other systems within the facility."

Sensors are inside GOJO and PURELL
dispensers for accurate measurement.

The primary components of the SMART­LINK solution include: 1.) an Activity Monitoring System that monitors soap and sanitizer dispenser activations and area entries and exits, capturing data and estimating HH compliance at a group or area level. It can be configured to monitor and measure HH compliance by facility, floor, unit, or room. If a facility doesn’t have real-time locating system (RTLS) technology, it can start with this system and upgrade at a later date by replacing an integrated communication module within the dispenser to work with a number of RTLS systems. 2.) RTLS Technology monitors that measure 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. 3.) Clinician-Based Support from GOJO clinical team members, which serve as an extension of the hospital’s infection-prevention team to provide customized implementation, onsite audits, baseline measurements, and detailed improvement plans.

"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," said Mackay. "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 an HH program."

McLarney, DebMed, offered advice to those looking to purchase an HH surveillance system. "The most important and common factors for consideration include cultural factors, such as the acceptance of an individual versus a group-based system; the importance of measuring compliance against the highest clinical standards of the WHO [World Healthcare Organization] Five Moments versus only before and after patient care; ease of implementation; proven accuracy and client outcomes; and cost.

"It is most important to measure HH compliance against best practices, such as standards set by the WHO Five Moments and Centers for Disease Control and Prevention (CDC)," continued McLarney. "Studies show that monitoring only if staff are cleaning hands as they enter and exit patient rooms miss 50 percent of opportunities for HH, including those critical times while the care provider is in the room providing care to the patient. With the DebMed GMS, success is measured as compliance with the WHO and CDC HH standards, not just before and after patient care. It compares how many times staff should have used soap or sanitizer versus how many times they actually did, taking into account the hospital type and size, unit type, hourly patient census, and staffing ratios."

McLarney, added, "The DebMed GMS is the only monitoring system that calculates compliance based on actual soap and sanitizer events compared to the expected number of HH opportunities, based on the WHO/CDC guidelines; hospital size and type; unit type; hourly patient census; and staffing ratios. The system’s accuracy has been validated in published research."3

In a case study of a 500-plus bed hospital outside of Chicago that used DebMed’s system, compliance increased from 32 percent to 62 percent. In another event, a "Six-hospital health system in South Carolina experienced a 22 percent reduction in multidrug-resistant organisms (MDROs) per 1,000 patient-days and 35 percent reduction in MDRO clusters per 100 units after implementing the WHO Five Moments standard and installing the DebMed GMS."

Hill-Rom’s Hand Hygiene Compliance Solution uses locating technology

To determine which system is best for your facility, Hussain, Hill-Rom, said "Look for a solution that automates HH events 24/7. It is equally important to ensure that alerts are generated to highlight noncompliance, so that lack of compliance to HH protocols is handled in real-time. Finally, many systems can generate reports, but reports are most useful when available in real-time. They need to report compliance by role, by location, by individual, and by team."

"Observation methods tend to lead to compliance scores being falsely inflated and don’t provide alerts to noncompliance," noted Hussain. "With the Hill-Rom solution, compliance is monitored 24/7, with no change to clinical workflow, and caregivers are actively alerted to potential missed opportunities, giving them the ability to address missed opportunities in real time."

Hussain explained how their system works. "Hill-Rom’s system generates reports at an individual level, unit level, and by title. Events also can be generated by location. Hill-Rom’s solution measures the caregiver’s compliance to entry and egress from the patient room and alerts caregivers of missed HH events. Hill-Rom’s Hand Hygiene Compliance Solution 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 staff tags."

Hill-Rom’s RTLS system fits inside of Ecolab’s touch-free Nexa dispenser.

Littau, Ecolab Healthcare, talked about how Hill-Rom and Ecolab Healthcare work together on HH compliance issues. "Last year, Ecolab Healthcare and Hill-Rom announced a partnership to provide integrative HH solutions for the healthcare market. The Hill-Rom Hand Hygiene Compliance Solution features Ecolab product and dispensers that work with the Hill-Rom RTLS to monitor HH compliance. The system continually monitors the patient-care environment, reminds personnel about critical handwashing events, and provides data to drive improved compliance."

Outlining advantages of an electronic system, Littau said, "Some of the challenges of direct observation include auditor bias, small sample sizes, and unequal representation of auditing during different shifts. With an electronic monitoring system, HH events are captured 24 hours a day, 7 days a week, sample sizes are large, and there is no bias, as anyone wearing a badge is treated equally."

"The WHO 5 Moments are the generally accepted standard to which hospitals train their staff relative to HH. Moments 1, 4, and 5, before and after touching a patient and after touching patient surroundings, usually can be measured via electronic monitoring methods. Moments 2 and 3, before aseptic procedure and after bodily fluid exposure risk, are more complicated and difficult to measure; however, they are no less critical."

