Hand Washing: Time Well Spent

Reston Hospital Center has boosted its hand-hygiene compliance, which has led to a drop in the infection rate.

By Manoj Jain
Special to The Washington Post
Tuesday, August 5, 2008

One morning on hospital rounds, I saw a physician colleague enter the intensive care unit where a patient lay intubated and sedated. With his hands unwashed and ungloved, the physician palpated the patient's abdomen, scratched his own head and then placed his stethoscope on the patient's chest to listen to his heart. Then he walked to the nurses station, rubbed his nose and entered a note in the patient's chart.

There was nothing unusual about this. Not washing hands scrupulously remains common practice for professionals at most hospitals, even though abundant research shows that it controls outbreaks of infectious disease, reduces transmission of resistant organisms and cuts infection rates among hospitalized patients.

That same day in a public restroom, I noticed a man go straight from the urinal to the door, bypassing the sinks. Unfortunately, that's a common occurrence, too.

Despite recommendations, nearly 60 percent of health-care workers do not wash hands while on duty. Among the general public, according to a Harris Interactive survey conducted last year, 12 percent of women and 34 percent of men do not wash their hands after using a public restroom. Why?

For one thing, rigorous hand washing is time-consuming. Guidelines advise that we first rinse, then soap for 20 seconds, then rinse again for 30 seconds; after this, we paper-dry our hands and turn the faucet off using the paper towel. For health-care workers, the procedure is supposed to be followed before and after every patient encounter. That means two minutes per patient visit, which adds up to an hour for a doctor who sees an average 30 patients a day, and 2 1/2 hours per shift for an ICU nurse. I have yet to find a doctor or a nurse who is so diligent.

In the past few years, the hand-washing exercise has gotten simpler, with the increased acceptance of alcohol-based gels. I enter a patient's room, squirt gel onto my palms from the wall dispenser, then rub the back of my hands, my fingertips and my thumbs as I introduce myself and ask the patient why he or she is there. Then as I exit, I gel my hands again as I ask, "Do you have any questions?"

Despite the ease of using alcohol gel, studies show that nearly a quarter of health-care workers do not regularly disinfect their hands. Few realize that our bodies are like petri dishes teeming with 300 trillion organisms and that our hands are like swabs for the transmission of antibiotic-resistant bacteria such as MRSA, pseudomonas and C. difficile.

What can we do to improve hand-washing rates?

First, we must admit that the "Just do it!" approach of the past 150 years has failed. Behavioral theory tells us that changing behavior in a change-resistant culture cannot be accomplished with a single intervention.

We need a carrot-and-stick approach. Let the carrot be a campaign of incentives and awards for hand washers, similar to the eat-more-vegetables campaigns that many parents conduct with their children.

Then we need the stick. Health facilities need to monitor the hand-washing rate for each unit and provide feedback and improvement strategies to health workers at the bedside. Observers need to be stationed in ICUs and hospital wards, much like traffic cops at the bottom of a hill. Repeated failures to comply, as in the case of my physician colleague, would result in a letter to the offender and a note in his credentialing file or employment record.

Hospital administrators, not just their staffs, also need a stick over their heads. Starting in October, hospitals will be penalized for the consequences of unwashed hands: Medicare will no longer pay for complications arising from certain hospital-acquired infections, which in many cases result from poor hand hygiene. This will be a powerful incentive for health executives to improve hand-washing compliance.

An aggressive approach to hand washing has worked. At the University of Geneva, a hospital-wide program promoting hand hygiene helped lower the hospital-acquired infection rate from 17 percent to 10 percent between 1994 and 1998.

At Novant Health hospitals in Charlotte and Winston-Salem, N.C., a 2005 hand-washing campaign -- complete with billboards and computer screen savers -- brought about a sustained drop in MRSA and hospital-acquired infections. At Reston Hospital Center, an awareness campaign introduced in 2006 has boosted hand-hygiene compliance to more than 90 percent; it also led to a drop in the hospital's infection rate.

A 2007 study from John Hopkins showed that using simple checklists as reminders about basic hygiene such as hand washing and about proper draping, gloving and masking reduced the central intravenous line infection rate by 66 percent in ICUs.

About my physician colleague: I approached him and gently reminded him. "The patient likely has resistant bacteria -- it is really important that we wash our hands after every encounter." Suddenly self-conscious, he groped for the alcohol gel dispenser just a few feet away.

As for the man in the public restroom: I'm sure that I got his germs on my hands from the door handle.

Manoj Jain is an infectious disease physician in Memphis and a medical director of Medicare's quality improvement organization in Tennessee. Comments:health@washpost.com.

10 Germy Surfaces You Touch Every Day

Experts Tell Where Cold and Flu Viruses and Other Germs Lurk
By JOSEPH BROWNSTEIN and RADHA CHITALE
ABC News Medical Unit
Sept. 5, 2008

Many surfaces and objects you come in contact with every day are covered in germs -- but then again, so are you. Many of the surfaces that we come into contact with on a daily basis are a breeding ground for dangerous germs -- including the viruses that can lead to cold and flu.

"Ninety percent of you is composed of germ cells," said Philip Tierno, director of clinical microbiology and immunology at NYU and author of "The Secret Life of Germs." He explained that while we are constantly in contact with germs, only a small minority will cause any harm. "Of the 60,000 types of germs that people come in contact with on a daily basis ... only about 1 [percent] to 2 percent are potentially dangerous to normal people with normal immunity," he said.

