Simple Techniques Slash Hospital Infections

Sat Mar 21, 2009 3:17pm
By Maggie Fox, Health and Science Editor

WASHINGTON (Reuters) - Jasper Palmer didn't think he was doing anything special when he balled up his paper hospital gown and stuffed it into one of his gloves. He just knew it was tidy and would stop the gown from spreading germs.

But the technique is one of the simple innovations that has reduced rates of infection with so-called superbugs at his and other hospitals by 26 percent to 62 percent, infection control experts told a meeting of the Society for Healthcare Epidemiology of America in San Diego on Saturday.

The U.S. Centers for Disease Control and Prevention estimates that 94,000 Americans get serious, invasive MRSA infections each year and nearly 19,000 die. Treating these patients costs between $3 and $4 billion a year, according to an estimate by Dr. Larry Liu of Pfizer Inc.

Reducing such costs is a goal of the just-started healthcare reform effort by President Barack Obama and Congress.

Palmer, a patient escort who wheels patients around the hospital, knew methicillin-resistant Staphylococcus aureus, or MRSA, was becoming more common and infected patients must be treated with great care so the bacteria do not spread.

Anyone who encounters a MRSA patient must wear gloves and gown, and yet the infection was spreading anyway. This is partly because hospital workers do not wash their hands as often or as thoroughly as they should, but experts know other factors are spreading germs.

"I figured that the safest way to reduce the risk of cross-contamination was to get rid of these gowns," Palmer, who works at Albert Einstein Healthcare Network in Philadelphia, said in a telephone interview. But the invisible microbes can be spread just from handling a contaminated gown.

"What I was doing was ... grabbing the outside of the gown then wrapping it up into a little ball and disposing of it inside my glove," Palmer said.


This made a compact package that had an unexpected bonus, said Dr. Jeff Cohn, chief quality officer at Einstein.

"One of the barriers to people not doing what they are supposed to do is if they go into a patient's room and see gowns and gloves spilling out over the trash can, they say 'well if I put a gown on, there is going to be no place to dispose of it'," Cohn said.

"So if Jasper's practice winds up being everybody's practice ... then people won't have that as an excuse."

And it is working. Palmer's idea, which he has successfully taught to fellow workers, was one of three so-called Positive Deviance approaches that the CDC has found reduced infection rates at hospitals. PD is based on the premise that in any group there are natural problem-solvers.

"It is innovative activities, such as Positive Deviance, that may have a transformative impact on infection control efforts, suggesting that MRSA and possibly other drug-resistant infections need not be inevitable," Rosemary Gibson of the nonprofit Robert Wood Johnson Foundation, which helped sponsor the CDC study, said in a statement.

And having the idea come from inside the hospital's own staff helped other staffers accept it more readily, said Cohn. "Jasper, who is a patient transporter, is the one being viewed as an expert and teaching quote unquote professionals -- nurses, doctors," said Cohn. "This is flipping things on their heads."

(Reporting by Maggie Fox, editing by Vicki Allen)

Risk of Transmission of Blood-borne Pathogens from Shared Use of Insulin Pens

Information for Healthcare Professionals

FDA ALERT [03/19/2009]: The FDA is issuing this alert to remind healthcare providers and patients that insulin pens and insulin cartridges* (see description below) are never to be shared among patients. Sharing of insulin pens may result in transmission of hepatitis viruses, HIV, or other blood-borne pathogens.

The FDA has received information that insulin pens may have been shared among numerous patients (two thousand or more) in one hospital in the United States from 2007-2009 (, and in a smaller number of patients in at least one other hospital.

Although the disposable needles in the insulin pens were reportedly changed for each patient, there is still a risk of blood contamination of the pen reservoir or cartridge. Patients who were treated with insulin pens at the hospitals in question are being contacted by the hospitals, and are being offered testing for hepatitis and HIV. Some of the potentially exposed patients have reportedly tested positive for hepatitis C; however it is not known if the hepatitis infection occurred through insulin pen sharing, or if those who tested positive had previously undiagnosed hepatitis C.

The current instructions for use for all insulin pens already state that the pens are not to be shared among patients. The FDA reminds healthcare providers, healthcare facilities, and patients that each insulin pen (and each insulin pen cartridge) is designed for single-patient use only and is never to be shared among patients.

Insulin pens are not designed, and are not safe, for one pen to be used for more than one patient, even if needles are changed between patients because any blood contamination of the pen reservoir could result in transmission of already existing blood-borne pathogens from the previous user. The FDA is working with the Centers for Disease Control and Prevention (CDC), professional societies and healthcare organizations to reinforce patient and healthcare provider education about proper and safe use of insulin pens.

This information reflects FDA’s current analysis of data available to FDA concerning this drug. FDA intends to update this sheet when additional information or analyses become available.

To report any unexpected adverse or serious events associated with the use of insulin pens or insulin cartridges, please contact the FDA MedWatch program and complete a form on line at or report by fax to 1-800-FDA-0178, by mail using the postage-paid address form provided online, or by telephone to 1-800-FDA-1088.

*Insulin pens are pen-shaped injector devices for insulin that are intended for use by a single patient. The pens have an insulin reservoir, or an insulin cartridge, that usually contains enough insulin for a patient to self-administer several doses (injections) of insulin before the reservoir or cartridge is empty. The patient changes the needle before each insulin injection. Insulin pens are designed to be safe for one patient to use one pen multiple times, with a new, fresh needle for each injection.

Recommendations and Information for Healthcare Professionals Regarding Insulin Pens and Insulin Cartridges, and other reusable injector devices:

Insulin pens containing multiple doses of insulin are meant for use by a single patient only, and are not to be shared between patients.

Identifying the insulin pen with the name of the patient and other patient identifiers provides a mechanism for verifying that the correct pen is used on the correct patient, and can help minimize medication errors. Ensure the identifying patient information does not obstruct the dosing window or other product information such as the product name and strength.
Be aware that the likelihood of sharing insulin pens and cartridges is increased when the pens are not marked with the patient name or other patient identifiers.

The disposable needle should be ejected from the insulin pen and properly discarded after each injection. A new needle should be attached to the insulin pen before each new injection.

Although the incident leading to this FDA alert occurred with insulin pens, the same risk may exist with shared use of any reusable injection device.

Hospitals and other healthcare facilities should review their policies and educate their staff regarding safe use of insulin pens.
Information for Healthcare Professionals to Provide When Counseling Patients:

Patients should be instructed that insulin pens containing multiple doses are meant for use by a single patient only.

Patients should be instructed to never share their insulin pen with another person.

Patients should be advised that sharing of their insulin pens could result in transmission of hepatitis viruses, HIV, or other blood-borne pathogens.

Background Information

The FDA has received information that insulin pens may have been shared among numerous patients (two thousand or more) in one hospital in the United States from 2007-2009 (, and in a smaller number of patients in at least one other hospital. At these hospitals, the same insulin pens may have been used for multiple patients, although the disposable needles were reportedly changed for each patient.

Because each of these devices can result in blood contamination of the pen reservoir or cartridge, even if the needle is changed before each use, patients who were treated with insulin pens at the hospitals in question are being contacted by the hospitals, and are being offered testing for hepatitis and HIV. Some of the potentially exposed patients have reportedly tested positive for hepatitis C; however it is not known if the hepatitis infection occurred through insulin pen sharing, or if those who tested positive had previously undiagnosed hepatitis C.

The current instructions for use of insulin pens already state that the pens are not to be shared among patients. The FDA reminds healthcare providers and patients that insulin pens and insulin cartridges are never to be shared among patients. Pathogenic contaminants can enter the cartridge after injection while the needle is still attached to the pen. Thus, insulin pens are not safe for use in multiple patients because of the risk of cross-contamination. The FDA is working with the Centers for Disease Control and Prevention (CDC), professional societies and healthcare organizations to determine if further actions or communications are needed.

How to Report Side Effects and Medication Errors
The FDA urges both healthcare professionals and patients to report side effects and medication errors from the use of insulin, insulin pens and insulin cartridges to the FDA's MedWatch Adverse Event Reporting program available:

online at

by returning the postage-paid FDA form 3500 available in PDF format at to:
5600 Fishers Lane, Rockville, MD 20852-9787

faxing the form to 1-800-FDA-0178

by phone at 1-800-332-1088

Guidance for Control of Infections with Carbapenem-Resistant or Carbapenemase-Producing Enterobacteriaceae in Acute Care Facilities


Infection with carbapenem-resistant Enterobacteriaceae (CRE) or carbapenemase-producing Enterobacteriaceae is emerging as an important challenge in health-care settings (1). Currently, carbapenem-resistant Klebsiella pneumoniae (CRKP) is the species of CRE most commonly encountered in the United States. CRKP is resistant to almost all available antimicrobial agents, and infections with CRKP have been associated with high rates of morbidity and mortality, particularly among persons with prolonged hospitalization and those who are critically ill and exposed to invasive devices (e.g., ventilators or central venous catheters).

