2024 HH columns – Healthcare Hygiene magazine

Pathogen Tracking and the Information Superhighway

By Robert P. Lee

This article originally appeared in the December 2024 issue of Healthcare Hygiene magazine.

How do you track pathogens in your healthcare system? If you use technology, does it have this functionality? There are digital technologies that utilize state-of-the-art data capture functionalities to capture workflow data, process that data in real time using a proprietary data management, mining and logic platform to provide actionable intelligence and predictive analytics and reporting. This platform is focused on the patient, the patient environment and the relationship of hand hygiene compliance, workflow and the environment in which the patient resides.

Current State
Most hospitals subscribe to a proxy of “foam in/foam “or “wash in/wash out” or “entry/exit” as a means of measuring hand hygiene compliance. Both the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) recommend a methodology that focuses on approaching the patient and leaving patient, not the patient room. This is considered to be a “patient-centric” approach versus a “room-centric” approach.

Additionally, both CDC and WHO recommend doing hand hygiene before touching anything in the patient setting/environment. This includes equipment, keyboards, mobile devices, etc., because it is assumed that all surfaces are contaminated. At the present time, no information is being captured from the patient setting/environment.

Future State
Moment 5 (patient environment) in the WHO Five Moments for Hand Hygiene is a key metric that needs to be measured and captured, and the relationship between patient and environment is clearly documented. Technology has the ability to create uniquely defined protection zones within a workflow that will provide important data that will allow us to understand the movement of both healthcare workers and pathogens. Data capture is key to the first step.

Technology can create a list of possible items within the patient environment that includes equipment, IV poles, workstations, mobile devices, fixtures, etc. Each object has a standard criteria that will help with determining the initial risk level of that object, known as a protection zone. Technology can capture expected performance data to provide the optimal state. During the course of the daily activities of healthcare providers, it can combine current performance data to provide a current state. Current performance data might include how often environmental services/housekeeping personnel visited the room or cleaned an item, or how often a healthcare worker visited/entered that protection zone. Also, maintenance data will be provided to help housekeeping, biomedical engineering staff, and others, to insure optimal performance from the hand hygiene dispensers.

The goal is to capture as much data as possible from Moments 1, 4, and especially 5 in the WHO Five Moments for Hand Hygiene, as well as process and report out this information on a real-time basis. It’s also desirable to get the information to move faster than the workflow, to become predictive using evidence-based practice rather than being reactive. The information superhighway of today require that data has to move faster than the workflow.

If you have any questions or needs, you can always reach out to me directly medicaldatamanagement@gmail.com

Robert P. Lee, BA, the CEO and founder of MD-Medical Data Quality & Safety Advisors, LLC, is the senior biologist and performance improvement consultant. MD-MDQSA is the home of The IPEX - The Infection Prevention Exchange, a digital collaboration between selected evidence-based solutions that use big data, technology, and AI to reduce risk of HAIs.

How Effective and Accurate is Your Hand Hygiene Technology?

By Robert P. Lee

This article originally appeared in the November 2024 issue of Healthcare Hygiene magazine.

Hand hygiene (HH) technology is an electronic data collection system that captures, organizes and reports data from healthcare workers and as they perform their daily patient-care tasks. It automates the process often performed by trained specialists, secret shoppers. Secret shoppers are not enough. Experts indicate that one major limitation to monitoring compliance is HH data collection.

Traditionally, “secret shoppers” observe healthcare professionals and document how often they clean their hands going into and out of patient rooms. These observations miss many hand hygiene opportunities inside the room, and it’s a labor-intensive project for what amounts to a limited number of observations.1 When we are observed by others, our behavior and performance is often governed by the Hawthorne effect,2 the principle of greater compliance with expected behaviors when we are monitored. Hence, this approach may, in some ways, compromise the accuracy of the secret-shopper mode of measuring HH compliance.

Insight into HH requires an understanding of hand HH workflow and the steps in patient care that require HH. Before pathogens reach the host/patient, there are many opportunities to decrease the transfer of pathogens to the patient and the patient’s environment. HH science involves both the transfer of pathogens to the patient/host or to the patient environment (an example of this is high-touch surfaces). If patients’ rooms were completely pathogen-free, then entry/exit might be an effective method to prevent and measure HH, but unfortunately, we all realize this is not the case.

There are currently two schools of thought regarding monitoring HH with technology:

Patient-Centric Model

Most available technologies utilize “entry/exit” methodology, assessing HH compliance at room entry and exit. A question to consider: Does measuring HH at room at entry and exit provide the data required to determine an accurate assessment of your HH compliance? Studies show that 70 percent of HH opportunities occur inside the room.3 Technologies that employ entry/exit monitoring do not measure HH within patients’ rooms, even though some may claim otherwise. In most cases entry/exit technology will have you assume that the entire patient room is enough to measure HH compliance, but after reading the Clack study, understanding how pathogens move and some common-sense biology, you should ask yourself the question, “Are we measuring the right thing? How accurate is our data? Do we have a tool that will help us move the needle on healthcare-acquired infections?”

WHO Five Moments for Hand Hygiene

Several technologies actually attempt to measure the World Health Organization (WHO)’s Five Moments for Hand Hygiene approach by placing sensors at the patient’s bed and tracking entry and exit in and out of these patient zones. Most of these technologies are challenged by accuracy, interference and lack of precision in their measurement, rendering data that can be questionable. Additionally, they do not consider other sites and vectors where pathogens may reside and can be transferred to the patient/host by healthcare workers as a result of poor HH within the room. This approach may not provide an accurate assessment of HH compliance. Some examples might be where a healthcare worker sanitizes their hands at the doorway and proceeds to touch a surface in the patient room prior to touching the patient, such as a workstation, computer, tablet, cell phone, chart, doorknob, IV pole, over-bed table, hands of visitors, etc. Another example might be, not only before patient contact, after patient contact. Does the healthcare worker go back and forth within the patient room during the care of patient and touch items and not sanitize their hands? Does HH need to be performed? Would you want to capture this data? Would you want to know if the healthcare worker is performing HH and that they are assisted with technology to remind them to perform HH between these transactions?