That works out well for us, because pretty much any surface contains some of these microscopic organisms. "There's very few surfaces that are truly clean," said Dr. Aaron Glatt, president and CEO of New Island Hospital in Bethpage, N.Y., and a spokesman for the Infectious Disease Society of America. "You're almost never going to culture something and not find some germs on it."

With that in mind, there is a simple activity that anyone can engage in to stay as safe as possible from surface germs.

"People should know that washing their hands is the single most important mechanism we have to prevent infection," said Glatt. While he stressed that "the optimal goal is to practice good personal hygiene, good household hygiene and good food hygiene," Tierno also noted the importance of clean hands. "You don't need to live in a bubble ... but you do need to be aware," he said. "You can touch surfaces, but just clean up before you eat or drink or before you touch your face." "If you wash your hands prior to touching your face or prior to eating or drinking, which should be the norm, you cut your risk to virtually nil."

Purses and Wallets:
Although they serve similar functions for women and men, purses and wallets are germy for entirely different reasons.
"It behooves you not to put your purse on the floor or outside ground if you can help it," said Tierno. But many women don't follow that bit of advice, so their purses pick up the bacteria from wherever they're placed -- from the soiled ground to the bathroom floor.

While some might be willing to put it there because they think the floors are cleaned regularly and thoroughly, that isn't always the case. "The way these places are cleaned is not ideal all the time," said Tierno. Instead, he recommends putting your purse on a bench or a seat.

Wallets, meanwhile, pick up a lot of bacteria from what goes into them."Men's wallets were pretty bad on the inside," said Charles Gerba, a professor of microbiology at the University of Arizona whose work has earned him the nickname "Dr. Germ."

Paper currency has a way of getting around, from germ-filled hand to germ-filled hand. It picks up germs, viruses and often trace amounts of illegal drugs -- that's not just an urban legend; several studies have confirmed that a majority of U.S. currency contains trace amounts of cocaine. And of course, all of that ends up in your wallet.

Because men keep wallets in their pockets, the wallet is close to body temperature -- an ideal temperature for bacteria to breed. "When handling the contents of your wallet, after it, wash your hands," said Tierno.

The problem isn't as bad with coins, largely because the metals -- particularly nickel -- often kill many of the bacteria.

Remote Control:
The next time you sit down for a late-night movie at home, you may want to keep your hand out of the popcorn bowl if you've been handling the remote. People are constantly handling their remote controls -- and, as Gerba points out, nobody ever disinfects them.

No wonder, then, that it is often the dirtiest object in a hotel room. Tierno recommends wiping it down at least once a week, and more often if someone who is sick handles it. Gerba points out that sickness will make the remote even worse, because people who have a cold or the flu tend to "jump in bed with the remote control and contaminate it."

The laundromat is hardly a bower of cleanliness, but even laundry done at home is rife with germs. There is about 0.1 gram of fecal material in a piece of underwear, Gerba said. That amounts to approximately 100 million E. coli bacteria in an average undergarment load.

Unfortunately, only 5 percent of people use very hot water to wash their clothes and then dry them for a full 45 minutes, a process Gerba said would kill more bacteria. Skipping these steps means that transferring wet clothing into a dryer leaves a film of germs all over your hands.

To minimize exposure to harmful bacteria, Gerba recommends doing laundry that requires bleach as a first load to disinfect the machines and saving undergarments for a final load. He also cautions against using the same sorting tables for clean and dirty laundry since the E. coli from the dirty clothes will transfer to the table and then back onto your freshly laundered clothes.

"Your clothes are a lot germier than they were 50 years ago," Gerba said. "Never kiss anyone who has just done laundry for you."

Foodwise - You may be better off preparing your food on another surface than a cutting board.

According to Gerba, there are 200 times more fecal bacteria on a cutting board than a toilet seat. The reason, he explained, is that many people rinse off their cutting board rather than thoroughly washing it. "You have potential pathogens when you're dealing with food," said Tierno. He recommended preparing a solution of a quart of water and "a jigger of bleach" and then wiping down food preparation surfaces before making anything on those areas of the kitchen.

Your Phone:
The telephone provides a convenient meeting place for two different sources of germs -- your hands and your mouth. After all, as Tierno, pointed out, "People are the source of most of the germs."These germs are not just from your hands, but sources like your saliva as well -- which is why the mouthpiece is often even dirtier than the handle.

And again, it's not a device people clean too often, which is why both land lines and mobile phones present a problem. A study done in Israel last year showed that 20 percent of hospital workers' cell phones had some form of harmful bacteria on them.

Buttons:
These innocuous-looking offenders are difficult to avoid, which is part of the reason why push buttons can be crawling with germs. Further, ubiquitous buttons, found on ATMs, elevators, telephones and drink machines, among other things, are located in areas that are not often cleaned and disinfected to kill bacteria and viruses.

Gerba noted that the first-floor buttons in elevators were the dirtiest."Everyone needs to go to the first floor," he said. Worse, these germs get transferred to the body part that comes in contact with faces the most -- fingers and hands. While avoiding these types of buttons can be almost impossible, Gerba does have a few recommendations. "Knuckle it or wait for someone else to push it for you."