This report provides updated recommendations from CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC) for the control of CRE or carbapenemase-producing Enterobacteriaceae in acute care (inpatient) facilities. For all acute care facilities, CDC and HICPAC recommend an aggressive infection control strategy, including managing all patients with CRE using contact precautions and implementing Clinical and Laboratory Standards Institute (CLSI) guidelines for detection of carbapenemase production. In areas where CRE are not endemic, acute care facilities should 1) review microbiology records for the preceding 6--12 months to determine whether CRE have been recovered at the facility, 2) if the review finds previously unrecognized CRE, perform a point prevalence culture survey in high-risk units to look for other cases of CRE, and 3) perform active surveillance cultures of patients with epidemiologic links to persons from whom CRE have been recovered. In areas where CRE are endemic, an increased likelihood exists for imporation of CRE, and facilities should consider additional strategies to reduce rates of CRE (2). Acute care facilities should review these recommendations and implement appropriate strategies to limit the spread of these pathogens.

For CRKP, the most important mechanism of resistance is the production of a carbapenemase enzyme, blakpc. The gene that encodes the blakpc enzyme is carried on a mobile piece of genetic material (transposon), which increases the risk for dissemination. Since first described in North Carolina in 1999, CRKP has been identified in 24 states and is recovered routinely in certain hospitals in New York and New Jersey (3). Analysis of 2007 data regarding health-care--associated infections reported to CDC indicated that 8% of all Klebsiella isolates were CRKP, compared with fewer than 1% in 2000 (CDC, unpublished data, 2008). CRKP poses significant treatment challenges, and CRKP infections have been associated with increased mortality, length of stay, and increased cost (4). The emergence and spread of CRKP and other types of CRE is another in a series of worrisome public health developments regarding antimicrobial resistance among gram-negative bacteria and underscores the immediate need for aggressive detection and control strategies (5).

A difficulty in detecting CRE is the fact that some strains that harbor blakpc have minimal inhibitory concentrations (MICs) that are elevated but still within the susceptible range for carbapenems. Because these strains are susceptible to carbapenems, they are not identified as potential clinical or infection control risks using current susceptibility testing guidelines. To address this challenge, in January 2009, CLSI published a recommendation that carbapenem-susceptible Enterobacteriaceae with elevated MICs or reduced disk diffusion zone sizes be tested for the presence of carbapenemases using the modified Hodge test (MHT) (6). The MHT is a phenotypic test used to detect carbapenemases in isolates demonstrating elevated but susceptible carbapenem MICs and has demonstrated sensitivity and specificity exceeding 90% in identifying carbapenemase-producing Enterobacteriaceae (6). If the MHT reveals the presence of a carbapenemase, CLSI recommends that a comment be added to the microbiology report to inform clinicians and infection preventionists. Because treatment information on MHT-positive, carbapenem-susceptible isolates is limited, CLSI guidelines do not recommend any changes regarding the reporting of susceptibility results themselves. Strains of Enterobacteriaceae that test intermediate or resistant to carbapenems should be reported as such and do not need to be subjected to the MHT.

Patients with unrecognized CRKP colonization have served as reservoirs for transmission during health-care--associated outbreaks (7). For example, during an outbreak of 39 cases of CRKP infection in a hospital in Puerto Rico in 2008, in addition to a review of infection control practices, active surveillance cultures were performed on patients in the same units as persons with confirmed CRKP infection. Cultures performed on 30 patients in the intensive care unit revealed two colonized patients who were not previously known to harbor CRKP and were not placed in contact precautions (CDC, unpublished data, 2008). Control of the outbreak was hindered by lack of compliance with infection control practices. Health-care personnel adherence to recommendations for gown and glove use was low (62%) at the hospital, and appropriate hand hygiene (i.e., hand washing or using a waterless alcohol-based hand rub before and after patient contact) was observed in only 48% of patient encounters. The hospital eventually was able to control the outbreak through enhanced infection control compliance, patient cohorting, and weekly perirectal surveillance cultures of patients in the outbreak units until no new cases were identified.

Experience from the outbreak in Puerto Rico and elsewhere (notably Israel) suggests that early detection through use of targeted surveillance and introduction of strict infection control measures (including reinforcement of hand hygiene and contact precautions) can help control the spread of CRKP (7). Other recent reports have demonstrated that microbiologic surveillance for CRKP can be accomplished using broth-based culture techniques that are widely available and also by in-house prepared molecular techniques and a commercial chromogenic agar (4,7--9); however, the latter two methods are not currently approved by the Food and Drug Administration. The screening tests used in several studies were performed on rectal or perirectal swabs; limited data indicate that surveillance screening of stool specimens, rectal swabs, or perirectal swabs might produce higher yield than testing of other body sites (e.g., nares or skin) (9).

CDC and HICPAC Recommendations

In light of the clinical and infection control challenges posed by CRE and advances in the ability to detect these pathogens, CDC and HICPAC have developed new guidance for CRE infection prevention and control in an effort to limit the further emergence of these organisms (Box). These recommendations are based on strategies outlined in the 2006 HICPAC guidelines for management of multidrug-resistant organisms in health-care settings (2).

All patients colonized or infected with CRE or carbapenemase-producing Enterobacteriaceae should be placed on contact precautions. Acute care facilities should establish a protocol, in conjunction with CLSI guidelines, to detect nonsusceptibility and carbapenemase production in Enterobacteriaceae, particularly Klebsiella spp. and Escherichia coli, and immediately alert epidemiology and infection control staff members if identified. All acute care facilities should review microbiology records for the preceding 6--12 months to ensure that previously unrecognized CRE cases have not occurred. If previously unrecognized cases are identified, facilities should conduct a point prevalence survey (a single round of active surveillance cultures) in units with patients at high risk (e.g., intensive care units, units where previous cases have been identified, and units where many patients are exposed to broad-spectrum antimicrobials) to identify any additional patients colonized with carbapenem-resistant or carbapenemase-producing Klebsiella spp. and E. coli. The recommended surveillance culture methodology is aimed at detecting carbapenem resistance or carbapenemase production in Klebsiella spp. and E. coli only, because 1) this method facilitates performing the test in the microbiology laboratory without the use of molecular methods and 2) these organisms represent the majority of CRE encountered in the United States. When a case of hospital-associated CRE is identified, facilities should conduct a single round of active surveillance testing of patients with epidemiologic links to the CRE case (e.g., those patients in the same unit or patients who have been cared for by the same health-care personnel).

The goal of active surveillance is to identify undetected carriers of carbapenem-resistant or carbapenemase-producing Klebsiella spp. and E. coli. Identification of other cases among patients with epidemiologic links to persons with confirmed infection suggests patient-to-patient transmission (7); in such instances, infection prevention measures should be vigorously reinforced, and surveillance cultures repeated periodically (e.g., weekly) until no new cases are identified. Situations where periodic point prevalence surveys repeatedly fail to identify other colonized patients suggest that infection control measures at the facility are effective in controlling transmission. In such instances, consideration should be given to halting active surveillance cultures in response to clinical cases and replacing them with periodic point prevalence surveys in units with patients at high risk to ensure that carbapenem-resistant or carbapenemase-producing Klebsiella spp. and E. coli do not reemerge.

Because the prevalence of CRE is low in the majority of U.S. hospitals, routine microbiologic surveillance of persons admitted, such as that performed in some facilities to detect carriage of methicillin-resistant Staphylococcus aureus, is not recommended. However, in some areas of the United States, notably New York City, CRE are routinely recovered, including from many patients who are admitted from the community. In these settings, point prevalence surveys in response to detected clinical cases might be less useful in controlling transmission of CRE. Facilities in regions where CRE are endemic should monitor clinical cases of CRE and implement the intensified (i.e., Tier 2) infection control strategies outlined in the 2006 HICPAC guidelines if rates of CRE are not decreasing (2). The challenges to hospitals of allocating additional resources to prevent and control CRE are balanced by the fact that an aggressive infection control strategy, such as that recommended in this report, offers an opportunity to limit the impact of these problematic pathogens while CRE prevalence remains low in most U.S. hospitals.