Key takeaways include:

• Understand what you want to measure
• Conduct a Lean 6 Sigma audit of your workflow, processes, protocols (current state)
• Develop your optimal design based on science, biology and common sense (future state)
• HH is not a single activity but a series of complex workflow activities
• Technology can enhance and help to sustain HH compliance
• Technologies vary in their capacity to accurately measure and acquire HH compliance data
• Some technologies may allow a more patient-centric approach to HH
• Not just entry and exit, but patient contact inside the patient’s environment
• Potentially capture data in real time 24/7
• Sufficient and accurate data to meet and exceed (desired) your accrediting regulatory requirements
Remember, “zero” is attainable, achievable and our duty to do no harm.
If you have any questions or needs, you can always reach out to me directly medicaldatamanagement@gmail.com

Robert Lee, BA, the CEO and founder of MD-Medical Data Quality & Safety Advisors, LLC, is the senior biologist and performance improvement consultant. MD-MDQSA is the home of The IPEX - The Infection Prevention Exchange, a digital collaboration between selected evidence-based solutions that use big data, technology, and AI to reduce risk of HAIs.

References:
1. https://edhub.ama-assn.org/cdc-project-firstline/pages/5-hand-hygiene-challenges
2. Hawthorne effect. (2024, September 30). In Wikipedia. https://en.wikipedia.org/wiki/Hawthorne_effect
3. Clack L, Scotoni M, Wolfensberger A. et al. First-person view of pathogen transmission and hand hygiene – use of a new head-mounted video capture and coding tool. Antimicrob Resist Infect Control. 6, 108 (2017). https://doi.org/10.1186/s13756-017-0267-z

One Patient’s Challenging Journey Through the Healthcare System

By Robert P. Lee

This article originally appeared in the October 2024 issue of Healthcare Hygiene magazine.

“By all rights I shouldn’t be here,” said my close colleague. A routine colonoscopy went from bad to worse in a hurry. When considering any medical or surgical procedure, how do you choose what facility and what physician will perform the procedure? I would imagine that most of us just accept the physician and site to which we are referred by our primary-care physician. As it is often said, we are more careful from whom we purchase an automobile than how we assess our physician(s) and site of care; however, it can make a difference. Let’s examine some of these considerations based on my colleague’s experience.

My colleague did his homework, as an experienced and careful individual with more than 40 years of healthcare provider experience. He considered the following factors:

Hospital website featured positive news
Word of mouth reflected that the facility was well-respected in the community
Quality scores from the Leapfrog Group indicated an “A” rating
CMS/Medicare database indicated no penalties for infection outcomes and no penalties for adverse outcomes
Surgeon/specialist performance data indicated an excellent performance
What began as a routine colonoscopy was complicated by a perforated colon which rapidly resulted in sepsis and required surgical intervention. I immediately traveled to support my colleague and provide some guidance/patient advocacy during the early days of his hospitalization. Prior to the colonoscopy, my colleague’s weight was 205 pounds, but during these events it had dropped to 135 pounds and he was in critical condition. Fortunately, after a second surgery, his condition normalized. What followed was clearly not a surgical failure but complications that were potentially preventable and resulted in a lengthy hospitalization and two surgeries to address the complications, including a Pseudomonas infection and a decubitus ulcer requiring skin grafting.

In a conversation with the surgeon, he noted, “I did my job, but how can I be let down by the quality of care post-operatively.” This is an important question, as excellent surgery must be supported by excellent pre- and post-operative care to avoid the many potential complications, such as sepsis and decubiti.

So, what were my observations? As a trained consultant and biologist, I think I understand what should have been done or what could have been done to potentially prevent some of the complications in this case. I observed the following:

Quality Processes: Hand hygiene compliance?
Environmental Services: How clean is the patient room?
Nursing Staff: Who and how many times nursing attended to the patient?
Infection Prevention: Any visits? Communications with family?
Nursing Management: Any visits? Communications with family?
Because of the lack of attention for this patient, a professional patient advocate was deployed to provide 24/7 coverage. The patient advocate was instructed to monitor patient activity and advise the family of key events. Additionally, I instructed the advocate to provide the following on each visit: cleaning and sanitizing of all high touch surfaces with disinfectant, monitor and note hand hygiene compliance (both ungloved and gloved)and note when personnel entered and exited the patient space.

What conclusions did I draw from my visit?

Hand hygiene compliance was suboptimal. Having a great deal of experience in this area, I was particularly critical of where/when and how hand hygiene was completed. An estimate during my presence at the bedside was less than 25 percent.
Gloves were used to replace hand hygiene; I did not observe personnel performing hand hygiene prior to or after donning gloves.
In the three days I was present, environmental services personnel never visited or cleaned my colleague’s room.
Regarding staff attention to detail, there were several medication errors noted by family and patient advocate.
It was alarming that the surgeon expressed concern about the post-op care of the patient.
The staff relied too much on technology; my colleague’s bed was equipped with sensing technology designed to prevent pressure ulcers, but more hands on treatment and assessment may have made a difference.
There were no visits by personnel from nursing management, Infection prevention or administration.
The following letter was written to the CEO at this facility: “I want to congratulate you and the XXXXXX Team on your facilities, staff and commitment to excellence.  Achieving ‘A’ Leapfrog scores should be recognized and applauded. I recently had the opportunity to visit your facility for a colleague of mine and spent three days caring for my friend. At the same time, I had the opportunity to observe what an "A" rated LeapFrog hospital does in practice when nobody is observing. So, I did a three-day consulting review.  I would welcome the opportunity to share with you my observations.  Being the best is always wanting to be better, and I know you and your Team want to be the best. Advise and thank you.”