Airplane Bathrooms:
"These are probably the worst," Gerba said. "They are the germiest restrooms you'll run across." But bathrooms in general are not as germ-ridden as other areas -- a kitchen sink or laundry machine, for example. Compared to several items on this list, toilets are a beacon of cleanliness because they are cleaned and disinfected on a regular basis, even public toilets.

Airplane bathrooms get cleaned, but the high volume of people they must cater to in a short amount of time leaves them very dirty very quickly.Gerba said a normal aircraft has one bathroom per 50 people. Discount airlines have one bathroom per 75 people.

"There is a thin layer of E. coli over the sink," and other surfaces, Gerba said, adding that many people, especially men, will not wash their hands effectively because the sink is small, and dirty hands transfer germs to the face easily. Interestingly, the cleanest toilets are probably those in public areas of a hospital, Gerba said.

Shopping Carts:
An individual probably has a fairly short interaction with the shopping cart at the local grocery store. Unfortunately, that interaction covers all the danger zones for contamination: hands, faces and food. In one study done by his group, Gerba said he found E. coli on almost half the shopping carts the group tested. These are the microbes and pathogens that are transferred from the cart to your hands, to the food you select and then to the face if the hands touch it.

In addition, children often sit in the seat provided in larger shopping carts, adding to the germ load on the cart. "That's putting a kid's butt where you put your broccoli," Gerba said. A shopping cart is a good example of an item where a quick wipe down with a disinfecting wipe and some alcoholic hand sanitizing gel recommended by the Centers for Disease Control and Prevention can prevent a lot of cross-contamination.

Prevention in a Pump

Sanitizers Give the Upper Hand Against Colds - by Dr. Clifford Bassett

From kindergarten through middle and high school, many schools and classrooms now have an abundant supply of donated liquid hand sanitizers.

These antiseptic gels are quickly becoming an additional level of protection between students and ubiquitous viruses, which, especially during the wintertime cold and flu season, are present on a variety of common surfaces.

Even the kids seem to notice a difference.

"Since we starting using liquid hand sanitizer in our school, my classmates seem to be healthier, with fewer kids getting colds," said Dylan, a seventh grader at East Side Middle School in New York City.

And in many ways, these sanitizers offer a low-cost, low-tech solution to a common, potentially costly seasonal problem.

Hand sanitizers are gaining popularity, as they are portable, easy to use and perfect for places where there is no faucet and sink available for hand washing, such as in the subway or on a train.

Thus far, several studies over the past few years have suggested that hand sanitizers do limit the spread of germs. In a September 2005 study in the journal Pediatrics, researchers showed that families who used alcohol-based gels had a 59 percent lower rate of gastrointestinal illnesses -- which cause diarrhea and vomiting -- caused by germs spread from one family member to another.

Other research has focused more on the germs that cause common colds and the flu, tracking rates of school absenteeism among kids whose families use the products.

As for my New York City based allergy practice, I have personally observed that among my employees and co-workers who aggressively use gel-based alcohol sanitizers, there has been a change in successfully avoiding the vicious cycle of recurrent cold-like infections. The goal is to reduce transmission of a variety of viruses, including the common cold as well as gastrointestinal infections.

The Centers for Disease Control and Prevention have recommended alcohol-based liquid gels over using soap and water, as long as your hands are not very soiled.

Not All Hand Sanitizers Created Equal -
One caveat: It is important to check the bottle for the level of alcohol in a sanitizer.

It is generally thought that it should contain at least 60 percent alcohol -- even better if the concentration is greater than 90 percent. Apparently, less potent solutions are not very helpful in killing the viruses that cause many household infections.

Of course, plain old soap and water is just fine if it's available. But this is not always the case when it comes to our busy lives -- especially bearing in mind that we will be taking on those pesky germs at home, school and work.

Nowadays, many different approaches are used in the fight against germs. We have "foam based" disinfectants, antibacterial soaps, cleaning wipes and aerosolized disinfectants. In a more vigorous environment, especially in health care or medical settings, iodine-based and other chemical disinfectants are frequently utilized for more robust infection-busting capability.

So now for the final question: Can hand sanitizers save you completely from cold and flu? The answer, most likely, is no. But just like conscientious hand washing, avoiding sick co-workers and maintaining a healthy diet may certainly help keep you well this holiday season.

Dr. Clifford Bassett is vice chair of the Public Education Committee for the American Academy of Allergy, Asthma and Immunology. He is also an assistant clinical professor of medicine and otolaryngology at the Long Island College Hospital in Brooklyn, N.Y.

Cheap Black Market Antibiotics- Bad Choice for Uninsured

No Prescription for Antibiotics? No Problem
By HOWARD MARKEL - Contributor to The New York Times

Jose Martinez, a 29-year-old Dominican immigrant who runs a bodega on the Upper West Side of Manhattan, almost always manages to find whatever his customers need on his store's bulging shelves.

When asked for medicine for an infection, Mr. Martinez often reaches for a box of pills called Ampitrex, a brand name for the antibiotic ampicillin.

The pills sell for 50 cents each and are easily bought at bodegas on the Upper West Side and in Washington Heights, East Harlem, Brooklyn, Queens and the Bronx.