Reported by: W Lledo, M Hernandez, E Lopez, MD, OL Molinari, MD, RQ Soto, MD, E Hernandez, N Santiago, M Flores; GJ Vazquez, MD, IE Robledo, MD, Univ of Puerto Rico; E GarcĂ­a-Rivera, MD, A Cortes, M Ramos, Puerto Rico Dept of Public Health. R Goering, PhD, Creighton Univ, Omaha, Nebraska. A Srinivasan, MD, C Gould, MD, N Stine, M Bell, MD, K Anderson, B Kitchel, B Wong, JK Rasheed, PhD, J Patel, PhD, Div of Healthcare Quality Promotion, National Center for the Preparedness Detection and Control of Infectious Diseases; K Tomashek, MD, Div of Vector-Borne Infectious Diseases, National Center for Vector-Borne, Enteric, and Mycotic Diseases; E Llata, MD, CJ Gregory, MD, EIS officers, CDC.

3 Steps Might Help Stop MRSA's Spread

E-monitoring of hand washing, better room cleaning and checks on patient transfers are key, studies find

Posted March 20, 2009
By Steven Reinberg
HealthDay Reporter

FRIDAY, March 20 (HealthDay News) -- A high-tech way of monitoring hand washing, a better means of disinfecting rooms and improved tracking of patients as they transfer from one hospital to another could all help prevent the spread of the MRSA "superbug" and other pathogens, researchers report.

Methicillin-resistant Staphylococcus aureus (MRSA) is a type of staph bacteria that's resistant to certain antibiotics. It can cause severe infections for people in hospitals and other health-care facilities, such as nursing homes. MRSA can also cause serious skin infections in healthy people who have not recently been hospitalized.

But MRSA can be beaten, suggest three studies that were to be presented this week at the annual meeting in San Diego of the Society for Healthcare Epidemiology of America.

In the first report, Dr. Philip Polgreen, an assistant professor of internal medicine at the University of Iowa, described an inexpensive way of electronically monitoring staff to be sure that they wash their hands before entering an intensive care unit. The system uses a wireless technology similar to Wi-Fi to transmit signals to a computer.

"Hand washing is one of the most important actions health-care workers can take to protect patients from developing hospital-acquired infections," Polgreen said during a March 12 media teleconference. "Yet hand hygiene compliance among physicians, nurses and other health-care workers remains unacceptably low," he said.

Currently, many hospitals have staff sit outside hospital rooms to record when people wash their hands, Polgreen noted.

In the new system, health-care workers wear a badge that interacts with a sensor on an automated hygiene dispenser placed outside or inside patients' rooms. Using this method, researchers were able to determine compliance with hand-washing protocols and identify staff who were following or not following hand-washing procedures.

"Testing has shown this new system to be accurate," Polgreen said, but he added that it still has to be tested in a variety of situations.

Dr. Marc Siegel, an infectious disease expert and associate professor of medicine at New York University School of Medicine in New York City, called the new system "impressive."

"We all agree that washing your hands is the way to go," Siegel said. But he is not convinced that hand sanitizers are totally effective. "Washing your hands with soap and water is better," he said.

In the second report, a team led by Rupak Datta, an M.D./ Ph.D. candidate at the University of California at Irvine, found that 40 percent of MRSA and vancomycin-resistant enterococci (VRE) infections are transmitted by touching nearby surfaces. VRE is another dangerous antibiotic-resistant pathogen.

"These infections can be cultured off a variety of surfaces, such as doorknobs, countertops, computer keyboards and bed trays," Datta said during the teleconference.

To combat this problem, the researchers developed a new cleaning method for disinfecting patient rooms. Instead of using spray bottles, the method involved cloths saturated with disinfectant and included instruction in proper cleaning techniques.

The enhanced cleaning significantly cut down on MRSA but was only moderately effective in killing VRE. The researchers believe that a different method will be needed to reduce VRE infections.

"This suggests that cleaning measures over and above national standards can be important in reducing the transmission of multi-drug-resistant organisms, such as MRSA and VRE in high-risk patient care areas, such as the ICU," Datta said.

"It is interesting," Siegel noted, "that VRE is even more resistant to standard cleaning techniques than MRSA. That implies that the more resistant a bug, the more crafty it becomes and harder to eradicate."

In the third presentation, Dr. Susan S. Huang, director of epidemiology and infection prevention at the University of California at Irvine School of Medicine, examined the transfer of patients between hospitals in Orange County, Calif.

Sharing patients often means sharing hospital-based infections, she noted. "Our study is focused on trying to quantify how much patient-sharing occurs between acute-care hospitals," Huang said during the teleconference.

For the study, Huang's team looked at almost 240,000 people admitted to Orange County's acute-care hospitals in 2005.

"We found that 22 percent of patients will be rehospitalized within a year of discharge," Huang said. Most are readmitted to different hospitals than the one where they were initially treated. In an average month, each hospital exposed other hospitals to 10 of their patients, she noted.

According to Siegel, the transmission of infections from hospital to hospital is "being overlooked."

"Patients become deposits of bacteria, especially when they go from one facility to the next," he said, adding that it should be assumed that someone coming from another hospital is infected with drug-resistant bacteria.

In fact, routine decontamination of patients -- whether they are known to be carrying dangerous pathogens or not -- should be the status quo, Siegel said. "It has to become standard practice to decontaminate all patients who are in areas of high prevalence of dangerous bacteria," he said.

Hand Hygiene Formula

Hand-hygiene formula: 2 clean hands 4 good health
Excerpted from Healthcare Purchasing News, Nov, 2008 by Susan Cantrell

Hand hygiene is virtually the first chapter and first verse of the healthcare worker (HCW)'s bible; yet it remains an issue. All agree it's a crucial step in preventing spread of infection; yet, compliance is low, an embarrassing overall average of 40% according to the Centers for Disease Control and Prevention (CDC)'s "Guideline for Hand Hygiene in Health-Care Settings."

It's not that HCWs don't want to comply; it's that there are legitimate obstacles, complicated challenges, and valid complaints. Suzanne M. Pear, RN, PhD, CIC, healthcare epidemiologist, associate director for infection prevention practices, scientific affairs and clinical education, Kimberly-Clark Health Care, Roswell, GA, agreed: "Hand-hygiene compliance is more complex than it would seem on the surface. Reported barriers are numerous and seemingly impossible to eliminate completely, but it's a challenge in which we must all continuously engage."

Obstacles, challenges, complaints

The reasons for lack of compliance to such a simple and basic tenet of healthcare are many, noted Alecia Cooper, RN, BS, MBA, CNOR, vice president, clinical services, Medline Industries Inc., Mundelein, IL. "We believe the many reasons can be summed up into three categories: lack of education, behavioral challenges, and poor skin condition."

Indeed there sometimes is a lack of knowledge as to when and how to sanitize hands and the appropriate procedures to follow when hand sanitation is performed; thus the need for constant reinforcement through education. Education is an area in which vendors are investing deeply.

Pear explained that, whereas "a single education Intervention doesn't often sustain behavior change, education is the initiator of behavior change and the foundation upon which conscious behavior changes are maintained. Education about the patient consequences of poor hand-hygiene compliance and the essentials of hand-hygiene technique and frequency are critical components of an ongoing multimodal, multidisciplinary hand-hygiene compliance program. We're learning by trial, error, and methodological research about what works and what doesn't to alter HCW behavior, even adopting industry's social marketing techniques to help effect these critical practice changes."

Kimberly-Clark demonstrates the connection between healthcare-acquired infections (HAIs) and hand hygiene in a very personal way, hopefully making an Indelible impression upon listeners. Pear said: "Kimberly-Clark Health Care's clinical education goals help to put a face on the devastating issue of HAIs by providing grants that fund speakers such as Victoria Nahum, whose life and family were irrevocably damaged by these preventable harms, at clinical education venues such as the 'Safe Care Campaign.' This program has helped healthcare administrators and clinicians connect the clinical dots between non-compliance to evidence-based practices and catastrophic patient outcomes."

Cooper highlighted an appalling obstacle in the category of behavior: "Behavioral challenges include the realization that there are no measurable consequences to the HCW who does not follow procedures." Incredible, but true. Hands harboring pathogens can be lethal weapons but are seldom viewed in that light. This perhaps is due partly to lack of positive examples, of which there is a dearth, noted Cooper: "Physicians are the least compliant, and other HCWs follow their lead."

