Pants policies and paranoia

Pants, Policies and ParanoiaDr Stephanie Dancer, NHS Lanarkshire

Pittet D et al, Lancet 2000

The global pursuit of clean hands Slide courtesy of Dr I. Gould

The global pursuit of clean hands• Pittet et al publish sentinel study, ‘Effectiveness of a hospital-wide programme to improve compliance with hand hygiene’, Lancet 2000• Use alcohol gel: UK National Patient Safety Agency, 2004. ‘Patient safety alert: clean hands help saves lives’.• WHO guidelines of hand hygiene in health care, Geneva 2005• ‘Why healthcare workers don’t wash their hands: a behavioural explanation’, 2006• ‘Five moments for hand hygiene’, WHO 2006• Interventions to improve hand hygiene compliance in patient care, Cochrane Review 2007• Educational interventions for prevention of HAI, Systematic Review 2008

Interventions to improve hand hygiene in the UK Cardboard cut-outs; educational packages; extra staff; more managers; hand-hygiene co- ordinators; committees; audits; nice-smelling soaps; UV detectors; antiseptic soaps, liquids and gels; soft towels; signs; talking boxes; stick- on gizmos; prominent hand-hygiene stations; badges (for staff); badges (for patients); more audits; notices; posters; e-mails; conferences; screen savers; Matrons; labels; observers; flyers; more audits; antiseptic containers attached to beds; antiseptic containers in pockets; reminder letters; feed-back; lectures; coloured stickies; more audits; flashing signs; cameras; violation letters; CCTV; more sinks; floor artistry; rewards; covert audits; T-shirts; lollipops; electronic detectors; laser beams; spies beneath beds; sniffer dogs; psychological Photo: BBC counciling; brain washing; torture....

Dept. of Health Social Services 2007; Dept. of Health Guidelines 2007; Scottish Government Health 2008• Bare-below-the-elbows• No wristwatches• No jewellery• No ties• No pens or scissors in outside pockets• No white coats• No leaving work in uniform

And now? ‘Zero Tolerance’..................... Scottish Executive: Zero tolerance to non hand hygiene compliance, 26th January 2009The expression ‘Zero Tolerance’ imparts both the idea of tackling low-levelhygiene misdemeanours and of doing so in a particular way, namelythrough aggressive, uncompromising law enforcement Pollard C, ‘Zero tolerance: Policing a free society’, IEA Health & Welfare Unit, 1998But……….if there are not enough sinks, staff, gel and/or beds, is poorhand hygiene really our fault? Goldmann D. System failure versus personal accountability – the case for clean hands, New Engl J Med 2006 There should be a balance between the system and an individual’s behaviour

Isn’t this ‘Zero Tolerance’?‘’Hospital worker in disciplinary case over hygiene’’, Mail, Sept. 21st, 2010

If there is little justification for ‘Zero Tolerance’, then what is there for hand hygiene?What is the evidence that cleaning hands stops patients getting infections? Reviewing current evidence..... concluded that there is a lack of rigorous evidence linking specific hand hygiene interventions with the prevention of HCAIs Backman et al, Am J Infect Control 2008Patients are still at risk of infection in today’s hospitals despite hugeinvestment in promoting hand hygiene….there must be other factorsimportant for controlling infections that erode the benefits fromimproved hand hygiene Dancer SJ, Leader J Hosp Infect 2010

What about bare-below-the-elbows? 149 medics were randomised into 2 groups; One group was BBE and the other was not; All medics had their hand washing technique evaluated using fluorescent gel There was no significant difference in the overall percentage area missed after handwashing The group wearing white coats did miss significantly more of the wrist area Being bare below the elbows improves wrist washing Do patients acquire hospital organisms from a doctor’s unwashed wrists?‘Bare below the elbows’ and quality of handwashing: a randomized comparison study. J Hosp Infect 2009

Alan Johnsoncleans his handsduring a visit to StMarys Hospital inLondonPhoto: Telegraph, 23 Sept 2008Looking the part………..That’s what it’s about