There was no response.

In conclusion, I advise the following:

Do your homework – what you read is not always what you get.
If feasible, find a way to avoid a stay in an acute care setting, and, if required, get out as fast as possible.
Ask your surgeon about outcomes, especially infections.
Depending on your unit, do not be afraid to ask about infection rates.
Ask to see the hand hygiene compliance data of your caregivers.
Create your own quality check list.
Signage for staff, visitors, and everyone, asking them to “wash their hands”
Ask the staff questions that make you comfortable: ask them to show you that they washed their hands, cleaned your room, and sanitized high touch surfaces.
Find an effective patient advocate.
The good news is that the patient is fully recovered and doing well and is back up to 180 pounds.

If you have any questions or needs, you can always reach out to me directly medicaldatamanagement@gmail.com

Artificial Intelligence and Hand Hygiene

By Robert P. Lee

This article originally appeared in the August 2024 issue of Healthcare Hygiene magazine.

In discussions with our nursing team, I was reminded that at the onset of their careers they operated off the “buddy system” and nursing was a team sport -- each nurse with a partner who complimented their provision of care. This is now unusual, as nurses today typically manage increasing numbers of patients a shift without any buddy system. Additionally, numerous travel/temp nurses are required to maintain operational efficiency. These factors challenge quality and safety standards with removal of checks and balances in the system. How do we reinsert these checks and balances back into the system? Is artificial intelligence (AI) a potential solution? Let’s explore these issues.

In simple terms, AI is a natural extension of computers, now automated and expedited to gather information but, of importance, analyze that data as well. AI can assemble all the data and consider the relationship of this data to outcomes. With this new ability, AI can predict expected outcomes. AI can create algorithms with the data, both accelerating the analysis and actually providing solutions based on the data.
Let’s review some definitions of terms related to AI.

Artificial intelligence is comprised of computer systems that perform tasks that previously required human input, for example, visual perception, speech recognition, and decision-making. Usually involves pattern recognition then followed by an action or a decision [I think it is more than pattern recognition, but rather analysis and decision-making capacity, i.e., analyzing and acting on the data with proposed actions, unrelated to human analysis.]

Machine learning is a subdomain of AI. The computer system “learns” from datasets to make predictions and recommendations about new data, as opposed to executing a set of programmed rules. In classic machine learning, programmers design and tune these algorithms.

Deep learning is a subdomain of machine learning. The computer uses a mathematical structure inspired by neural networks to learn from very large datasets to make predictions about new data. The neural network builds the algorithms automatically by finding novel relationships between inputs and outputs. The algorithms cannot be analyzed by humans as they involve millions of small decisions about data.1

With the advent of hand hygiene technology and real time location systems (RTLS), we now have real-time workflow data, specific to individuals, spaces, assets, and equipment, which is highly accurate and simultaneously provides this data 24/7. As this data is linked to electronic medical records/electronic health records (EMRs/EHRs), we now have patient and facility health data at our fingertips. These linked data bases allow AI to develop algorithms that can provide timely, accurate and precise information, allowing decisions and actions to be predictive rather than retrospective

I remember when computers were introduced to our medical research lab where I worked at Tufts New England Medical Center in the late 1960s. Receiving one of the first IBM boxes at the cancer research lab, the chief researcher said to me, “Figure this thing out.” I and fellow co-op colleagues spent days on this project using all the punch cards to determine the computer’s capabilities and how it could bring value to the laboratory.

Data is the new currency in the marketplace and AI is the next evolution in computer technology, an exponential change and potential advance. Hand hygiene technology is helping us to gather and harvest this data and AI should allow an increase in the speed and analysis of the data with much more informed and timely decisions. When a healthcare provider uses hand hygiene technologies, it is like the “buddy system” discussed above. The badge technology gathers the data and the internal algorithms help to interpret this data, providing feedback, reminders, reporting and analytics that is equivalent to a buddy system. Additionally, if you are still using secret shopper to audit, train and educate your staff, hand hygiene technology and AI will bring you into the 21st century, not only discarding the clipboards and notepads, but providing real time analysis and direction of the appropriate actions based on the data.

We are all challenged at times by the increasing monitoring of our every action, whether via video monitors in our communities or the data collected during our professional endeavors in the health care arena. However, this will certainly continue as it provides information essential to improving patient care, whether diagnostic assessments or infection prevention endeavors. The key is using the information not in a punitive or negative feedback loop but rather information to improve our performance around preventing health care associated infections. I doubt anyone in the infection prevention arena would argue that we cannot do better, and the hope is that AI and informed, prospective decisions will provide a more effective armamentarium to take the next step.

A recent study at Stanford University assessed the application of automatic detection of hand hygiene using computer vision technology, a critical step in the development of novel ways to apply AI-based monitoring to improve patient care and safety. The lead author notes, “The potential is really limitless when you are monitoring something continuously and automatically. It is time for hospitals to start investing in autonomous monitoring and discovering the benefits.” 2
There were many lessons learned both during and after the COVID pandemic. Our processes and systems could not keep up with the amount of generated data that required analysis and action. One example was contact tracing capabilities. How did we acquire the information? How robust? How timely? This was basically a manual process with manual analytics and analysis. With technology and AI, this could have been as simple as the touch of a button, with consequent knowledge of pathogenic pathways, contact points and direction of pathogen spread, locally, nationally, and globally. As previously discussed, proactive rather reactive infection prevention could have allowed us to predict, prepare and respond more effectively.