Under federal law, ampicillin, like all antibiotics, requires a doctor's prescription. But Ampitrex is made in the Dominican Republic, where it is readily available and smuggled in small quantities into the United States. It is then sold in small markets much like over-the-counter pain relievers.

''In my country you can go into any store and get antibiotics like this one,'' Mr. Martinez said. ''This Ampitrex, it's 500 milligrams and absolutely pure. For throat pain, infections, it works by the next day. One to two days tops. Once you feel better, that's it. You're done taking the pills.''

Carlota Hurtado, 69, of Washington Heights said that getting antibiotics without seeing a physician, or even a pharmacist, was easy. ''Once in a while, when I have been sick with a cold or a sore throat, I have gone into a bodega to buy antibiotics,'' she said. ''I know a lot of people who when they are sick do the same thing. I take them until I feel better. When the cold goes away, I throw the pills away.''

Easy access to antibiotics is now common in certain areas around the nation, especially in border states. Dr. Richard Besser, director of the Campaign for Appropriate Antibiotic Use for the Centers for Disease Control and Prevention, said the sales at bodegas were only part of a much broader problem involving antibiotic overuse in America.

Many health officials are increasingly concerned. Antibiotics are prescribed only for bacterial infections. They are ineffective against viruses. Different antibiotics are used for different types of bacteria, so merely taking one does not mean it will cure an ailment. Taking the wrong antibiotic may cause worsened infections or allergic reactions.

Most antibiotics need to be taken for 7 to 14 days. When taken for only a few days, the likelihood of a mutation in a bacterium's genetic structure is increased. These changes can make the germs resistant to the antibiotics meant to kill them.

Unlike folk remedies, some of which may be toxic but pose a risk only to the person taking them, antibiotic misuse has far wider ramifications. For example, until recently, ampicillin was the drug of choice for infections of bacteria called streptococcus pneumoniae, a common causes of pneumonia and ear infections. But according to the C.D.C. about 35 percent of the strains of this germ across the nation are now resistant to ampicillin.

Dr. Stuart Levy, a microbiologist and the author of ''The Antibiotic Paradox: How the Misuse of Antibiotics Destroys Their Curative Powers,'' published this year, described antibiotics as societal drugs. ''Their use by an individual impacts others in the society because of the drug's ability to affect the bacteria in that community and to propagate resistant germs,'' he said.

''Over-the-counter antibiotics are more likely to be misused,'' he added, increasing the likelihood of resistance and the spread of resistant bacteria to others.

This problem often begins as a local phenomenon, he said, but the resistant germs spread as people move from place to place.

Dr. Jaime Lopez-Santini, a physician at Settlement Health, a nonprofit clinic in East Harlem, says his patients tell him they can get any antibiotic they want. ''By the time they come to see me with a sore throat,'' he said, ''they have already treated themselves with antibiotics they purchased at bodegas.''

Pharmacists like Orlando Cueva of Morningside Heights try to warn customers of the dangers of self-prescribed antibiotics, but often with poor results. ''Many people come in and ask for antibiotics, and I tell them that it requires a prescription from a doctor,'' he said. ''But they say: 'No, it doesn't. I can buy them at any bodega.' ''

An East Harlem pharmacist, Godette Wallace, said, ''You have to understand, these are very poor people, and they don't have the money to see a doctor.'' As a result, he added, they have to find other ways to get medicine.

Elissa Maas, vice president of community health for the California Medical Association Foundation, which researches health care for the state, said her agency had seen ''an antibiotic underground,'' extending from the Mexican border to northern California.

''In our focus groups, Chinese and Russian immigrants, as well as Latinos, spoke about the relative ease with which they can obtain antibiotics at small markets, even swap meets,'' Ms. Maas said.

In El Paso, Salvador Balcorta, who directs the Faith Family Health Center, a community health and human services organization, says that many people in the United States are just beginning to experience a phenomenon that is part of daily life on the border. ''When you couple the problems of poor access to health care and poverty with the ease of self-medication, you have a much bigger problem,'' Mr. Balcorta said.

Dr. Jeffrey Brosco, a pediatrician who sees many Cuban and Nicaraguan patients in Miami, said it was not enough to ask what medicines a child was taking or if he was taking home remedies.

''We also ask if the child is already taking antibiotics and, specifically, which antibiotic, and how frequently they are taken,'' Dr. Brosco said. ''Amoxicillin is the most common, but I have seen many others. All are self-prescribed and easily purchased.''

While the practice is illegal, it is extremely difficult to control. Dr. David A. Kessler, the former Food and Drug Administration commissioner, who is now dean of Yale Medical School, said: ''F.D.A. 101 tells us that this is illegal. No question. It is being sold illegally and shipped into this country in ways that don't comply with our laws.''

But practically, he added, the agency cannot go to every bodega, although it can go after the company that makes these antibiotics if they are involved in their distribution.

In New York, the sale of Ampitrex and other antibiotics without prescription goes largely unchecked. Spokesmen for the State Health Department, the New York City Health Department, the Drug Enforcement Administration, the State Board of Pharmacy and the State Education Department's Office of Professional Discipline all said that while they occasionally reported complaints to the state attorney general's office, they neither seized the antibiotics nor apprehended those selling them.

The New York City Police Department said it rarely, if ever, arrested people for the sale of antibiotics.

Dennis Murphy, a spokesman for the Customs Service, said seizing antibiotics at the borders was not a high priority.