As for the third category, the CDC's handwashing guideline states: "... approximately 25% of nurses report symptoms or signs of dermatitis involving their hands, and as many as 85% give a history of having skin problems (249). Frequent and repeated use of hand-hygiene products, particularly soaps and other detergents, is a primary cause of chronic irritant contact dermatitis among HCWs (250)."

The more handwashing is performed, the more likely hands become dry, cracked, and painful and the less likely those hurting are to comply. Cooper added: "Healthcare workers may put on and take off gloves as many as 30 times per shift, also leading to skin irritations. All combined effects lead to less compliance."

Other reasons for noncompliance were outlined by Cheryl A. Littau, PhD, senior scientist, skin care innovation, Ecolab Healthcare, Eagan, MN: "For some, it's lack of time due to understaffing or critical patient needs, whereas others do not recognize the situation as an opportunity that requires hand washing. For example, an HCW may touch a piece of equipment that is contaminated, although not visibly soiled, and therefore may not perceive a need to wash his or her hands. Other common reasons include sinks or sanitizer dispensers that are not in close proximity to the patient."

Products offer a helping hand

Hand hygiene is big business. Companies are constantly striving to develop products that offer solutions to the compliance problem. Jeanne Medvick, BAMT (ASCP), MBA, CIC, manager of clinical studies, STERIS Corporation, Mentor, OH, offered advice for purchasers and users of hand-hygiene products: "Hand-hygiene products should be formulated to offer the customer three benefits: clean the hands of visible soil, assure antimicrobial efficacy to kill transient microorganisms, and be mild to the skin so that skin health is not put at risk. In today's world, a hand-hygiene product has to do more than clean skin and kill microorganisms. Healthcare workers who know that a product will cause dryness and irritation will be reluctant to use it and are less likely to be in compliance with good hand-hygiene practices if their skin hurts. STERIS conducts clinical studies to prove both antimicrobial efficacy and mildness." ...

Hand Hygiene Compliance Remains a Goal Unrealized

By Gina Rollins
2008 Hospital Infection Control Survey

About this report … Materials Management in Health Care assembled this report from a survey conducted in cooperation with the Association for Professionals in Infection Control and Epidemiology, the Association for Healthcare Resource & Materials Management in Health Care of the AHA and extensive interviews with hospital leaders and experts in hospital infection control.

We surveyed a sample of 3,227 infection control specialists to learn about hospital infection control practices and their effectiveness, gauge the prevalence of hand hygiene compliance-building programs and identify what steps hospitals are taking to reduce hospital-acquired infections. The response rate was 16.7 percent or 539 completed surveys.

Data by Suzanna Hoppszallern

Preventing hospital-acquired infections remains a top priority for infection prevention and control specialists, yet many organizations are still struggling to achieve full compliance with hand hygiene protocols in particular. Many health care leaders seem unable to make hand hygiene become second nature to workers, even though they believe that type of cultural change is essential to curbing infections in health care settings.

These were among many findings in a recent survey conducted jointly by Materials Management in Health Care (MMHC), the Association for Professionals in Infection Control & Epidemiology (APIC), Washington, D.C., and the Association for Healthcare Resource & Materials Management, Chicago.

“People don’t go to work with the intention of causing harm. They want to do the right thing. We need to work with them so that hand hygiene is ingrained like a habit,” says Lillian Burns, C.I.C., infection control coordinator at Greenwich (Conn.) Hospital.

Although the online survey explored overall issues related to hospital-acquired infections, it focused predominantly on hand hygiene. According to the Centers for Disease Control and Prevention (CDC) in Atlanta, hand hygiene is identified frequently as “the single most important practice to reduce the transmission of infectious agents in health care settings.”

Conducted in March 2008 by Perception Solutions, Aurora, Ill., the survey was e-mailed to 3,227 APIC members and MMHC readers identified as infection control specialists. A total of 539 people participated, for a 16.7 percent return rate, which is comparable to similar studies conducted by Perception Solutions. The response rate resulted in a 95 percent confidence interval with a 5 percent plus or minus margin of error. Nearly all participants reported that their organization had mandatory employee training on infection control and hand hygiene (93 percent). Other common measures included ensuring the use of proper gloves with effective barrier protection (88 percent), using preventive antibiotics prior to surgery (86 percent) and using maximum sterile barrier while placing central intravenous catheters (77 percent).

Specifically related to hand hygiene, two-thirds of respondents indicated that their hospital had reorganized the physical layout of hand hygiene stations within the past three years and 41 percent report strict enforcement and reporting of hand hygiene practice violations.

Many hospitals have found location of hand hygiene stations to be a particularly challenging issue. “We did three reviews and found we needed more every time,” explains Tim Brooks, director of surgical services materials management at Yuma (Ariz.) Regional Medical Center. “Logistics plays a huge part. If they’re close enough for families or physicians to use, then they’re not right for someone else. There’s no good location that’s 100 percent right for everyone in every situation, so we targeted multiple locations in visible areas.”

Logical placement

Representatives from Yuma Regional’s product supplier assisted in this process by working closely with every nursing unit to determine the ideal number and best placement of each hygiene station.

Logistics has been a challenge at Greenwich Hospital, too. “Our staff reported that sinks in some patient rooms might be blocked by chairs, patients’ personal items, or visitors, so there wasn’t easy access,” says Burns. The hospital added hand hygiene stations just inside the entrance of patient rooms and “in abundance throughout the facility,” she adds. It also placed smaller containers on medication carts, isolation stations and at nursing units, and distributed pocket-sized dispensers to patient care employees.

State-by-state building codes also factor into the placement and overall number of hygiene stations. For example, fire officials in Wyoming, Mich., “were concerned about the volume of alcohol-based hand-rub dispensers in hallways, so Metro Health Hospital initially placed most sanitizer stations in patient rooms, says Deb Paul-Cheadle, R.N., manager of infection control. However, due to varying room configurations “you couldn’t say it would be in the same place for every room, and it was in odd places in some rooms,” she adds. Updated fire codes and a new facility, which opened in September 2007, were responsible for the placement of more hygiene stations in hallways. “We’re seeing more compliance since then,” says Paul-Cheadle.

A multifaceted approach

The majority of survey respondents reported using an array of measures to improve hand hygiene compliance. Virtually all indicated that they rely on staff education and intervention (98 percent), and the vast majority employ monitoring or observation of hand-hygiene practices (92 percent) and visual support materials such as signage and posters to raise hand hygiene compliance (91 percent).

Del E. Webb Hospital in Sun City West, Ariz., is typical in displaying posters on all patient care units and incorporating hand hygiene in orientation, continuing education and annual infection control training sessions. A “Clean Hands Save Lives” poster has been adopted as a screen saver on unit computers, according to Cindy Hammond, R.N., infection control nurse.

Highland Hospital in Rochester, N.Y., also uses a variety of staff education initiatives and launches new hand hygiene campaigns about every six months, according to Ann Marie Pettis, R.N., C.I.C., director of infection prevention. One of the most successful included “It’s In Your Hands” posters, which featured images of organisms cultured from employees’ hands. “It was so visual it really captured the staff’s attention,” she says.

To these traditional approaches, providers are adding novel strategies to boost compliance and foster cleaner patient care environments. At Yuma Regional Medical Center, Brooks developed a strict schedule for all IV pumps, code carts and other equipment to be taken to central sterilization for disinfection.

Patient care staff are still allowed to clean equipment and keep a small inventory on patient care units, but all pumps are subject to the disinfection regimen. “By everything coming downstairs it gets more rigorously cleaned. We increased the number of pumps overall because previously, people were holding on to them. They were afraid they wouldn’t have one when it was needed, but now with our tight schedule [of picking up and cleaning equipment] they’re not hoarding them,” he says. Highland Hospital began placing antiseptic finger wipes on patient meal trays, but found patients were using them after, rather than before, eating. So it collaborated with the vendor that provides napkins and utensils to custom package the wipes inside the utensil wrapping along with a written reminder to use them before eating, according to Pettis. The system was implemented in May 2008.

The value of observation

Del E. Webb Hospital and Metro Health Hospital are typical of survey respondents in using covert observers to assess staff compliance with hand hygiene policies. Both facilities aim to capture 30 observations per unit per month, and both break down the observations by category of health care worker to assess if there is a particular concern with certain groups. Procedures for addressing staff who do not perform appropriate hand hygiene vary between the institutions, but in general, violations are reported to the individual’s manager who is responsible for addressing the issue.