Hand hygiene is the most effective method to prevent the spread of pathogens. Technology and AI are significant steps forward to help us move the needle. Data capture, even if incomplete is of value; however, with more effective capture via technology and real time analysis and data directed action via AI we can take an exponential leap forward prevention of health associated infections. We are not there, and there is yet necessary analysis of AI direction to deal with its potential deficits and errors. However, there is little doubt that AI is being utilized in many areas of health care and this utilization will no doubt continue. As infection prevention is so data based, it is clear it will provide critical value to the infection prevention community. The more data and the more interoperability of this data, the more predictive we can be with understanding and preventing pathogen transmission.

So, I close with some final questions. Could big data, technology and AI be the answer to the HAI (hospital-acquired infection) challenge? Could digital be an alternative to a pharmacological solution, eliminating unintended consequences and side effects? Could digital be our 1st line of defense when we encounter our next pandemic?

References:
1. Fitzpatrick F, Doherty A and Lacey G. Using Artificial Intelligence in Infection Prevention. Curr Treat Options Infect Dis. 12, 135–144 (2020). https://doi.org/10.1007/s40506-020-00216-7
2. Singh A, Haque A, Alahi A, Yeung S, Guo M, Glassman JR, Beninati W, Platchek T, Fei-Fei L and Milstein A. Automatic detection of hand hygiene using computer vision technology. J Am Med Informatics Assoc. Vol. 27, Issue 8, August 2020, Pages 1316-1320. https://doi.org/10.1093/jamia/ocaa115
3. McGaghie WC, Issenberg SB, Cohen ER, Barsuk JH and Wayne DB. Does simulation-based medical education with deliberate practice yield better results than traditional clinical education? A meta-analytic comparative review of the evidence. Acad Med. 2011;86(6):706–11. https://doi.org/10.1097/ACM.0b013e318217e119.

How Hand Hygiene Data Can Save Lives

By Robert P. Lee

This article originally appeared in the July 2024 issue of Healthcare Hygiene magazine.

Data is the new currency in the marketplace, including the potential impact of artificial intelligence (AI). Focusing on hand hygiene (HH), how does HH data potentially save lives? Electronic health records (EHRs), connectivity, interoperability, AI, actionable intelligence, real-time, prospective, retrospective, etc., are the terminology of the moment and probably the future, the result of its unlimited potential to solve our most complex problems in both business and our focus, healthcare. What do these terms have in common? Data should be accurate, robust, trusted, universal, common language, etc. Data is the common thread in our maize of processes and systems designed to facilitate our decisions. We see significant efforts to address our challenges in ERP, EHR, remote monitoring, home health, etc. What about infection prevention, HH data, and the potential of compliance data?

A major challenge is the ability to automate the process of data input with the resultant digital strategy. Clinical teams can spend up to 50 percent of their time inputting data into the various systems. Can technologies such as voice recognition, scribes, automated data entry and AI analysis relieve this burden?

What is the potential impact of the coming wave of HH technology? We have seen the benefits of real-time location systems (RTLS) technology, but have you considered “real-time location” for your human assets? Each human asset could have its own unique wearable sensor that provides location, time stamp and identification real-time, completely automated. Current HH technologies compile this data and translate it to HH compliance scores, accurate robust, real-time and automated.

How can an automated HH system be effectively utilized? First, your HH data is collected real-time, simultaneously with other units, 24/7, across the spectrum of care and free of the Hawthorne effect. This contrasts with a manual system such as secret shopper, limited in scope, time of collection, and requiring personnel to collect the data. Statistically, data captured in 30 seconds using technology is far more accurate and robust than a complete secret shopper engagement.

A client described its use of HH data to provide location data on physicians within a large integrated delivery network (IDN). By knowing their location and time with patients, they were able to more effectively schedule resources, visits and care for the patient, physician and staff. Additionally, they linked their data to a patient room audiovisual that provided the patient with the physician and staff names and titles as they entered the room.

Additionally, one company has experimented in linking its hand hygiene system to other departments like environmental services (EVS), dietary, lab, radiology, and others, with the goal to provide real-time data on the clinical and operational health of the facility. Imagine a facility dashboard that provides room clean status, HH compliance by room and healthcare worker, air clean status, and location status equipment for that room.

Why is it important to know your facility’s health? What if this data was available in a consolidated, automated platform where you could see IDN, acute-care, non-acute care, department, unit, and individual assets, both human and technologic? What might be the benefits? Consider:
• Pandemic preparedness
• Contact tracing
• Performance improvement data
• Automated infection prevention and epidemiology
• Connectivity – acute, non-acute, other
• Efficiencies – improves workflow
• Patient satisfaction
• Reduction in the risk of healthcare-associated infections (HAIs) and antibiotic resistance

HH technology provides not only compliance but potentially a methodology to drive greater performance, efficiencies and cost savings for your business entity and, most importantly, improve patient care and facility health (as previously defined).

Data is the new currency in the marketplace.

If you have any questions or needs, you can always reach out to me directly medicaldatamanagement@gmail.com

Facility Health and Hand Hygiene: Economic and Operational Status

By Robert P. Lee

This article originally appeared in the June 2024 issue of Healthcare Hygiene magazine.

Facility health is a collective term introduced here to describe the state of quality and safety, both operationally and financially, for a healthcare site that addresses the continuum of care from IDN, acute care, non-acute care, clinics, offices, nursing homes, etc.

Why is facility health an important consideration as a consumer/patient and/or as a service provider? Would you fly an airplane, travel into space or even drive a car without the proper indicators and data? As a consumer, would you choose to place your family’s health in the hands of a provider that does not have this information? Or is the information available but not shared?