Dennis Baker of the office for regulatory affairs of the F.D.A. said:

''Even when a local or state regulatory authority moves in to close down these operations, they tend to move to another location. It's very difficult to get our hands around this.''

Infection Risk Linked to Premature Delivery

Each year in the United States, more than half a million babies are born prematurely, before 37 completed weeks of pregnancy. Many pre-term births are induced labor or cesarean delivery due to pregnancy complications or health problems in the mother or fetus, the premature rupture of membranes (PROM), or infections such as vaginal or urinary tract. But the trigger of almost half of all preterm births remains unknown. However, researchers suspect that an undiagnosed infection may be the trigger in a significant number of these cases.

To better understand the role infection plays in preterm birth, researchers at Stanford University in California studied samples of amniotic fluid saved from 166 women who went into premature labor at the Hutzel Women's Hospital in Detroit from 1998 to 2002. At the time, doctors used standard tests to check for signs of infection, but doctors David Relman and Dan DiGiulio used more sophisticated molecular testing known as polymerase chain reaction (PCR). They discovered that of the 113 women who delivered prematurely, 25 showed infection-those with the heaviest infection delivering the earliest. "We were surprised with the amount of unexpected bacteria we found in the fluid and the fact we encountered new species of bacteria," said Dr. DiGiulio.

Dr. Robert Goldenberg of the Drexel University College of Medicine in Philadelphia was not surprised by the results and suspects that as scientists continue to study amniotic fluid with improved techniques many more pathogens will be identified, according to ScienceNews. "We only know the names of relatively a few of all the bacteria that exist, and a lot of them are difficult to culture or can't be cultured with our current technology."

The researchers say this is likely their findings are an understatement, considering that the samples were so old the DNA in them had begun degrading. Currently, Dr. Relman and his team are studying fresh, rather than stored, amniotic fluid from 2,000 women who get routine amniocentesis in their second trimester. They hope that by identifying the infections before they induce preterm labor or birth, they "could potentially create a treatment for these infections and prevent a lot or possibly all of premature births."

Premature birth is a serious health problem. Premature babies are at increased risk of developing a wide range of health problems, as well as lasting disabilities, which include cerebral palsy, mental retardation, neurological, lung and gastrointestinal problems, vision and hearing loss, and learning disabilities. Premature babies often require care in a neonatal intensive care unit (NICU), whose specialized staff and equipment can deal with the multiple problems these ‘preemies' face.

The Stanford study was reported in PLoS One, the online journal of the Public Library of Science.

Top Of Page

Increased Scrutiny Has Hospitals Focusing More on Safety

By Keith Darcé
UNION-TRIBUNE STAFF WRITER
August 9, 2008

Sharp HealthCare executives have spent the past two weeks trying to reassure the public that their hospitals are safe amid news that recent lapses in management and medical care at Sharp Grossmont caused the deaths of at least three patients.

They're not alone in that challenge. Hospitals everywhere are vulnerable to human error, and they've all had to deal with patient-care crises.

In the past 16 months, state and federal regulators have named at least five hospitals in San Diego County with serious problems that contributed to the deaths of five patients, including those at Sharp Grossmont, and put hundreds of others in harm's way.

Since the California Department of Public Health began issuing fines in January 2007 for “immediate jeopardy” mistakes – those causing death or grave injury – it has penalized 39 hospitals statewide.

Local hospital administrators have strived to reduce errors by boosting training for their staffs, hiring more workers who focus on regulatory compliance and borrowing ideas from the airline industry, where workers contend with pressures and risks similar to those in an operating room or emergency department.

GROWING SCRUTINY
Health regulators and the public are paying more attention to the quality of patient care at hospitals:

California regulators are imposing fines as high as $25,000 on hospitals for each “immediate jeopardy” mistake that endangers patients. They're also publicizing the penalties.

In October, Medicare will stop paying for the cost of treating many infections and injuries caused by hospital errors.

Consumers, emboldened by the power of the Internet, are increasingly choosing hospitals based on quality rankings and reports.

The administrators said significant mistakes at their facilities generally have not increased over the years, but that scrutiny and prevention efforts have.

“I don't think there is any question that hospitals are more focused on quality and safety than ever before,” said Chris Van Gorder, president and CEO of Scripps Health, which operates four hospitals in the county.

Two of the network's hospitals – Scripps Memorial and Scripps Green, both in La Jolla – have suffered “immediate jeopardy” cases since last year.

The other facilities with such incidents include Sharp Grossmont, UCSD Medical Center in Hillcrest and UCSD's Thornton Hospital in La Jolla.

Besides handing out penalties, California health regulators are drawing the public's attention to big hospital mistakes by issuing news releases.

Starting in October, Medicare will stop paying hospitals for the cost of treating many of the mistakes their doctors and nurses cause.

And consumers concerned about the quality of their medical care can tap dozens of Web sites to compare hospitals.

Other policies are helping to create an overall carrot-and-stick approach to making hospitals safer. For example, Medicare and a growing number of private insurers base some of their payments on hospitals' ability to meet or exceed quality standards for patient care.

The elevated scrutiny is transforming the way many hospitals operate.

Teamwork has become the mantra among doctors and nurses, who traditionally have been divided by strict codes of hierarchy. Also, some hospitals have asked patients to join their systems of checks and balances.