Are there benefits in using alcohol gel?Introducing alcohol hand antiseptic into a hospital reducedVRE but had no effect on MRSA Larson et al, Behav Med 2000; Lai et al 1CHE, 2006Hand hygiene rates improved dramatically afterintroducing hand gel into two ICU’s, but there were NOchanges in the rates of device-associated infection, orinfections due to multi-resistant pathogens or C.difficile Rupp ME et al, ICHE 2008Excessive use of hand hygiene products is not an efficientway of reducing infections in low-prevalence wards Herud et al, AmJIC 2008Hand hygiene compliance and consumption of alcohol gel doesnot correlate with pathogen transmission in ICU Eckmanns et al, JHI 2006

Does hand hygiene compliance and consumption of alcohol gel correlate with pathogen transmission in ICU’s? Eckmanns et al, JHI 2006

Does alcohol gel aid in the control of C.difficile? No effect! (Boyce et al, ICHE, 2006) Norovirus? Probably not (Lages et al, JHI, 2008) Acinetobacter? Left wondering.... (Edwards et al, JMM 2007; Pittet et al, LID, 2008)Alcohol enhances the pathogenicity of clinical CNS (Milisaviljevic et al, AmJIC 2008)....and vulnerable people drink it (24dash.com, 2008)

Have hand hygiene interventions had any effect on MRSA? S.aureus bacteraemia, HPA 2009

Yes! No! Maybe...........MRSA rates are downBUT – these rates are based upon bacteraemias. How do we know that totalMRSA acquisitions are down? No one is counting these.MRSA bacteraemias surely have reponded to enhanced screening, topicalclearance strategies and intravascular catheter care bundles; but not necessarilyincreased hand hygiene.What a pity meticillin-SUSCEPTIBLE S.aureus bacteraemia rates havebarely changed.If enhanced hand hygiene is responsible for the decrease in MRSA rates, thenwhy have MSSA rates stayed the same, or even gone up?What about C.difficile?HPS Weekly Report 6/10/10; Dancer SJ, J Hosp Infect 2010; Dancer et al, ECCMID 2010;S.aureus bacteraemia, HPA 2010; Orthopaedic SSI 2004-9, HPA 2009

Ceftriaxone consumption and cases and cases ofhospital over a two Ceftriaxone consumption of C.difficile in a C.difficile in a year period hospital over a two year period 90 3.5 80 3 Cases C.difficile/1000pt/occ.bds 70 2.5DDDs 1000pt/occ.bds 60 50 2 40 1.5 30 1 20 0.5 10 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Months Dec 2007-Dec 2009 Ceftriaxone consumption No. of cases of C.difficile

Why isn’t hand hygiene having an effect? Overall compliance for hand disinfection was 22% from nearly 600 opportunities for hand hygiene Kim PW et al, AmJIC 2003 Staff are too busy! Dancer et al, AmJIC 2007; Hugonnet et al, Crit Care Med 2007; Erasmus et al, ICHE 2010 Overcrowding & understaffing Beggs et al, BMC Infect Dis 2008; Clements et al, LID 2008 The effects of hand hygiene are eroded if the environment is heavily contaminated….. Farr et al, LID 2001

People are dirty b*****s Compliance with hand hygiene after toilet visits was 84% for ECCMID attendees, 75% for men in public toilets and 46% for hospital staff! Van der Vegt & Voss, JHI 2009 28% commuters have faecal bacteria on their hands Judah et al, Epidem Infect 2010Only 43% of mothers wash their hands after changing adirty nappy Curtis V et al, Soc Sci Med 2003 34% male and 56% female members of the public wash their hands after using public toilets Jumaa & Hately, BMJ 1999Americans Don’t Alter Hygiene Amid Swine Flu ThreatBradley Corp., USA Sept. 2009

Healthcare Workers are more concerned about protecting themselves than protecting their patients Scheithauer et al, J Hosp Infect in press 2010

Where’s the REAL risk?Activities such as handling curtains orpatient’s notes do not register as ‘dirty’, yetthey could pose more of an infection riskthan removal of a bed pan, because staffare more likely to clean their hands afterperforming the latter. Contamination of hospital curtains with healthcare associated pathogens. Trillis et al, ICHE 2008 …beliefs about the importance of self-protection are the main reasons for performing hand hygiene Whitby et al, ICHE 2006; Erasmus V et al, ICHE 2009; Dancer SJ, ICHE 2010