Facility health is based on the principle that certain key processes, protocols and activities that are clinically and evidenced-based should be performed simultaneously and delivered without exception. Their purpose is to reduce the overall bioburden of potential pathogens within a facility. Hand hygiene compliance is critical to the maintenance of the lowest bioburden possible and the prevention of the movement/migration of potential pathogens. Key components of facility health are environmental management initiatives to ensure:
• Patient rooms are cleaned/sanitized daily
• Medical equipment and devices are properly cleaned and processed between use
• Hand hygiene compliance is monitored for healthcare personnel, support staff, visitors
• All non-patient spaces are sanitized, including nursing stations, break rooms, supply storage, etc.
• Incorporation of a high-touch cleanse as part of nursing turnover process

Internally, these are easy boxes to check. However, more importantly, how do you measure performance and assess if your processes are enhancing quality and safety? Typically, the key performance indicators (KPIs) are not widely shared in an organization and are usually an “eyes only” event, meaning that only certain individuals might see or have access, such as risk management, human resources, legal, and key administrators.

There is some assessable public/published data from the Centers for Medicare & Medicaid Services (CMS) and The Leapfrog Group that can provide some information regarding your facility’s performance. This can be put into dashboard format and serially updated.

These example dashboards provide a snapshot of infection reported to CMS (12 months in arrears) and the Leapfrog Group scores for these hospitals.
This integrated delivery network (IDN) will spend $83 million over five years servicing infections, based only on data reported to CMS.
What is this facility’s health?

Creating Accountability and Doing the Right Thing in Hand Hygiene

By Robert P. Lee

This article originally appeared in the May 2024 issue of Healthcare Hygiene magazine.

What is accountability? It is doing what you are supposed to be doing at the right time and the right place. With respect to something as simple as hand hygiene, it is performing this procedure of sanitizing your hands because it is good for the patient, your teammates and yourself. This should be accomplished without someone (secret shopper) or something (technology) looking over your shoulder. It should be something you do because you need to be accountable to yourself. This is not like cheating on an exam. When you cheat here, people get sick and die.

How does one create a culture of accountability? Accountability is a basic leadership principle that successful leaders need to prioritize in their organizations. Accountability is the obligation to others that you are going to what you say you are going to do. I found this model that highlights key components of accountability: https://www.leadingwithhonor.com/engage-with-honor-main/

How does this apply to hand hygiene? For a long time, we have known that this simple, fundamental process reduces the risk of infection, but we have not embraced the idea that we must be personally accountable to ourselves for our knowledge, performance and transparency. Once we embrace “personal accountability” we can begin to entertain new ideas to help us deliver on our promise and that will allow us to answer the following questions:

• If using technology to help us be more accountable, does your technology measure “real hand hygiene compliance”?
• If using secret shopper, does your secret shopper program measure “real hand hygiene compliance”?
• Hand hygiene audits of your process as recommended by the Leapfrog Group, how accurate and what is the variance?
• Are you measuring just nursing? Why not visitors, supporting departments like EVS, Dietary, Lab, Radiology, etc.?
• Does your data connect to your EMR? Is it real-time? Actionable?
• Does your data correlate with your rate of HAI (hospital acquired infections)?
• Do you measure “facility health”? Facility health equals hand hygiene compliance plus EVS compliance

Accountability must be the culture within an organization. Leaders in an organization should not accept excuses. We hear dozens of excuses from staff when engaging in a hand hygiene process improvement project of why they can’t embrace this accountability , from “I don’t want big brother watching me” to “my hands get chapped with too much hand hygiene” to “I am good and too busy.” Well, when hand hygiene compliance is still between 25 percent to 38 percent average when measured correctly, we have a great deal of opportunity to improve, and it starts with personal accountability.

Next month we will address how to use the data from hand hygiene projects.

If you have any questions or needs, you can always reach out to me directly medicaldatamanagement@gmail.com

Robert Lee, BA, the CEO and founder of MD-Medical Data Quality & Safety Advisors, LLC, is the senior biologist and performance improvement consultant. MD-MDQSA is the home of The IPEX- The Infection Prevention Exchange, a digital collaboration between selected evidence-based solutions that use big data, technology, and AI to reduce risk of HAIs.

Hand Hygiene Compliance: A Common Sense Approach

By Robert Lee

This article originally appeared in the April 2024 issue of Healthcare Hygiene magazine.

We have all heard that hand hygiene is the most effective intervention to prevent both infection and the dissemination of potential pathogens to other patients and the healthcare environment. Hand hygiene is not simply washing and/or sanitizing your hand, but it is a conscious, intentional effort, knowing where, when, and how to maintain safe, pathogen-free hands.

While attending the 2024 HIMSS and AORN annual meetings, I had the opportunity to interview a number of individuals from the technology, data and clinical sectors to attain their perspective on hand hygiene. Three issues emerged from these conversations:

Hand hygiene has once again been pushed to the back of the line as a prevention priority
Hand hygiene compliance remains an elusive target
The standard for hand hygiene compliance is a minimal standard
As one technology executive noted, “The market only wants a minimum standard. Just checking the box is acceptable. We are looking at return on investment (ROI), not healthcare-associated infection (HAI) reduction.”

So, what is hand hygiene compliance and why is the bar set so low? Reports of compliance at different sites vary from 15 percent to 95 percent. What level of compliance will allow your unit to operate safely, pathogen-free and decrease the incidence of HAIs? One chief medical officer said, “If hand hygiene compliance is measured properly, could 70 percent be the optimal, efficient and cost-effective metric for our staff?”

Compliance is establishing a process, adhering to that process, and measuring adherence to that standard. HAI is the measurement of your established workflow in digital terms, expressed as a fraction, the denominator total identified opportunities and the numerator the actual observed hand hygiene events, usually calculated and reported as a percentage.

Total HH opportunities (denominator) includes touch points in the workflow where hands come in contact with personnel or objects in the environment. Examples include but are not limited to charts, IVs, cell phones, tablets, workstations, doorknobs, patients, etc., anything that might harbor pathogens. This applies whether a healthcare worker is or is not wearing gloves.