At Thornton Hospital and the UCSD Medical Center in Hillcrest, surgery patients go through a checklist with their doctors and nurses before receiving anesthesia. Among other things, the list is designed to ensure that the right person has the right operation.

It was modeled after safety checklists that pilots use before flying.

“The culture of silence and the culture of secrecy that used to exist in hospitals is being stripped away,” said Memphis-based hospital consultant Stephen Harden, a commercial airline pilot and former Navy Top Gun instructor.

He helps hospitals, including those in the University of California system, and physicians apply safety practices from the aviation world to their health care settings.

The higher level of monitoring will push even the best medical centers to do a better job of preventing errors, said regulators and some hospital operators. But they also wonder whether heightened attention to each “immediate jeopardy” case will help patients make better decisions when choosing a hospital.

“It's difficult for consumers to judge whether a particular problem is isolated or whether it's part of a series of events,” said Ken August, spokesman for the state Department of Public Health. “Trying to decide the quality of care of a facility strictly from news stories is difficult at best.”

Sharp HealthCare's four hospitals have always done as much as possible to keep patients safe, said Nancy Pratt, the network's senior vice president of clinical effectiveness.

“Every health care organization wants to fix these things. It's not a lack of interest or effort,” she said.

But for decades, hospitals largely didn't face outside pressure to improve patient care.


In California, the shift kicked into high gear in January 2007, when state regulators began issuing fines as high as $25,000 for each serious safety breach. Regulators are developing rules to double that limit, and there is a bill in the Legislature to raise the maximum penalty even higher.

Nationwide, the current drive to minimize hospital mistakes dates back to 1999, when the Institute of Medicine issued its landmark report “To Err is Human.” The study estimated that 98,000 Americans die each year because of hospital and physician errors.

The recent increase in federal and state requirements for hospital patient care suggests that regulators aren't satisfied with the pace and breadth of change, said Roy Snell, CEO of the Health Care Compliance Association, which represents 7,000 professionals who manage regulatory compliance for hospitals and physician groups.

Most health care organizations are proficient at identifying lapses, Snell said, but they often fall short when correcting a weakness that requires changing well-established routines or punishing specific staff members.

Part of the problem is that the people charged with enforcement and disciplinary actions frequently come from the same ranks of doctors and nurses who make the mistakes, he said.

One solution is to transfer those duties to regulatory compliance specialists.

In a recent survey, about 52 percent of the compliance association's members said their responsibilities include helping ensure the quality of patient care, Snell said. That represents a major shift since the association was created 12 years ago, when almost none of the group's members dealt with quality assurance.

But some health care providers worry about giving oversight of medical care to people lacking clinical backgrounds. They said those individuals might not fully understand the complex and technical nature of hospital medicine.

“The idea is to improve patient care, not to punish doctors,” said Dr. Gary Vilke, who heads UCSD Medical Center's peer review committee.

An increasingly punitive regulatory system runs the risk of discouraging hospitals from disclosing mistakes, said Debby Rogers, vice president of quality and emergency services for the California Hospital Association.

“There's a balance of creating an environment where reporting (errors) is rewarded,” she said. “The last thing we want is for people not to report.”

Sharp Rise In Skin Infections In U.S.

ScienceDaily (July 29, 2008)

A national analysis of physician office and emergency department records shows that the types of skin infections caused by community-acquired MRSA doubled in the eight-year study period, with the highest rates seen among children and in urban emergency rooms.

The study, conducted at the University of California, San Francisco, examined annual data from the National Center for Health Statistics of patient visits for skin and soft-tissue infections from 1997 to 2005. The results appear in the July 28, 2008 issue of the Archives of Internal Medicine. During that time period, office and emergency room visits for all skin infections rose from 8.6 million nationwide to 14.2 million, according to Adam Hersh, MD, PhD, lead author on the paper and a fellow in the divisions of general pediatrics and of pediatric infectious diseases at UCSF.

The vast majority of that increase was attributable to visits for abscesses or cellulitis, which Hersh called the hallmark signs of infections from the variety of staph bacteria known as MRSA, or methicillin-resistant Staphylococcus aureus. Those infections rose from 4.6 million to 9.6 million during the study period. “This shows that community-acquired MRSA infections are occurring nationwide and affect all subsets of the population,” Hersh said. “But there clearly are some subsets that are disproportionately affected, such as children.“

The increase was predominantly seen among children and among patients who visit emergency rooms in urban areas at so-called safety net hospitals. Those are hospitals in which at least half of the patients receive Medicaid or are uninsured. From 1997 to 2005, the number of visits for abscesses or cellulitis nearly quadrupled in safety-net emergency departments, from 1.3 people per 1,000 total population to 4.9. Among children, the incidence nearly tripled from 10.1 patients per 1,000 children to 27.6. By contrast, incident rates among patients older than 45 rose less than 50 percent, from 27.9 to 41.3 patients per 1,000 adults in that age group.

By comparison, the number of patients who sought medical care for any skin infection rose from a rate of 32.1 to 48.1 visits per 1,000 people during the same period. Previous studies at UCSF and other urban medical centers have indicated that MRSA had begun to spread outside hospital settings in the late 1990s, but until now, no one had been able to verify those suspicions with hard data or to indicate the extent of MRSA nationwide, Hersh said. There also was no way of assessing whether the rise was due to population shifts or to people visiting emergency rooms instead of family physicians.

