Hiroko Masuike/The New York Times
A staff member at Beth Israel Medical Center in Manhattan using a hand sanitizer.
A staff member at Beth Israel Medical Center in Manhattan using a hand sanitizer.
At North Shore University Hospital on Long Island, motion sensors, like those used for burglar alarms, go off every time someone enters an intensive care room. The sensor triggers a video camera, which transmits its images halfway around the world to India, where workers are checking to see if doctors and nurses are performing a critical procedure: washing their hands.
This Big Brother-ish approach is one of a panoply of efforts to promote a basic tenet of infection prevention, hand-washing, or as it is more clinically known in the hospital industry, hand-hygiene. With drug-resistant superbugs on the rise, according to a recent report by the federal Centers for Disease Control and Prevention,
and with hospital-acquired infections costing $30 billion and leading
to nearly 100,000 patient deaths a year, hospitals are willing to try
almost anything to reduce the risk of transmission.
Studies have shown that without encouragement, hospital workers wash
their hands as little as 30 percent of the time that they interact with
patients. So in addition to the video snooping, hospitals across the
country are training hand-washing coaches, handing out rewards like free
pizza and coffee coupons, and admonishing with “red cards.” They are
using radio-frequency ID chips that note when a doctor has passed by a
sink, and undercover monitors, who blend in with the other white coats,
to watch whether their colleagues are washing their hands for the
requisite 15 seconds, as long as it takes to sing the “Happy Birthday”
song.
All this effort is to coax workers into using more soap and water, or alcohol-based sanitizers like Purell.
“This is not a quick fix; this is a war,” said Dr. Bruce Farber, chief of infectious disease at North Shore.
But the incentive to do something is strong: under new federal rules, hospitals will lose Medicare money when patients get preventable infections.
One puzzle is why health care workers are so bad at it. Among the
explanations studies have offered are complaints about dry skin, the
pressures of an emergency environment, the tedium of hand washing and
resistance to authority (doctors, who have the most authority, tend to
be the most resistant, studies have found).
“There are still staff out there who say, ‘How dare they!’ ” said Elaine
Larson, a professor in Columbia University’s school of nursing who has
made a career out of studying hand-washing.
Philip Liang, who founded a company, General Sensing,
that outfits hospital workers with electronic badges that track
hand-washing, attributes low compliance to “high cognitive load.”
“Nurses have to remember hundreds — thousands — of procedures,” Mr.
Liang said. “Take out the catheter; change four medications. It’s really
easy to forget the basic tasks. You’re really concentrating on what’s
difficult, not on what’s simple.”
His company uses a technology similar to Wi-Fi or Bluetooth. The badge
communicates with a sensor on every sanitizer and soap dispenser, and
with a beacon behind the patient’s bed. If the wearer’s hands are not
cleaned, the badge vibrates, like a cellphone, so that the health care
worker is reminded but not humiliated in front of the patient.
Just waving one’s hands under the dispenser is not enough. “We know if you took a swig of soap,” Mr. Liang said.
The program uses a frequent-flier model to reward workers with
incentives, sometimes cash bonuses, the more they wash their hands.
Gojo Industries, which manufactures the ubiquitous Purell, has also developed technology that can be snapped into any of its soap or sanitizer dispensers to track hand-hygiene.
At North Shore, the video monitoring program, run by a company called
Arrowsight, has been adapted from the meat industry, where cameras track
whether workers who skin animals — the hide can contaminate the meat —
wash their hands, knives and electric cutters.
Adam Aronson, the chief executive of Arrowsight,
said he was inspired to go from slaughterhouses to hospitals by his
father, Dr. Mark Aronson, vice chairman for quality at Beth Israel
Deaconess Medical Center in Boston and a professor at Harvard Medical
School.
“Nobody would do a free test — they talked about Big Brother, patient
privacy — nobody wanted to touch it,” Mr. Aronson said.
He finally got a trial at a small surgery center in Macon, Ga., and in
2008, North Shore also agreed to a trial in its intensive care unit. The
medical center at the University of California, San Francisco, is also
using Arrowsight’s video system, and Mr. Aronson said eight more
hospitals in the United States, Britain, the Netherlands and Pakistan
had agreed to test the cameras.
North Shore’s study, published in the journal Clinical Infectious
Diseases, found that during a 16-week preliminary period when workers
were being filmed but were not informed of the results, hand-hygiene
rates were less than 10 percent. When they started getting reports on
their filmed behavior, through electronic scoreboards and e-mails, the
rates rose to 88 percent. The hospital kept the system, but because of
the expense, it has limited it to the intensive care unit, where the
payoff is greatest because the patients are sickest.
To get a passing score, workers have to wash their hands within 10
seconds of entering a patient’s room. Only workers who stay in the room
for at least a minute are counted, and the quality of their washing is
not rated. Scores for each shift are broadcast on hallway scoreboards,
which read “Great Shift” for those that top 90 percent compliance.
Technology is not the only means of coercion. The Greater New York
Hospital Association, a trade group, and the health care workers union,
1199 S.E.I.U., train employees to be “infection coaches” for other
employees.
In a technique borrowed from soccer, hospital workers hand red cards to
colleagues who do not wash, said Dr. Brian Koll, chief of infection
prevention for Beth Israel Medical Center
in Manhattan, who trains coaches. (Unlike soccer players, however,
workers do not have to leave.) “It’s a way to communicate in a
nonconfrontational way that also builds teamwork,” Dr. Koll said.
“You do not want to say, ‘You did not wash your hands.’ ”
Doctors, nurses and others at Beth Israel who consistently refuse to
wash their hands may be forced to take a four-hour remedial infection
prevention course, Dr. Koll said. But to turn that into something
positive, they are then asked to teach infection prevention to others.
Dr. Koll said that he was not aware of malpractice suits based on
hand-washing, but that hand-washing compliance rates often become part
of the information used when suing hospitals for infections.
A hospital in the Bronx gave out tickets — sort of like traffic tickets —
to workers who did not wash their hands, he said. “That did not work in
our institution,” he said. “People made it a negative connotation.”
Beth Israel finds that positive reinforcement works better, Dr. Koll
said.
Like other hospitals, Beth Israel also uses what it calls secret
shoppers — staff members, often medical students, in white coats whose
job is to observe whether people are washing their hands. Beth Israel
gives high-scoring workers gold stars to wear on their lapels, “hokey as
this sounds,” he said; after five gold stars they get a platinum star,
or perhaps a coupon for free coffee. “Health care workers like
caffeine,” Dr. Koll said.
There are buttons saying, “Ask me if I’ve washed my hands,” and Dr. Koll
said that patients’ families did ask because they understood the risks.
Especially in pediatrics, he said, “parents do not have a problem at
all asking.”
To avoid slogan fatigue, Beth Israel has at least five buttons, including “Got Gel?” and “Hand Hygiene First.”
Dr. Larson, the hand-washing expert, supports the electronic systems being developed, but says none are perfect yet. “People learn to game the system,” she said. “There was one system where the monitoring was waist high, and they learned to crawl under that. Or there are people who will swipe their badges and turn on the water, but not wash their hands. It’s just amazing.”
Excerpt from: The New York Times