Observed hand hygiene events completed (numerator) is the number of events where hand hygiene is indicated/required and successfully completed.

What are the challenges associated with calculating hand hygiene compliance?

HH science and HH compliance may differ from unit to unit, care team and/or workflow.
Measuring HH compliance with an entry-exit process does not consider activities and potential pathogen hand contact that occurs inside the patient care space after entry HH.
Some institutions state they measure hand hygiene compliance during patient care, including contact with the surrounding care space but actually only measure entry and exit.
Many institutions state they do not have the ability to measure hand hygiene compliance inside the patient care space.
Many institutions do not clearly understand their workflow and have not standardized it using Lean/6 Sigma principles (denominator).
Many institutions indicate they just check the box and accept a minimal standard.
Questions to consider regarding the effectiveness of your hand hygiene compliance program: Do you know what you are measuring? Are you measuring the correct components of hand hygiene? Are you just conforming to minimal standards and checking the box?

Hand hygiene is a science, defining how the hands of healthcare personnel interact with the patient and their environment during daily patient care. As I have noted previously, pathogens do not have legs, we give them legs. Understanding how pathogens move, providing barriers to mobility by appropriate hand hygiene at the correct time and place, coupled with excellent surface and environmental disinfection, will move the needle to decrease HAIs and antibiotic resistance.

A common sense roadmap:

Understand your workflow
Workflows differ by unit/department/provider
Design the most efficient workflow to allow your staff to provide optimal care
Identify the key hand hygiene touchpoints in your workflow
Ensure your dispenser infrastructure is as close to these touch points as possible
Design your hand hygiene process based on current guideline (5 Moments) and common sense
Ensure your process addresses both gloved and ungloved hands
Train/educate/reinforce specifically to your defined workflow and hand hygiene protocols
Utilize your simulation center if available
Measure performance and report as close to real-time as possible
Design a certification program that defines performance standards for each unit
Currently, the science of hand hygiene education and training is suboptimal and too general. Staff do not have time to think about when, where and how to perform hand hygiene. It must be ingrained, become habit and be a conscious activity.

Please don’t hesitate to reach out to our Team at THE IPEX (The Infection Prevention Exchange) for any questions or guidance at <medicaldatamanagement@gmail.com

Education, Certification, Compliance: A Day in the Life of a Patient Advocate and Observer

By Robert P. Lee

This article originally appeared in the March 2024 issue of Healthcare Hygiene magazine.

Recently, I visited a seriously ill, hospitalized friend and colleague. He and I have collaborated on numerous projects in our careers and both of us knew the dangers of spending too much time in a hospital bed. The hand hygiene observed during my 48-hour visit seems all too common and acceptable at many hospitals. The medical staff was very professional, and I admired their responsiveness, care and empathy.

In this discussion, I will focus on the staff hand hygiene and its execution I observed during my visit. Of note, this hospital has an A rating from the Leapfrog Group.

Environment:
• Hand hygiene gel dispensers were deployed outside each room
• A second hand-hygiene gel dispenser was deployed just inside the doorway
• Soap dispenser but no gel dispenser at the sink
• No gel dispenser in the bathroom

Observations:
• Could not validate that each healthcare worker sanitized upon entry
• Some healthcare personnel sanitized upon exit
o Nursing often did “fly-bys,” attempting to sanitize but not properly activating the dispenser
o Physicians were not observed sanitizing upon exit
• Healthcare workers often touched IV station, workstations, etc., but no consequent hand hygiene prior to patient contact
• No hand hygiene prior to donning gloves or after gloves were removed
• Gloved healthcare personnel touched IV station, workstations, etc., without changing gloves prior to touching the patient
• No healthcare personnel used soap/water at the sink
• No environmental services (EVS) visits to perform a room cleaning or a cleaning of high-touch surfaces
• Nursing did not perform a high-touch cleaning
• High-touch cleaning was performed by family and the patient advocate
• Advised by nursing staff that this unit was one of the highest performing regarding hand hygiene.

Clearly, my observations suggested issues with compliance as well as with education and training. It was my impression that the staff were not reluctant to perform hand hygiene, and even welcomed their recognition as a high performing unit. However, as noted above, there appeared to be significant gaps in the staff members’ understanding of appropriate hand hygiene. What education and training could address the observed deficits? Here are some suggestions:

1. Establish and reinforce where and when hand hygiene is required during patient care:
a. WHO 5 Moments (entry/exit is inadequate)
b. Environmental contact prior to patient contact requires hand hygiene, even if hand hygiene occurred at room entry, and much like requirements in the operating room (OR), glove contamination requires re-gloving.
c. Develop a planned workflow: If you touch parts of the environment before patient contact, realize that this will require repeat hand hygiene.
i. Am I going in to adjust the IV pumps?
ii. Am I going to log into the electronic health record (HER)?
iii. Am I going directly to the patient?
iv. Will I be gloving?
2. Establish a high-touch surfaces protocol:
a. High-touch cleaning is required daily.
b. Define who will perform this cleanse, the healthcare worker or EVS personnel

Training/Education/Certification

Clearly, education and training is critical, and the best way to learn is through observation, where errors become valuable teaching opportunities, whether in a simulation center (if available) or observation and training at the bedside. Requiring each staff member to demonstrate knowledge and competence in appropriate hand hygiene during patient care via a practicum each year and consequent certification would assure a well informed and competent staff regarding hand hygiene. Technology can provide significant assistance with observation real time, with electronic monitoring and/or videotaping patient encounters to provide feedback and education as noted above.

Additionally, I would hope that the Leapfrog Group would enhance their survey to include EVS and high-touch surface protocols, just as they enhanced their hand hygiene protocols and guidance over the years.