All hands on deck

With all the options available, Littau recommended determining how to get the most for the money in an HH surveillance system. "Facilities should consider how to get the best return on the investment they will be making in a tracking system and determine if the investment can be leveraged for multiple uses. For example, many systems can handle a variety of applications such as HH compliance, asset tracking, environmental monitoring, and nurse call."

Amna Handley, SafeHaven Sales Director, Georgia-Pacific Professional, Atlanta, GA, considered the importance of engaging leaders of departments involved in, and affected by, the execution of a new HH surveillance system. "It is best to use an interdisciplinary approach, involving key stakeholders such as nursing, the infection control department or committee, environmental services, engineering, information technology, and materials management. Each department will have an interest in the decision-making process. The hospitals that have the greatest track record of success with SafeHaven are those whose leadership and management team are able to help drive a cultural shift and behavioral change among participants," explained Handley. "We have a support program to help facilitate this which, together with the technology and the hospital management team, can help create the level of engagement necessary for success."

Georgia-Pacific’s SafeHaven Automated Hand Hygiene Monitoring system featuring enMotion dispensers and sanitizer.

Handley described how the SafeHaven system works. "SafeHaven measures the entry and exit of every associate who is wearing a badge. It captures HH performance within time parameters that are customized to fit the hospital’s HH policy. The technology is capable of detecting when soap versus sanitizer is being used, which can be very helpful in tracking HH compliance during Clostridium difficile outbreaks. It measures dispensed volumes and can alert environmental services for replenishment so that no dispenser ever goes empty. Reports can be customized to meet the needs of the HH program—by individual, disciplines, or units, enabling facility leadership to help make real-time process changes to improve adherence performance and patient outcomes.

"The volume of HH events captured by the SafeHaven system provides actionable data that is statistically significant, objectively gathered, and a more credible view of HH participation in a facility. In a 3-month hospital trial conducted in a medical-surgical unit with 38 beds, the SafeHaven system captured 165,000 HH dispenses (independent research commissioned by Georgia-Pacific and Versus Technology, March-June, 2014)," noted Handley. "Caregivers tell us the system fosters increased mindfulness of HH, because they are aware of its presence at all times through strategic placement of dispensers, educational signage, and updated staff reports."

David Sellers, President, Proventix Systems Inc., Birmingham, AL, emphasized the necessity of cultural change when instituting a new HH surveillance system. "Leaders and patient-care teams should assess their commitment to do the work necessary to improve. Improvements are not achieved by simply installing a monitoring device. It comes only with a dedicated and consistent application of performance data derived from the system. We advocate a multi-factorial approach that includes visible, active leadership; an education and awareness campaign; clear goal setting; and consistent, transparent communication of progress toward team and individual goals."

The Proventix nGage application includes
a robust suite of reporting tools. 

Sellers explained how the Proventix system measures HH performance. "The Proventix nGage application includes a robust suite of reporting tools. Standard HH compliance reports stratify data by department, team, role, location, and individual. Users can drill down into specific patient-care events and individual hand cleansings. Dispenser-use reports include soap and alcohol-based hand-rub dispenses by device and location. Caregiver rounding reports enable managers to ensure hourly rounding. Healthcare-associated infection (HAI) tracking tools allow infection preventionists to compare HH trends to infection trends at the unit level. Graphing tools provide a variety of data display options, and all reports are exportable to common spreadsheet, slide presentation, and word-processing applications. Proventix also provides role-based benchmarking of similarly matched units, including comparisons of nursing and medical-staff teams, as well as ancillary services such as laboratory, radiology, physical therapy, and environmental and food services."

A clinical team, comprised of infection preventionists, nurses, public-health experts, microbiologists, and healthcare executives, provides ongoing education and guidance, to ensure HH data is translated into improved care at bedside. "Incremental goals are set and systematically reached through the application of a variety of educational and behavioral modification tools," said Sellers. "Sustainable HH compliance is attained by gradually changing the culture and making adherence to HH an ingrained, habitual activity."



1. Chassin M, Mayer C, Nether K. Improving hand hygiene at eight hospitals in the United States by targeting specific causes of noncompliance. The Joint Commission Journal on Quality and Patient Safety. 2015;41(1):4-12. http://www.jointcommission.org/assets/1/18/JQPS_1_15.pdf. Last accessed February 2, 2015.

2. Chassin M, Nether K, Mayer C, et al. Beyond the collaborative: spreading effective improvement in hand hygiene compliance. The Joint Commission Journal on Quality and Patient Safety. 2015;41(1):13-25. http://www.jointcommission.org/assets/1/18/JQPS_1_15.pdf. Last accessed February 2, 2015.

3. Diller T, Kelly JW, Blackhurst D, et al. Estimation of hand hygiene opportunities on an adult medical ward using 24-hour camera surveillance: validation of the HOW2 Benchmark Study. Am J Infect Control. 2014;42(6):602-607.