‘I wonder what’s on his hands....his white coat......his stethoscope.......’ SHOULD I REMIND HIM TO WASH HIS HANDS? Photo courtesy of Clean Path Solutions, LLC, Nevada USA Dancer, J Hosp Infect 2010; Burnett E, J Hosp Infect 2010

Bye bye social niceties Bye bye friendly touch Jang et al: Staff physician: ‘If … someone is upset and they’re crying and they want human contact, you can’t say, just a second I’m going to wash my hands.’ Jang et al, J Hosp Infect in press 2010

On the state of public health: Annual report, Chief Medical Officer 2006 Dept of Health, London. The CMO stated that hand hygiene is a major priority and quoted examples of poor practice by doctors and nurses. But overuse of NHS facilities is a critical factor in controlling infection – so why are increasing bed occupancy rates, increased turnover and lack of isolation facilities not mentioned?Richardson NBG. What about reducing turnover? BMJ 2007; 335: 221

Bed occupancy, turnover intervals and MRSA rates Cunningham et al, Br J Nursing 2006

Crowded wards add to patient infection risks Overcrowding of wards and staff shortages contribute to hospital infections. One in 10 patients admitted to hospital in Britain acquires an infection and the threat from MRSA and Clostridium difficile is the direct result of efforts to reduce beds and increase efficiency. In England, the number of hospital beds has been cut by more than 25 per cent since 1981 but patient numbers have soared. Over 70% of NHS trusts exceeded the Governments target bed occupancy rate of 82%. Clements et al, Lancet Infectious Diseases 2008

Microbial load in the environment....is associatedwith bed occupancy rates S.aureus & MRSA are found on lockers, overbed tables and beds; finding these at any site was significantly associated with higher aerobic colony counts from that site (p=0.001) as well as bed occupancy rates Dancer SJ et al, IJEHR 2008 ‘Priority should be given to improving the cleaning of sites around the patients bedside. These are the sites that are both frequently contaminated and frequently touched, thereby making them important for transferring bacteria to patients.’ Peter Obee, PhD thesis, 2009

There is a heavy bioburden on all hand-touch sites Microbes can survive on surfaces for months. X denotes tested surfaces Hayden et al, SHEA 2004

What’s on YOUR hands??!Even if you keep your hands clean ALL THE TIME, any benefits from hand hygiene are eroded if there is MRSA or C.difficile on the very next surface you touch Bobulsky G et al, CID 2007; Farr et al, LID 2001

When are the hands of healthcare workers positive for MRSA? 5% fingertips from 500 HCWs were MRSA positive; 6% after clinical contact; 7% after environmental contact; and 4% after no specific contact. MRSA was recovered on 3% occasions after using alcohol rub; 6% after 4% chlorhexidine; 3% after hand washing with soap & water; and 5% with NO hand hygiene. Creamer et al, JHI, 2010What is the point in continually askingHCWs to clean their hands, if it isinevitable that they are going to touchsomething in the environment?

It’s just as easy to pick up organisms after touching a patients environment as it is by touching the patient MRSA and VRE in this room are picked up by attendant staff – and also by the next patientBoyce et al, ICHE 1997; Huang et al, Arch Intern Med 2006; Drees et al, ICHE 2008; Hayden et al, ICHE 2008

Date Specimen site Environment PFGE profile24.7.06 Foot 15e§10.8.06 Nose 15b/15z/15-7118.8.06 *Foot 16-237/16-29621.8.06 Groin 15h/15-13321.8.06 Nose 15a§ Table to show the23.8.06 Nose 15e§23.8.06 Groin 15h/15-133 molecular relationships26.8.06 Groin 16-237/16-29631.8.06 Nose 15a§ between patient and08.9.06 Nose 15d/15-7421.9.06 *Groin 15b/15z/15-71 environmental strains of25.9.06 Computer 15-73§06.10.6 Patient notes 15-73§ MRSA on one surgical11.10.06 Overbed table 15-73§13.10.96 Throat 15a§ ward over a one year18.10.0607.11.06 Heel Hoist 15b/15z/15-71 16-237/16-296 period07.11.06 Door handle 16-237/16-29627.11.06 Throat 15b/15z/15-7113.2.07 Hoist 15a13.2.07 Bedside locker 15a§13.2.07 Desk 15e/15-12114.2.07 *Arm 15b/15z/15-7118.2.07 *Catheter line 15b/15z/15-7119.2.07 Bed frame 15e/15-12119.2.07 Overbed table 15b21.2.07 *Throat 16-98/16-11808.3.07 Bed frame 15a22.6.07 Bed frame 15e/15-12127.6.07 Hoist 15d/15-74/15-30404.7.07 Desk 15b/15z/15-7112.7.07 *Throat 15z/15-71/15-11921.7.07 BP stand 15b§ Dancer et al, BMC Med 200923.8.07 Nose 15a