Exceptional hand hygiene does not just happen and requires investment to support training that results in the outcome we all strive for, reduction in healthcare-acquired infections (HAIs).

Robert Lee, BA, the CEO and founder of MD-Medical Data Quality & Safety Advisors, LLC, is the senior biologist and performance improvement consultant. MD-MDQSA is the home of The IPEX- The Infection Prevention Exchange, a digital collaboration between selected evidence-based solutions that use big data, technology, and AI to reduce risk of HAIs. Lee may be reached at: medicaldatamanagement@gmail.com

Why is Exceptional Hand Hygiene Compliance Not More Effective in Reducing HAIs?

By Robert Lee

This article originally appeared in the February 2024 issue of Healthcare Hygiene magazine.

Your facility reports hand hygiene compliance of greater than 90 percent, ranked as one of the best by your state for environmental services (EVS), and your Leapfrog Group grades are all As. If this is your integrated delivery network (IDN) or hospital, one might ask why patients continue to acquire an infection during and after their visit to your hospital. The Centers for Disease Control and Prevention (CDC) reports, “Each day, approximately 1 in 31 U.S. patients and 1 in 43 nursing home residents contracts at least one infection in association with their healthcare, underscoring the need for improvements in patient care practices in U.S. healthcare facilities. While much progress has been made, more needs to be done to prevent healthcare-associated infections in a variety of settings.”1

Fast forward to 2023 and the post-COVID era, where rather than a decrease, there was an increase in HAIs last year despite our intense focus on universal precautions. Is hand hygiene compliance, environmental cleaning, and other interventions ineffective or is reporting inaccurate?

Focusing on hand hygiene compliance, the CDC reported that the average hand hygiene compliance in the U.S. is less than 40 percent.2 The goal of hand hygiene is to eliminate or greatly decrease microorganisms on hands and thereby prevent or significantly decrease the transmission of these potential pathogens to patients. If hand hygiene is performed before entering a patient’s room and soon after there is hand contact with a cell phone, tablet, bedrails, etc., hands can become colonized with microorganisms present on those other surfaces, and, of course, potentially spread those organisms to the patient if no hand hygiene is performed in the interval before patient contact.

Clack, et al. (2017) found that hospital personnel contaminated their hands by touching surfaces in the patients’ room within 4.5 seconds post entry.3 Therefore, even though compliant with hand hygiene prior to room entry, contamination occurred during non-patient environmental contact prior to patient contact. Returning to the preceding discussion, if your institution’s hand hygiene compliance score is 99 percent but you have environmental contact soon after entering the room before patient contact, what is the efficacy of such exceptional compliance in infection prevention? Consider behavior in the operating room; if anyone on the surgical team contaminates their gloved hands, an immediate glove change is required before any further contact with the patient, sterile instruments, or the surgical field. In surgery, hand hygiene guidelines are strictly enforced even after entering the patient’s space, in contrast to the behavior that often occurs in other patient-care areas.

What steps can be taken to adjust to this data and prevent hand contamination prior to patient contact? One obvious consideration in measuring hand hygiene compliance at the point of care (POC) rather than the doorway. Adding dispensers inside the room and improving training to change behavior to be more consistent with what occurs in the operating room where any break in technique requires re-gloving at a minimum would be a start. A torn or damaged glove in the OR requires repeat hand cleansing and re-gloving; the same approach to regular patient care would move us closer to more effective hand hygiene where it really matters (POC) and potentially enhance the outcome of all these efforts, a decrease in HAIs and improved patient outcomes and care.

Of course, this is not the only intervention or factor impacting HAI, but one of the factors within our control. Other considerations to enhance infection prevention include high compliance with environmental cleaning and disinfection, visitor and patient hand hygiene compliance, and controlling antibiotic use, etc. No single intervention alone is appropriate but rather, as noted by the Society for Healthcare Epidemiology of America (SHEA), a global and “horizontal” approach to the infection prevention interventions is within our control to achieve the ultimate outcome, reducing HAI.4

References:
1. CDC HAI Progress Report. 2022. https://www.cdc.gov/hai/data/portal/progress-report.html
2. CDC Hand Hygiene Core Guidelines. https://www.cdc.gov/handhygiene/download/hand_hygiene_core.pdf
3. Clack L, Scotoni M, Wolfensberger A, Sax H. "First-person view" of pathogen transmission and hand hygiene - use of a new head-mounted video capture and coding tool. Antimicrob Resist Infect Control. 2017 Oct 30;6:108. doi: 10.1186/s13756-017-0267-z. PMID: 29093812; PMCID: PMC5661930.
4. Septimus E, MD, Weinstein RA, Perl TM, Goldmann DA and Yokoe DS. Commentary: Approaches for Preventing Healthcare-Associated Infections: Go Long or Go Wide? Infection Control and Hospital Epidemiol. Vol. 35, No. 7, July 2014.

How Important is Hand Hygiene in the Use of Gloves, Masks, Surgical Drapes and Gowns, and other Medical Devices?

By Robert Lee

This article originally appeared in the January 2024 issue of Healthcare Hygiene magazine.

Infection prevention is not a singular intervention; as Septimus, et al. (2014) note, multiple interventions implemented simultaneously is recommended. And as Wohrley and Bartlett (2018) observe, “Horizontal strategies seek to broadly reduce the burden of common healthcare-associated pathogens including S. aureus, Enterococcus, gram-negative bacteria, and Candida through interventions such as hand hygiene and environmental cleaning.”

As a result, it is very difficult to determine the cause and effect of each intervention. We know that hand hygiene is a key component, but high levels of hand hygiene compliance do not always result in infection rate reduction. Why?

In this article, I consider the relationship between hand hygiene and medical devices such as gloves, masks, surgical drapes/gowns, etc., as well as explore how this relationship reduces or accelerates the risk of infection transmission.