At Greenwich Hospital, designated observers forward documentation to Burns of any inappropriate hand hygiene they observe. She, in turn, sends a memo to the offender specifying the date and time of the incident and reinforcing the hospital’s patient safety policies and that repeated noncompliance could result in disciplinary action.

As common as this system of observation and counseling about hand hygiene violations is, it gives a decidedly imperfect picture of actual practices and does little to change hand hygiene practices, argues Maryanne McGuckin, president and CEO of McGuckin Methods International and senior scholar in health policy at Jefferson Medical College in Philadelphia. “Unless you’re observing every single action, you’re capturing such a small number of interactions, it’s just not effective,” she says. “And if people just document violations and it gets passed on to someone else, by the time [the violation] gets followed through all those chains, how many health care workers haven’t washed their hands?”

Burns agrees that “observation will not capture everyone in every patient interaction, but that’s not my intent,” she says. “It’s like stopping at a stop sign when no one’s there. You do it because there’s the potential you could get caught.” The majority of survey respondents apparently agree with that sentiment, as less than one-half reported using strict enforcement and reporting of hand hygiene policy violations. Several facilities cited the need to boost compliance further before resorting to sanctions. Denver Health is one example. “We’ve gotten from 39 percent compliance to 70 percent without taking a punitive approach, so we’d like to continue in that way,” says Marie Fornof, R.N., C.I.C., infection control manager.

One of the hospital’s compliance campaigns involved supervisors giving tickets to employees observed performing proper hand hygiene. All the ticket holders were then eligible for a monthly drawing with sought-after prizes like tickets to a Denver Broncos game.

Similarly, at Del E. Webb Hospital, “we’ve tried to concentrate on the positive, thanking [employees observed performing good hand hygiene] for protecting our patients,” says Hammond. “We don’t have a zero-tolerance policy, but we’re heading toward that.” The hospital also includes hand hygiene knowledge as part of employees’ annual performance evaluations.

Two less common approaches used by survey respondents to boost hand hygiene compliance include hand hygiene product measurement (62 percent) and patient empowerment (65 percent). McGuckin advocates tracking hand hygiene product use per patient bed day, supplemented by physical observation to pinpoint why particular units are performing poorly. She maintains a database of several thousand inpatient and outpatient sites.

As of April 2008, participating intensive care units (ICUs) increased the mean hand hygiene events per patient bed day to 67, up from 41 at baseline; participating departments that aren’t ICUs increased to 45 hand hygiene events per patient bed day from 36.

Highland Hospital in Rochester, N.Y., monitors sanitizer use by unit and is aiming for 60 episodes of hand hygiene per patient day this year, up from 40 episodes, according to Ann Marie Pettis, R.N., C.I.C., director of infection control. The hospital no longer uses visual monitoring. “When we used observation we found that people started to game the system,” she adds.

In patients’ hands

McGuckin also believes patients hold the key to their own safety. With staff coming in and out of the room throughout the day, “what is the single variable that’s always there to piece it together? The patient,” she says. McGuckin’s research indicates that once patients are empowered to ask health care workers whether they have washed their hands, about 80 percent will do so. Many facilities educate patients and visitors by posting signs with the message “It’s OK to ask,” which encourages patients to ask health care workers if they have cleaned their hands.

Still others have employed a variety of measures to engage patients actively as sentinels in the war against hospital-acquired infections. For instance, Denver Health gives patients response cards when they register at one of its community health clinics. Patients are asked to indicate whether their health care providers cleaned their hands and to drop the card in a comment box before leaving the facility. Highland Hospital has a hot line for patients to call if they see a health care worker not practicing hand hygiene.

APIC, Safe Care Campaign and the CDC recently developed a hand hygiene video for patients and visitors in hospitals, which emphasizes the importance of hand hygiene in hospital settings and that it is OK to ask hospital staff if they have washed their hands. The video is available for free download from the CDC Web site ( “It’s absolutely imperative that we engage patients in their own care and have them be willing to speak out when they see someone not clean their hands,” says Janet Frain, R.N., C.I.C., president of APIC and director of integrated quality services at Sutter Medical Center, Sacramento, Calif.

Regardless of the strategies employed, infection control experts say the goal should be to create a culture that addresses staff attitudes such as those noted in the survey.

Major challenges to hand hygiene compliance reported by participants include staff not thinking about it (43 percent), being too busy (31 percent), having patient needs take priority (25 percent) and not having role models (24 percent). “Those are very honest responses. It tells me people are not appreciative of the magnitude of the problem when they don’t practice good hand hygiene,” says Frain. “We need to get to the point where it’s an embedded practice, and we’ve got to have people willing to call each other on their behavior, regardless of title, so that there is an equality and focus on the mutual goal of patient safety.”

Social schema

At New England Baptist Hospital in Boston, Infection Control Manager Maureen Spencer, R.N., C.I.C., has implemented a series of hand hygiene compliance initiatives based on social learning theory, which holds that people learn and change their own behavior by observing the behavior of others. The efforts have raised observed hand hygiene compliance to 66 percent before patient contact, up from 27 percent, and to 90 percent after patient contact, up from 44 percent.

Techniques include role modeling, self-efficacy, reinforcement, contracting and reciprocity. All are incorporated in creative hand hygiene campaigns launched at varying intervals, and through a variety of other employee communication and education initiatives. Exemplary campaign themes include Let it SNOW (stop nosocomial organisms by washing), Cruise on the LUAU (let us always use good hand hygiene) and LOVE=WASH (lose organisms very easily=workers assuring safe hands). “Our goal is to have everyone stand in front of patients and wipe their hands before and after they interact with the patient,” Spencer says.

This article first appeared in the July 2008 issue of Materials Management in Health Care.

Patient Safety Awareness Tips from the Joint Commission

Joint Commission urges patients, families to be involved and informed

OAKBROOK TERRACE, Ill., March 9 /PRNewswire-USNewswire

The Joint Commission is marking National Patient Safety Awareness Week from March 8-14 by helping patients and their families become more involved and informed in their health care through its award-winning Speak Up(TM) education campaign. As the accreditor of more than 16,000 health care organizations in the U.S., The Joint Commission advocates for safe, high quality care.

"Patient safety is a critical component of quality care, and is one of the most challenging issues in health care today," says Mark R. Chassin, M.D., M.P.P., M.P.H., president, The Joint Commission. "The Joint Commission is actively working with health care organizations to build higher levels of safety into the health care system. Patients can be effective partners in this improvement by being engaged in and informed about their care." Click here for a podcast with Dr. Chassin.

Speak Up(TM) brochures are available on preventing infections, preventing medication mistakes, avoiding wrong site surgery, recovering after leaving the hospital, understanding medical tests, understanding what your caregiver says, preparing to become a living organ donor, and preventing errors in care. The brochures can be found at All of the Speak Up(TM) brochures are available in an easy-to-read format and are also available in Spanish.

The Speak Up(TM) campaign urges patients to:

Speak up if you have questions or concerns. If you still don't understand, ask again. It's your body and you have a right to know.

Pay attention to the care you get. Always make sure you're getting the right treatments and medications by the right health care professionals. Don't assume anything.

Educate yourself about your illness. Learn about the medical tests you get, and your treatment plan.

Ask a trusted family member or friend to be your advocate (advisor or supporter).

Know what medicines you take and why you take them. Medicine errors are the most common health care mistakes.

Use a hospital, clinic, surgery center, or other type of health care organization that has been carefully checked out. For example, The Joint Commission visits hospitals to see if they are meeting The Joint Commission's quality standards.

Participate in all decisions about your treatment. You are the center of the health care team.

The Joint Commission has been actively involved in patient safety for more than 50 years. At its core, accreditation is a risk reduction activity; compliance with Joint Commission standards is intended to reduce the risk of adverse outcomes. More than 75 percent of Joint Commission standards relate to patient safety. These national standards give organizations the framework to prevent health care-associated infections, safely manage medications, involve patients and their families in all care decisions, create a safe physical environment for care and provide competent caregivers.

Accredited organizations also must comply with the Universal Protocol and National Patient Safety Goals that establish safe practices for important aspects of the care process for common risks like effective communication, hand hygiene, accurate patient identification and medication safety, among others. In addition, The Joint Commission regularly issues national Alerts to warn health care organizations and professionals about safety issues. Past issues have addressed hospital infections, medication errors, blood transfusion errors and magnetic resonance imaging (MRI) accidents.

National Patient Safety Awareness Week is a national observance sponsored by the National Patient Safety Foundation as an education and awareness campaign to improve patient safety at the local level.