Dancer et al, BMC Med 2009

Cross-transmission audit of surfaces, clinical equipment and patient: Who touches what? We undertook 40x30 minutes covert audit of entries into a side-room on a medical ward. Overall compliance with hand hygiene among A room with a view clinical staff before and after entry was 25% (38/154)Over half (58%) of clinical staff touched the patient;Most frequently handled equipment inside: IV drip (27%) & BP stand (13%);outside: computer (25%), notes trolley (23%) and telephone (22%).Monitoring the sequence of hand-touch events highlighted potential microbialtransmission pathways.Since hand hygiene compliance is so low, should we nottarget high risk sites for cleaning? Smith et al, in preparation, 2010

What is the evidence for cleaning as a viable control mechanism for hospital-acquired infections ? We introduced one additional cleaner into two matched wards from Monday to Friday, with each ward receiving enhanced cleaning for six months in a cross-over design; Enhanced cleaning was associated with a 33% reduction in levels of microbial contamination at hand-touch sites; The number of new MRSA infections decreased from 9 to 4, despite higher bed occupancies and MRSA colonisation pressures (p=0.032: 95% CI 7.7%, 92.3%). Dancer et al, BMC Med, 2009BBC website, 2008

Total aerobic colony counts (ACC) from ten hand-touch sites on two surgical count from tenstudy cleaner moved Total aerobic colony wards; the hand-touch sites on two matched surgical wards from Ward A to Ward B at week 13. 140 120 100Total ACC 80 60 40 20 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Weeks NB. Middle 6 months of study Ward A Ward B Dancer et al, BMC Med, 2009

The Hand-Touch equation = Hand Hand-touch siteWHY is all the emphasis on cleaning hands and not on cleaning the things that they touch?‘Zero tolerance’ should exclude inadequate cleaning in our hospitals

DYNAMIC TRANSMISSION CYCLE OF HOSPITAL PATHOGENS Patients (infected and/or colonised)AntibioticPressuresBerntsen et al,NEJM 1960; Chenget al, JHI 2008 Hands Environment (whose?) including air

Could patients’ hands constitutea missing link? Banfield & Kerr, J Hosp Infect 2005 Figure from Pittet et al, Lancet Infect Dis 2006What is the impact of systematic patients’ hands disinfection onMRSA infection rates? Gagne et al, J Hosp Infect 2010

Distribution of S.aureus in general population and nasal carriers General Population: S.aureus nasal (+): Wertheim et al, Lancet Infect Dis, 2005; Dancer S, Lancet Infect Dis 2008

The ‘Cloud Adult’ – sort ofCourtesy of the American Association for the Advancement of Science

Let’s screen everyone for MRSA!Is it ethical to subject a population to mass screening, given the lowprevalence and the relatively high rate of false positive tests?(Millar M, J Hosp Infect & BMJ 2009)Is it ethical to screen every patient coming into hospital when we donot routinely screen healthcare staff?Is it sufficient to only screen the nose rather than include other sitesknown to be common staphylococcal reservoirs?How good is mupirocin nasal cream for eliminating carriage?Is there a risk that we might encourage resistance to mupirocin?Can the laboratories cope with the extra workload?Do our hospitals have the infection control infrastructure tocope with an increase in newly identified MRSA patients? Dancer SJ, Considering the introduction of universal MRSA screening, J Hosp Infect, 2008