“This validates what San Francisco physicians have been suspecting for several years,” says Henry Chambers, MD, a co-author of the study and UCSF professor of medicine at San Francisco General Hospital. “This is the first national report to look at the impact of MRSA on public health nationwide.” Chambers is lead scientist of a large multi-centered clinical trial recently funded by the National Institutes of Health to study treatment of community-acquired MRSA infections.

While the rate of this rise is dramatic, public health researchers say these infections can be limited with simple behavioral changes in hygiene. “This is certainly a cause for increased awareness among clinicians and the public nationwide, but it is not cause for alarm,” said Erica Pan, MD, MPH, a UCSF assistant professor of pediatric infectious diseases and a medical epidemiologist at the San Francisco Department of Public Health. Pan was not involved in this study, but works frequently with the UCSF team on MRSA research.

“A simple way to avoid these and many other infections is to practice good hygiene habits, such as routine hand-washing with soap and water, as well as by covering open cuts and wounds when participating in sports or other activities involving skin-to-skin contact with other people,” she said. “If you notice that you or your child has a skin infection that does not seem to get better on its own after a few days, consult a medical provider.”

The study also found a shift in prescribing practices among physicians seeing these patients. The number of prescriptions written for medications effective against MRSA infections more than tripled over the study period. At the start of the study, less than 8 percent of antibiotics prescribed nationwide for skin infections were those effective for MRSA infections. By 2005, 28 percent were in that category.

“We had anticipated seeing a rise in office visits for abscesses due to the emergence of community-acquired MRSA, but we were somewhat surprised by the rapid changes in antibiotic prescribing,” Hersh said. “It is evidence of growing awareness of community-acquired MRSA nationwide among physicians.”

Hersh acknowledged that the data, which is the most recent available, is too old to show what is happening right now, or even last month, but does confirm that the emergence of community-acquired MRSA in the 1990s led to a rapid increase in the number of patients with skin and soft tissue infections nationwide. It also raises opportunities for further research, including determining the risk factors for developing an abscess and how best to care for patients with recurrent infections, he said.
Ralph Gonzales, MD, MSPH, a professor in the UCSF departments of medicine and of epidemiology and biostatistics, is the senior author on the paper. It was co-authored by Judith H. Maselli, MSPH, also with UCSF.

The research was supported by a grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development.

Positive Deviance Reducing MRSA

The Positive Deviance Initiative (PDI) and Plexus Institute collaborate to reduced MRSA infection in hospitals.

Hospital Acquired Infections (HAI) kill an estimated 90,000 people in US hospitals every year. These individuals enter the hospital to address specific health problems, and die from an infection that directly results from their stay in the hospital.

Methicillin-resistant Staphylococcus aureus (MRSA) is one on the most lethal of the HAIs.

In August 2005 the PDI began collaborating with the Pittsburgh VA hospital (VAPHS) to utilize PD to address the problem of MRSA. The PD approach enabled the hospital to reduce MRSA infection by an estimated 50%.

To learn the steps they took to accomplish the reduction in infections, go to: www.positivedeviance.org

She Expected Routine Surgery - But Not Flesh-Eating Bacteria

Two years later, Alicia Cole says she's still recovering from her experience at Providence Saint Joseph. The hospital says it ranks 'above average' in the state for surgical infection prevention.

By Rong-Gong Lin II, Los Angeles Times Staff Writer

On Aug. 15, 2006, Alicia Cole entered Providence Saint Joseph Medical Center for a routine surgery -- removing noncancerous growths from her uterus. Several days after the procedure, it was clear something was wrong.

The actress' abdominal area was red and swollen. She had a temperature of 103 degrees. At one point, the inflamed incision site oozed a brown fluid. A hospital record dated Aug. 21, 2006, said Cole had a postoperative wound infection, according to a state report.

But it would take four more days before doctors made a presumptive diagnosis that she had necrotizing fasciitis, better known as flesh-eating disease, according to the state report. On Aug. 25, she underwent the first of five surgeries to remove dying flesh and infected tissue.

"All this area was on fire," Cole said, pointing at her abdomen. "I was being eaten alive." The diagnosis of flesh-eating bacteria -- an infection that destroys muscles, skin and underlying tissue -- was confirmed on Aug. 31.

"They took me back and strategically cut apart my abdomen and left butt cheek to the point where I basically looked like a shark attack victim," said Cole, now 46. "I had a big cavernous hole where the center of my body was."

A friend of Cole's filed a complaint with the California Department of Public Health regarding the hospital's infection control practices. Cole later followed up, and state health officials visited the medical center Oct. 10, 2007, to examine hospital records involving her case.

The state later cited the hospital for failing to report the case to the Public Health Department, which requires that any "unusual occurrence" that threatens the health of patients be reported to public health officials.

State inspectors also wrote that the hospital failed to follow its policy on monitoring and controlling hospital-acquired infections. They said a review of the minutes from the hospital's infection control meeting held on Aug. 22, 2006, showed no discussion of Cole's postoperative infection.

In a written response to the state, hospital officials said they would report such cases to public health authorities in the future. They also said staff discussions on Cole's illness were held at her bedside.