Founded in 1951, The Joint Commission seeks to continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations. The Joint Commission evaluates and accredits more than 16,000 health care organizations and programs in the United States, including more than 8,000 hospitals and home care organizations, and more than 6,200 other health care organizations that provide long term care, behavioral health care, laboratory and ambulatory care services. In addition, The Joint Commission also provides certification of more than 600 disease-specific care programs, primary stroke centers, and health care staffing services. An independent, not-for-profit organization, The Joint Commission is the nation's oldest and largest standards-setting and accrediting body in health care.

Learn more about The Joint Commission at

Scientists Learning to Target Bacteria Where They Live

By Kari Lydersen
Washington Post Staff Writer
Monday, March 9, 2009

CHICAGO -- In the arms race between humans and bacteria, the ability to form "biofilms" -- large aggregations of microbes embedded in a slimy matrix -- has been one of the weapons the organisms use to defeat the immune system, antibiotic drugs and other threats. But scientists, who only recently recognized the role that biofilms play in antibiotic resistance, may be closing in on promising prospects for defeating pathogens.

Scientists have learned that bacteria that are vulnerable when floating around as individual cells in what is known as their "planktonic state" are much tougher to combat once they get established in a suitable place -- whether the hull of a ship or inside the lungs -- and come together in tightly bound biofilms. In that state, they can activate mechanisms like tiny pumps to expel antibiotics, share genes that confer protection against drugs, slow down their metabolism or become dormant, making them harder to kill.

The answer, say researchers, is to find substances that will break up biofilms.

"Since the time of Pasteur, we've been working on trying to kill off and control planktonic bacteria, but we've made very little progress in the control and understanding of biofilm bacteria," said David Davies, a biofilm expert at the State University of New York at Binghamton. "Now we're very good at getting rid of acute bacterial infections, which used to be a real scourge of mankind, but we have this incredible number of chronic, debilitating bacterial infections" often linked to biofilms.

Notorious biofilm infections come from the bacterium Pseudomonas aeruginosa, which often affects lungs and can debilitate and kill cystic fibrosis sufferers, and methicillin-resistant Staphylococcus aureus (MRSA), which can spread quickly through prisons, hospitals and even beaches. Acinetobacter baumannii infections, which plague wounded soldiers, are also probably caused by biofilms, as are more mundane afflictions such as sinusitis and ear infections.

A successful means of dispersing biofilms, Davies said, would be a medical breakthrough akin to the discovery of penicillin in 1928.

The March edition of the Journal of Bacteriology features Davies's research on forcing biofilm dispersion by using bacteria's own chemical signals against them. Biofilm colonies disperse naturally in response to environmental factors or to spread and form new colonies. Davies and his colleagues have discovered a chemical signal, in the form of a fatty acid, that tells bacteria it is time to break up.

He hopes this naturally occurring molecule, cis-2-decenoic acid or CDA, which is approved by the Food and Drug Administration as a food additive, could be used to fight infection. Because it does not kill bacteria, he says, it should not trigger the development of resistant bacteria, which could happen through natural selection if the chemical killed its targets.

At North Carolina State University in Raleigh, two chemistry professors say they might have found a potential key to biofilm dispersion in the oceans, which scientists are mining for a variety of new drugs. When John Cavanagh and Christian Melander saw photos of the sea sponge Agelas conifera looking clean and healthy on a coral reef smothered by bacterial biofilms, they had a eureka moment.

"We were looking at that and said this sponge probably has it figured out," Cavanagh said. "It has no immune system, but it's found a way to defend itself against all the biofilms in the ocean, where there is a lot of nasty stuff floating around."

Melander said "a throwaway sentence in an obscure journal" -- the Bulletin of the Chemical Society of Japan -- gave them another clue. They isolated a compound from the sponge that disperses biofilms and figured out how to synthesize it quickly and cheaply.

The professors said that in laboratory tests, the compound, paired with an antibiotic, has effectively dispersed and killed previously antibiotic-resistant forms of MRSA, A. baumannii and other bacteria, though the scientists do not know how it works.

Although they hope to pair it with antibiotics to be taken orally, Melander and Cavanagh first plan to impregnate the compound in implanted medical devices that are prone to bacterial contamination, such as catheters, stents and artificial limbs.

Similar projects are in the works at other labs worldwide.

"In the last 15 years or so, we've really seen things take off. There will be lots of novel technologies coming out," said Rodney Donlan, team leader of the biofilm lab at the Centers for Disease Control and Prevention. The agency is experimenting with using phages -- viruses that can kill bacterial cells -- to prevent biofilm formation on medical devices.

The Canadian company Kane Biotech plans to submit plans to the FDA this year for a wound gel containing a natural enzyme found in human mouths that disperses biofilms, which it has named DispersinB. The enzyme is nontoxic but makes biofilms susceptible to antibiotics and immune responses.

"The world is now turning their attention to the fact we just can't keep developing more and more drugs," said Gord Froehlich, Kane Biotech's president and chief executive. "We have to look at how the bacteria actually live and survive rather than just shooting more bullets."

University of Florida molecular biologist Tony Romeo describes the research as still in its nascent stages and said that discovering exactly why and how biofilms form is crucial.

"By understanding the factors that are needed for biofilms to develop, we hope to identify chinks in the armor that can lead to novel ways to treat or prevent such kinds of infections," Romeo said.

But dispersing biofilms without understanding all the ramifications could be a "double-edged sword," Romeo warned, because some bacteria in a biofilm could wreak worse havoc once they disperse.

"Simply inducing biofilm dispersion without understanding exactly how it will impact the bacterium and host could be very dangerous, as it might lead to spread of a more damaging acute infection," he said.

House Passes Legislation to Monitor MRSA

By Adam Wilson | The Olympian • Published March 10, 2009
Lawmakers moved forward Monday with an effort to track drug-resistant staph infections and slow the bacteria's spread.

Once the subject of stiff resistance from some medical groups, Rep. Tom Campbell's House bill passed unanimously. It will require hospitals to develop a system to identify patients carrying the potentially deadly disease, and policies to control the infections.

That includes telling people when they are sharing a hospital room with someone who is carrying drug-resistant staph, said Campbell, a Republican from Yelm. "At the very least, the hospital will have to disclose that to the patient, that they are indeed roomed with an infectious person."

The Senate approved its own bill on the so-called superbug, methicillin-resistant Staphylococcus aureus, or MRSA. The organism is immune to common antibiotics. It can be treated, but it also can be lethal, particularly for those whose immune systems are already fragile.

The Senate bill, backed by Sen. Karen Keiser, would require hospitals to screen all patients entering and leaving their intensive care units for drug-resistant staph. If more than 5 percent of patients contract the germ during treatment, the hospital must continue the program. All patients found to be carrying the germ would be advised and counseled under Senate Bill 5500.

The House version — House Bill 1329 — had been opposed as too burdensome by some health professionals, including the Washington State Medical Association, which represents doctors.

The measure was changed, notably dropping a requirement to screen every patient for the germ before certain scheduled surgeries. Campbell pledged to return to that issue.

Rep. Ross Hunter, D-Medina, said he was hospitalized for a month in 2007, and thought about the possibility of contracting a drug-resistant staph infection.

"This kind of infection is the kind that kills people. ... This is something I feared every day," he said.

Measuring the Prevalence of Clostridium difficile-Associated Disease in Hospitals

More Is More: Measuring the Prevalence of Clostridium difficile-Associated Disease in Hospitals: An Expert Interview With William R. Jarvis, MD and Medscape

Clostridium difficile infection (CDI) is the most frequent cause of healthcare-associated infectious diarrhea in industrialized countries; it affects more than 300,000 hospitalized patients yearly in the United States alone. C difficile-associated disease (CDAD) can range from uncomplicated diarrhea to sepsis and even death. C difficile transmission occurs primarily in healthcare facilities via the fecal-oral route following transient contamination of the hands of healthcare workers and patients and contamination of the patient-care environment. The rate and severity of CDAD are increasing. This trend may be the result of changes in the epidemiology of C difficile (which may arise from changes in antimicrobial use, other drug-prescribing practices, or infection-control practices) and/or a new strain of C difficile that appears to produce greater quantities of toxins A and B, is more resistant to fluoroquinolones, and is associated with higher rates of morbidity and mortality. To date, all of the large epidemiologic studies of CDAD are incidence studies. Susan L. Smith, MN, PhD, Scientific Director of Medscape Infectious Diseases, interviewed William R. Jarvis, MD, about the first national prevalence study of CDAD in US hospitals. This study will be published in the American Journal of Infection Control in March 2009. Dr. Jarvis is an emeritus professor at Emory University School of Medicine in Atlanta, Georgia.