Gloves
Why do you wear gloves and when do you perform hand hygiene? According to the Food and Drug Administration (FDA), “Use medical gloves when your hands may touch someone else's body fluids (such as blood, respiratory secretions, vomit, urine, or feces), certain hazardous drugs or some potentially contaminated items. Hand hygiene should be performed prior to and after removing gloves. Unfortunately, gloving has been used as a substitute for hand hygiene. Gloving protects the wearer, but improper glove use can result in pathogen transmission from patient to patient, patient to surfaces, etc. When reminding staff on how to use this medical device, many acknowledge and are appreciative, but an alarming number demonstrate that their only concern is their own protection.”

Masks
So, did you know that masking can both help prevent transmission of microorganisms or can accelerate the transmission of such organisms? You must ask which microorganism/pathogens you are trying to address. Is it viral or bacterial? Most masks are designed for bacterial not viral protection. Unless you are using a sheet of plastic, viruses will permeate your mask. Bacteria and viruses use vehicles such as liquid, moisture, particulate matter, blood, bodily fluids, even airborne dust, as well as hand contact, etc. So, if you are trying to prevent viral transmission, as in SARS-COV-2, and you are not sanitizing your hands, touching your face, your cell phone, and your mask, then you may be risking viral contamination. We are told to wear masks, but we are not told how to use this medical device properly. Thus, this can contribute to increased transmission. You must ask yourself, why are we not being told how to properly use masks if they are so effective in reducing the risk of catching and spreading a viral pathogen?

Evidence-based studies show the average individual touches his or her face 23 times per hour (Kwok, et al., 2015). Tajouri, et al, (2021) showed that 45 percent of cell phones carried SARS-CoV-2 during the pandemic. Do you think that individuals performed proper hand hygiene each time they touched their faces or handled their cell phone? Of course not. Think of a couple of common scenarios. How about your children at school who were required to mask, usually with a single mask worn all day. How about members of the public in a grocery store wearing masks and gloves, touching everything in sight and never doing hand hygiene? Watch television and you’ll see public officials or other personalities who are wearing and touching their masks but never doing hand hygiene.

Drapes and Gowns
Over the past 30 years, surgery has demonstrated the importance of barrier material and the science of sterile technique. The same principles as articulated above apply, but the difference in the operating room (OR) is that OR personnel revisit these principles during each case. They also hold each other accountable for maintaining proper technique. Surgical drapes and gowns are manufactured with the knowledge that fluid, blood, particulate matter, and touch are all vehicles for pathogen transmission. Drape and gown technology is focused on fluid penetration barrier performance while balancing comfort and drapeability. Materials are either permeable or impermeable; performance is matched to the expected opportunity for them to encounter blood, fluid, or particulate matter, as well as taking into consideration the length of case, risk of foreign bodies, etc. Even with all this technology, hand hygiene and hand hygiene science are important parts of the sterile process. Should hands become contaminated (usually gloved), rescrubbing may be required and/or re-gloving. Nevertheless, in the OR the hands play a pivotal role in the infection prevention chain.

So, considering the above scenarios, what should we take away from this article?
1. Use your critical thinking skills. Consider both sides of the equation, what is said and what is not said.
2. Understand the science and follow the science. Understand microorganisms and their mode of transmission.
3. Use your common-sense logic.
4. Audit your personal behavior and apply these principles of science and logic.
5. Come to your own conclusions. Don’t blindly accept what is pushed on you by the media.

I ask the question that if hand hygiene is the No. 1 way to reduce the risk of infection, why do we not get the correct guidance on how and, most importantly, when to perform hand hygiene? Additionally, with so many vehicles and modes of transmission of pathogens (cell phones, masks, etc.) with hands at the center, why are we not educated and made aware of how, when, and why hand hygiene is as important, if not more important, than using this medical device (masks, gloves, etc.)?

I am not against the use of any of these medical devices if they are used properly, training and education is provided (how to use and how not to use) and are supported by evidence-based research. Anything short of this I view as medical malpractice. We have been seriously uninformed for whatever reason and, as individuals, we have not assumed our responsibility to use our critical thinking skills to arrive at the proper conclusions. This lack of critical thinking has resulted in the loss of thousands of lives; many who might have been our own loved ones. So, put on your thinking cap and let the science, data and common sense set you free and maybe save your life.

Robert Lee, BA, the CEO and founder of MD-Medical Data Quality & Safety Advisors, LLC, is the senior biologist and performance improvement consultant. MD-MDQSA is the home of The IPEX- The Infection Prevention Exchange, a digital collaboration between selected evidence-based solutions that use big data, technology, and AI to reduce risk of HAIs. He may be reached at: medicaldatamanagement@gmail.com

References:

Septimus E, Weinstein RA, Perl TM, Goldmann DA, Yokoe DS. Approaches for preventing healthcare-associated infections: go long or go wide? Infect Control Hosp Epidemiol. 2014 Sep:35 Suppl 2:S10-4. doi: 10.1017/s0899823x00193808.

Wohrley JD and Bartlett AH. Healthcare-Associated Infections in Children. Springer Nature. Published online July 16, 2018; 17-36. doi: 10.1007/978-3-319-98122-2_2

Kwok YLA, Gralton J, McLaws M-L, et al. Face touching: a frequent habit that has implications for hand hygiene. Am J Infect Control. 2015 Feb;43(2):112-4. doi: 10.1016/j.ajic.2014.10.015.

Tajouri L, Campos M, Olsen M, et al. The role of mobile phones as a possible pathway for pathogen movement, a cross-sectional microbial analysis. Travel Med Infect Dis. 2021 Sep-Oct;43:102095. doi: 10.1016/j.tmaid.2021.102095. Epub 2021 Jun 9. PMID: 34116242.