Hospital officials declined to talk specifically about Cole's case, but said no other patients contracted necrotizing fasciitis when she was in the hospital. They said they sympathize with patients who acquire infections while at the hospital, adding that the facility ranks as "above average" in the state for "surgical infection prevention."

Nonetheless, hospital officials said they are beefing up oversight of infection control issues.

In the meantime, Cole, who has had roles in movies and television shows, is still recovering from her wounds and suing the hospital.

Ideally, she said, hospitals should be required to report infection rates to the public. She supports such efforts in the state Legislature; similar efforts died last year along with the proposed comprehensive overhaul of California's healthcare system.

"If you go to a restaurant, you can decide where you want to eat by looking at the letter grade in the window," Cole said. "I would like to see that for hospitals."

ron.lin@latimes.com

Hospital's Blood Stream Infections Down to Zero

For Nurse.com
By Anne Federwisch

Ever since her article on achieving zero catheter-related blood stream infections (CRBSIs) appeared in the Journal of the Association for Vascular Access (JAVA) in December 2007, Sophie Harnage, RN, BSN, has become very popular.

“I get calls and e-mails daily from everywhere throughout the country,” says the clinical manager of infusion therapy services at Sutter Roseville Medical Center (SRMC) in Roseville, Calif. “People asking me specific questions about the team, how many members, how long you’re there, what catheter do you use — many different types of questions.”

Her popularity is not surprising, due to the magnitude of the problem in terms of patient outcomes and financial costs, as well as the nationwide focus on hospital-acquired infections. The Centers for Disease Control and Prevention (CDC) estimates there are at least 250,000 cases of CRBSI annually, with an associated attributable mortality rate of 12% to 25%, and a cost of $25,000 to $56,000 per infection. Reducing CRBSIs was a target of the Institute for Healthcare Improvement’s (IHI) 100,000 Lives Campaign, which was underway when Harnage started building her bundle, and has been folded into the IHI’s updated 5 Million Lives Campaign.

Harnage’s bundle builds on best practice models from around the country, CDC and IHI recommendations, an extensive literature review, and new product technology. In her JAVA article, she cites the specific rationale for each particular practice in her bundle, which varies for each of the seven steps.

Other practitioners’ intense interest also stems from the facility’s impressive results. Before SRMC developed the bundled practices, the hospital recorded 11 CRBSIs in 2005. However, in the two years since implementation, there have been no infections on any of the more than 4,000 PICC lines that have been inserted using the sequence of seven practices (see sidebar).

Notably, during the 15-month period of time chronicled by Harnage’s article, PICC insertions increased by 103%, while interventional radiology referrals decreased to less than 2%. Patients are sent to interventional radiology if an anatomical blockage prevents the nurse from threading the catheter completely through, because a radiologist can bypass the blockage. “I don’t know what the industry standard is, but I wouldn’t be surprised if it’s 30% in other areas,” says Deborah Dix, RN, MS, director of cancer services at SRMC.

What’s the secret?

And their success can be replicated, Harnage notes. “It’s not rocket science,” she says frequently.

The key to success is the use of a specially trained team of nurses to insert PICCs, instead of other non-tunneled central venous catheters, using the bundle and following up on the patients throughout their stay. Team members must complete a course on ultrasound-guided PICC insertion; demonstrate competencies in understanding the anatomy of the veins and chest; commit to using ultrasound-guided technique in all insertions, rather than falling back on a previously learned technique; and religiously follow the bundle. “It’s self-fulfilling,” Harnage says. “The team [members have] generated a tremendous level of confidence in their [own] abilities. Thereby, they insert a tremendous number of PICCs, which results in consistent, repeated, reliable results, which increases the confidence in their skills.”

The first step is locating the basilic vein in the upper arm using ultrasound. Evidence has shown that the bacteria counts are much less on the upper arm versus subclavian, jugular, or femoral insertion points, she notes.

Nurses use full-barrier precautions during the procedure. “The insertion process is something like you would see in an OR,” Dix says. “The patient is covered. The nurse is covered. The skin is prepped just like it would be before an incision. They don’t let people wander in and out while they’re doing it. When we use the term ‘maximum barrier precautions,’ that’s the level of scrutiny that’s being applied.”

Next in the sequence is the central line dressing kit, which was revised to include a two-step cleansing and disinfecting process, a chlorhexidine gluconate impregnated foam disk, and a stabilization device.

The facility decided to change its connector system for the subsequent step in the process. “We chose a neutral system needle-less connector because you don’t have to worry about clamping,” Harnage says. While it’s not magic, its ease of use helps prevent problems “if you correctly flush your line and take care of your line,” she says.

The smooth septum of this new connector also facilitates the next practice — IV connector septum disinfection. “You’re not dealing with crevices in the grooves,” she says. The protocol calls for a vigorous, back-and-forth scrubbing of the connector with an alcohol pad for 5 to 10 seconds.

The flushing protocol comes next. The nurses flush implanted ports and dialysis catheters with heparin, but all other central lines are flushed with normal saline. The team members conduct an inservice for the rest of the nursing staff on proper technique. “We are really on top of the educational piece to maintain these lines,” Harnage says.

The final — and essential — practice involves diligent monitoring of the lines by the team.

“I think the big message is, you can’t just be a PICC-stick-and-run team,” Harnage emphasizes. “You can’t just insert the line and never see it again. I think that’s where you lose the consistency and the reliability.”