A universal, rapid MRSA admissionscreening strategy did NOT reducenosocomial MRSA infection in a surgicaldepartment with endemic MRSA ……Harbarth S et al, JAMA 2008

S. aureus dispersal from nasal & perineal carriers Solberg, Acta Med Scand Sppl.1965

Surgeons! In fact, everyone……did you know that yourchoice of underwear could be an infection control risk?It is only a matter of time before the Dept. of Health insists that we allwear elasticated pants. Please see me afterwards for website details. Hill et al, Effect of clothing on dispersal of S.aureus by males and females, Lancet 1974

Bacterial contamination of white coats......Stethoscopes, pens,cuffs, ties, rings,watches, and so onLet’s get rid of them!

What’s wrong with ties?Steinlechner et al, Microbes on ties: do they correlate with wound infection? Ann R C Surg Engl, 2002

What’s wrong with wristwatches? About three-quarters of watches from 100 staff were colonised with skin bacteria, with retrieval of just one pathogen (S.aureus) from one watch only. The group concluded that wristwatches are unlikely to be common sources of healthcare- associated infections A more recent study suggests that the risk of bacterial contamination on the hands of watch wearers originates from manipulation of the watch, but not necessarily from the wearing of it Bhusal et al, AmJIC 2009; Jeans et al, JHI 2009

What items of attire do patients perceive as an infection risk? Items perceived as an infection risk 80 75 Nose ring 70 62 Bracelet 60 50 49 Wrist watch 50 Engagement ring 40 37 % of 34 Earrings 31 29 patients 30 25 24 Long sleeves 20 Neck tie 10 Wedding ring Necklace 0 Items Bow tie Ardolino et al, J Hosp Infect, 2009

If we can’t wear white coats and ties, what do we wear instead? This? Or this? Shelton et al, J Hosp Infect, 2009

Goodbye white coats……………….

Cartoon from Private Eye, 2007

Letter, BMA News Review Sept 2008‘.......... no-evidence knee jerk interventions such as bare-below-the-elbows, no watches, even hand hygiene - implythat staff, visitors and even patients themselves areresponsible for ...... hospital infectionsHospitals actually need more space, beds, isolationrooms, nurses and cleaners - not targets, clipoards or aculture of blame. And yes, we want laundries back on site,with clean coats (white), uniforms and linen for everyonewho needs it, every day.The problem is, all this costs money, and it costs a lotmore than a few bottles of alcohol gel, posters anddictatorial fingers pointing at healthcare staff.’ Magos A et al, A cheap sound bite, BMJ 2007

Sunday Telegraph, November 29th 2009

ConclusionThere is little if no evidence for the recent policies imposedupon healthcare staff in the name of infection controlThe interventions that would really make a difference costa lot of money and are difficult to implementZero tolerance is a politician’s mandate to reassure theelectorate on hygiene behaviour in our hospitals; BUT, ifwe ever get the system right, the focus will be on personalaccountabilityIf you are a hospital employee, then you have NO CHOICE but to comply with these policies……..so, Be seen to keep your hands clean

Acknowledgements • ICN’s Pia Kirkpatrick and Christina Coulombe (for info) • Mike Stewart and staff in the Hairmyres microbiology lab (for support) • BMA (ditto) • Miss N. Sturgeon, Scottish Health Minister (for good intentions)Please note that the views expressed in this presentation will not necessarily berepresentative of the views of the Hospital Infection Society nor NHS Lanarkshire

They didn’t wash their hands..........

What is Zero tolerance?…..a politician’s mandate to reassure the electorate on hygienebehaviour in our hospitals. Commentators and others latch on to thisterm because it is seen as the latest fashionable label to prescribe thesolution to all our hygiene problems…..a simplistic, short-term quick-fit fix, which will not, and cannot, reachinto the heart of the infection control problems in our hospitals‘….zero tolerance is no more than one fundamental principle of several that needto be carefully and sensitively woven together if infection control is to work well’However, BEWARE! We need to get the system right, and when we do, the focuswill be personal accountability AND THE CHARGE WILL BE VIOLATION! Pollard C, IEA Health & Welfare Unit 1998; Dancer S, 2009; Goldmann D, N Engl J Med, 2006

Pants policies and paranoia

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