Medscape: Please describe the published studies to date examining the incidence or prevalence of CDI.

Dr. Jarvis: Several studies have looked at the incidence of CDAD. A study frequently referenced is by Lennox Archibald and coworkers, published in the Journal of Infectious Diseases in 2004[3] when I was at the Centers for Disease Control and Prevention (CDC). We analyzed data from the CDC's National Nosocomial Infections Surveillance (NNIS) system from 1987 to 2001. At that time, the NNIS system was no longer collecting hospital-wide data, so we focused on intensive care unit (ICU) component. We found that in hospitals with 500 or more beds, the rate of CDAD increased from about 2.8 to 3.0 per 10,000 patient-days in 1986 to about 5.5 episodes per 10,000 patient-days in 2001. So there was a significant increase in the rate of CDAD during that time, but again it was limited to episodes in ICU patients only.

There are a number of limitations of the NNIS system (now the National Healthcare Safety Network). First, NNIS includes data from only a small number of US hospitals. At the time of our analysis, only about 350 hospitals were participating, but only a fraction of those (about 211) were reporting ICU data. So only about 211 hospitals out of the more than 5000 hospitals in the United States were participating in NNIS. Second, the NNIS sample is a nonrandom (convenience) sample and it is biased towards large teaching hospitals. Third, as I mentioned before, hospital-wide component reporting was discontinued a number of years ago, so there are really no hospital-wide incidence data. Fourth, there are no data from non-acute-care facilities or acute-care facilities that had 100 beds or fewer. And finally, as with any surveillance system, there is considerable variability in surveillance intensity, compliance with applying the definitions, and even the microbiologic methods used to identify CDAD patients. However, it was the best and only prospective healthcare-associated infection incidence data available at the time to do such analyses.

Another study, also a CDC study and conducted by Dr. Clifford McDonald and co-workers, was published in Emerging Infectious Diseases in 2006. They took a different approach. Rather than looking at the NNIS data, they analyzed National Hospital Discharge Survey (NHDS) data for CDAD as either a first-listed diagnosis or any diagnosis for the period 1996 through 2003. The rate for any diagnosis in 1996 was about 30 cases per 100,000 population, and by 2003 it was about 60 cases per 100,000 population. It's important to realize that Archibald and co-workers used patient-days in the hospital as the denominator, whereas in this study, general US population was the denominator. Again, there are some limitations to using hospital discharge data: First, the NHDS database includes only about 475 acute-care hospitals; there are no data from Veterans Administration hospitals, military hospitals, or non-acute-care hospitals. Second, it has been well documented that healthcare-associated infections (HAIs) are grossly underreported in hospital discharge data. This database is totally dependent on medical-record reviewers and medical-record coders accurately coding for CDAD using international classification of diseases (ICD)-9 codes to capture CDAD in this administrative database.

Several studies have looked at the validity of using administrative data, such as ICD-9 codes to capture either HAIs in general or CDAD in particular. A study done in a Veterans Administration hospital found that less than 50% of the CDAD cases were captured with ICD-9 coding. Another study from Washington University (St. Louis, Missouri) found that administrative data were comparable to active prospective surveillance data, but they also found 2 types of errors: CDAD patients who were not reported, and patients reported as having CDAD who did not.

With ICD-9 codes there is no standardization of definitions for infections. In contrast to the NNIS system, for which there are specific definitions (and the infection-control personnel are very familiar with these), there is a lot of variability in how medical-record reviewers apply ICD-9 codes, particularly for HAIs. It has been shown that infection preventionists, who conduct active surveillance, detect HAIs much better than medical-records personnel do retrospectively.

Subsequent to the study by McDonald and coworkers, the Agency for Healthcare Research and Quality conducted a similar subsequent analysis of the same database for the period 1995 to 2005. They found that the rate of CDAD had increased from about 35 cases per 10,000 discharges (they used cases per 10,000 discharges vs cases per 100,000 population) to 78.6 per 10,000 discharges by 2006. So the case rate more than doubled during that 12-year time period.

Subsequently, a study by Zilberberg and coworkers[8] was published in Emerging Infectious Diseases. They used an established database, the National Inpatient Survey (NIS), which is similar to the NHDS but includes data from a larger number of hospitals and a larger number of states. They looked at data from 2000 to 2005 and found that for all patients, the rate had not increased as dramatically as some of these other studies indicated, but the CDAD rate in patients 65-85 years of age and patients 85 years and older had increased dramatically. They found that in 2000 there were about 134,000 cases of CDAD and that by 2005 there were 291,000 cases.

Some additional points are important in terms of the NHDS and the NIS. First, the limitations of the NHDS that I mentioned earlier, in particular the total dependence on ICD-9 coding, is also true for the NIS. The NHDS, as I also mentioned, includes about 475 acute-care facilities; the NIS includes a larger number of facilities from a larger number of states. During the period 2000-2005, the number of participating states increased, so there is the issue of hospitals coming in and hospitals going out. Second, the NHDS has the capacity to capture the first 7 discharge diagnoses, so if CDAD is listed as a diagnosis beyond that (ie, 10th or 12th), the database will not capture it. And although the capability of the NIS was expanded to capture about 15 discharge diagnoses, the average number of diagnoses actually captured during this study period was only 5. The capture rate varies from state to state; some capture more discharge diagnoses than others.

Medscape: Would you tell us about a CDAD prevalence survey that you recently conducted?

Dr. Jarvis: Because the NNIS system data were relatively limited to ICU patients, and because the different surveys I mentioned were based on incidence data and limited in the ways that I described, we felt that it was important to conduct a different type of survey to get a different picture of CDAD. Rather than doing an incidence study, we decided to do a prevalence study. And with that, we went to the Association for Professionals in Infection Control, which is the largest infection-control organization, with approximately 10,000 infection preventionists or infection-control personnel at hospitals in the United States. We asked them to choose 1 day during a 15-week period that was convenient for them and to tell us how many inpatients were at their facility and how many inpatients had CDAD, again on that 1 day only. We did not want them to do any additional testing; we only wanted them to look at their microbiology, infection control, or other records (such as antimicrobial use) to identify current inpatients with CDAD.

Medscape: Why did you do a prevalence study vs another incidence study?

Dr. Jarvis: There are several reasons. Incidence studies usually capture data over a longer period of time, usually measured in years. The CDC's NNIS system collects a limited amount of information over a long period of time, similar to the NHDS and the NIS. In other words, people are asked to collect data, usually for years, and so the trade-off is that you are very limited in the amount of data that you can capture. For example, within the NNIS, NHDS, or NIS, there is relatively little, if any, information about the hospitals (other than size and location), treatment of the patient, patient risk factors for CDAD, or outcomes other than possibly death.

We wanted to collect a greater amount of data over a shorter period of time. One of the benefits of a prevalence survey is that you can ask much more detailed questions. In fact, our survey questionnaire was 6 or 7 pages long. We asked information about the hospitals, what their CDAD infection-control practices were, what they used for environmental cleaning, what kind of isolation protocols they used for CDAD, what kind of ICUs they had, and what HAI surveillance they performed. We asked about antimicrobial stewardship programs and the different elements of those programs. Then we asked questions to capture information about CDAD. Among those patients identified, we collected extensive information about exposures that those patients had, what treatment they received, and their outcomes. If you tried to capture all of that data in either the CDC NNIS system, NHDS, or NIS, it would be so overwhelmingly burdensome that no one would be willing to do it. So it's a very different type of study. One is capturing a narrower amount of information over a long period of time, and the other is capturing a more extensive amount of information over a short period of time.

Medscape: A total of 648 hospitals responded to your survey. How does this compare with the distribution of US acute-care facilities?

Dr. Jarvis: This is an important question because, as I mentioned, the NNIS system is a convenient sample of a relatively small number of hospitals and is biased toward large academic centers. There are fewer data available on who is reporting to the NHDS or NIS. We looked at the hospitals that were participating in our survey and then went to the American Hospital Association (AHA) database, but unfortunately this database lags behind several years. However, there is not a very big change in the number or geographic distribution of US hospitals from year to year. We looked at 2 things: the hospital size as measured by the number of beds and the geographic distribution of the surveys.

As I mentioned earlier, the NNIS system (before it became the CDC National Healthcare Safety Network ) did not include hospitals with fewer than 100 beds. Because the average US hospital has fewer than 100 beds, we wanted to see how well we were capturing information from those hospitals. When we examined hospital respondents by their number of beds, we found that the AHA database had a larger number of facilities with 6-24 beds (7.3% of the AHA sample vs 1.8% of our sample). For 25-29 beds, the AHA sample reported 19.8% vs 6.5% of our sample; and for 50-99 beds, the AHA sample reported 21.8% vs 10.2% of our sample. So as you can see, hospitals with fewer than 100 beds account for almost 50% of US hospitals, whereas in our survey, less than 20% of the hospitals were in this category. As a result, if you look at hospitals that had 100-199, 200-299, 300-399, 400-499, or 500 and more beds, we had larger percentages, but often they were not that different from the AHA hospital percentages. For example, 22.9% of the AHA sample was 100-199 beds vs 26.8% in our sample. In general, we found that our sample included significantly fewer respondent hospitals with fewer than 100 beds vs the AHA sample: 18.5% vs 48.9%, respectively. In contrast, we had a larger proportion of hospitals with 100 beds or more: 81.5% vs 51.1% for AHA. In general, however, we captured data from hospitals in all size categories.

Next, we looked at the geographic region distribution of our and the AHA surveys. The AHA divides the country into 9 different census divisions: New England, Mid-Atlantic, South Atlantic, East North Central, East South Central, West North Central, West South Central, Mountain, and Pacific. We found that our respondents represented a smaller percentage of hospitals in the West North Central, Mountain, and Pacific divisions compared with the AHA's, but that we had the same distribution as the AHA for the South Atlantic, East South Central, and West South Central divisions. We had a slightly higher percentage of respondents in the New England, Mid-Atlantic, and North Central divisions compared with the AHA. The lowest percentage we had in any division was 4.9% (in the Mountain Division) compared with AHA's lowest percentage of 4.2% (New England) in any region. The largest percentage we had in any division was 19.1% (in the East North Central division) compared with AHA's largest percentage of 15.1% (South Atlantic and East North Central Divisions). What we've found doing this type of comparison with the AHA -- which has not been done with the NNIS, NHDS, or NIS participants -- is that we have a very good cross-section of all types of hospitals by bed size and geographic regions of the country.

Medscape: Can you tell us more about the types of facilities that responded to your survey?

Dr. Jarvis: In terms of hospital characteristics, we found that medical school-affiliated hospitals accounted for 26.5% of our respondents and 24.4% were reported as being tertiary-care centers. The median number of licensed beds was 224 and the mean number of inpatients on the day that each survey was conducted was 171. The hospitals had a median of 16 ICU beds. We also asked them about room design because that can have an influence on infection-control practices. The median number of private rooms was 50 and the median number of semiprivate rooms was 15. We also asked what percentage of their rooms are designed for 3 patients or more, and the median was zero. So the majority of facilities have a room design, whether it be private or semiprivate, that should facilitate the correct procedures for isolation of a patient infected with C difficile.

Medscape: Were C difficile rates increasing or decreasing at the respondent hospitals in your survey?

Dr. Jarvis: That is a very important question, because if you look at the CDC's multidrug-resistant organism (MDRO) guidelines published in 2006, infection-control recommendations were divided into 2 tiers. The first tier addresses basic infection-control practices for acute-care facilities. The second tier is for facilities where the MDRO (C difficile, methicillin-resistant Staphylococcus aureus, multidrug-resistant Acinetobacter species, etc.) rate is not decreasing. If that is the case, hospitals should advance from tier 1 to tier 2, which means that they need to apply more aggressive infection-control measures. We asked the hospitals to look at their C difficile incidence rates for the last 3 years and tell us whether they were increasing, stable, or decreasing. Forty-one percent reported that their C difficile infection rates were increasing and 41% said that they were remaining stable. In other words, 82% of the hospitals reported that their C difficile infection rates were not decreasing and, therefore, would have to move to tier 2 for more effective control of CDAD. In contrast, 18% of hospitals said that their C difficile-associated infection rate was decreasing. We think this is very important; it shows that the majority of US hospitals fall into tier 2 of the MDRO guidance and need to apply more aggressive infection-control measures if they're going to control CDAD.

Medscape: What prevalence rate for C difficile did you find?

Dr. Jarvis: Of the 648 hospitals that participated, 1443 C difficile-positive patients were reported. On the days that the point-prevalence surveys were conducted, the total number of patients was 110,550. If you look at AHA data, that is about 20% of the US inpatient population, giving us a point-prevalence rate of 13.1 per 1000 inpatients. We also found that there was a fair amount of geographic variability when we categorized the rates per 1000 inpatients as follows: 20 or more cases, 15 to < 20 cases, 12.5 to < 15 cases, 10 to < 12.5 cases, 7 to < 10 cases, and 0-7 cases. The highest CDAD rate for 20 or more cases per 1000 inpatients was in Rhode Island, where the rate was 28.9. The CDAD rate in another New England state, Maine, was 23.8. The rates for Michigan, Arkansas, and Kentucky were 22.7, 26.7, and 21.8, respectively. So 5 states had CDAD rates of greater than 20 cases per 1000. In contrast, the lowest rates tended to be in states that generally have small populations, such as Idaho. Other states with lower CDAD rates were Nebraska, Iowa, Louisiana, Mississippi, and North Carolina. We did not see geographic clustering of very high rates of CDAD but rather variation across the country.

Medscape: What infection-control precautions were your respondent hospitals using for patients with C difficile?

Dr. Jarvis: Again, an important question, because CDAD is controlled through a variety of measures, including rapid detection, placing the patient in contact isolation, improving antimicrobial use, and making sure that you have very good environmental cleaning. We asked about the infection-control measures used in 2 different settings: ICU and non-ICU. We were happy to see that in 91.3% of ICUs and 92.2% of non-ICU settings, contact isolation was used for CDAD patients; in 8.3% of ICUs and 7.1% of non-ICU settings, contact isolation-plus was used. This means that almost 99% of the hospitals were using contact isolation or more. Less than 1% reported using "standard precautions," which are not recommended for CDAD, and none reported using no isolation at all.

Placing patients in contact isolation is being done correctly in terms of what isolation precautions they're using. A few questions come up that we really don't know the answers to: When are they placing CDAD patients in contact isolation? Are they waiting until a patient develops diarrhea, gets a test, and then (hours or days later) that patient is moved into contact isolation after the test result is returned? And when are they moving those patients out of isolation? There have been several studies showing that CDAD patients continue to contaminate the environment for 2-3 days after symptoms resolve. How frequently are CDAD patients being removed from isolation as soon as their symptoms resolve? We also do not know how well environmental cleaning is being done and, very important, how compliant healthcare workers are with the contact precautions. You can place the patient in a private room, or you can cohort the patient and require that a gown and gloves be worn and that hand hygiene be practiced by all healthcare workers going into that room and touching the patient or contaminated environment. But healthcare worker compliance determines whether it works or not. Although we did not capture that type of data, we were happy to see that only a very small proportion of the respondents were not using the appropriate contact-isolation precautions.

Cell Phones Helping Spread Hospital Superbugs?

March 7, 2009
An excerpt by Chris Matyszczyk

Perhaps you, too, have friends who go nowhere without their hand sanitizer. Perhaps you, too, laugh at them beneath your clenched top lip.

However, researchers at Ondokiz Mayis University in Turkey are discovering that germs lurk everywhere. Especially in cell phones belonging to doctors and nurses, according to an Agence France Presse report. In fact, these phones may be a significant source of infections such as MRSA, which seems to have become an increasing danger in hospitals all over the world.

In researching the cell phones and dominant hands of 200 doctors and nurses, the researchers found that 95 percent of the phones were home to at least one bacterium. Nearly 35 percent hosted two. And 11 percent enjoyed three or more bugs of various descriptions.

What is perhaps most stunning is that 1 in 8 were found to harbor the potentially deadly MRSA bug, which is said to be the cause of 60 percent of all hospital infections.

It's something that few people think about, but how often does anyone clean their cell phone? We're all being told relentlessly to wash our hands. Especially if we're employees of the restaurant in which the restroom that carries the notice is housed.
But cell phones sit in fluff-filled pockets, on dirty train tables, in scarcely pristine meeting rooms, on car seats that may have recently been vacated by the bottom of someone not necessarily as anally retentive as ourselves, and then we put them to our fingers, our ears, and our mouths.