Infection control: could hospital real time location tracking (RTLS) help (part 2)

This is a quick followup to the captioned post, (part 1). Commenters highlighted the Joint Commission 2010 report “Hand Hygiene: Best Practices from Hospitals” [PDF]. That’s an excellent resource. See also the Joint Commission Newsroom on the hand-hygiene topic. From these resources, here’s a few excerpts illustrating the complexity of this challenge. It’s good to see the hospitals adopting process engineering methods.

From the NY Times “A Hospital Hand-Washing Project to Save Lives and Money”:

(…) The disease control agency estimates there are 1.7 million infection cases a year in hospitals and that 99,000 patients die after contracting them (although infection may not be the sole cause). It projects the cost of treating those patients at $20 billion a year.

Despite the daunting statistics, and what would seem to be the ease of saving thousands of lives, old habits have proven stubbornly resistant to cultural change. Research has found that constant vigilance, individualized solutions and an upending of hospital hierarchy are all required.

“It seems really simple, but even this one turns out to be complicated,” Dr. Chassin said in an interview.

Some excerpts of good/bad news from the study report:

(…) Another surprising example was at Cedars‐Sinai Medical Center. The surveillance team cultured everything in the patient environment and discovered that privacy curtains—required around all patient beds in California—were colonized with multi‐drug resistant organisms in some rooms. According to chief medical officer Michael Langberg, MD, the information “stunned” them. “Patients in the room did not have infections, but the organisms were sitting on the privacy curtains,” he said. Even if health care personnel were doing effective hand hygiene before walking in the room, they might touch the curtains without realizing it. The hospital swapped out every curtain and changed how and when they cleaned them. Subsequently, zero such organisms have grown on the curtains, said Langberg. This hospital also addressed the potential spread of germs on lab coats by adding hooks outside patient rooms, which allows health care personnel to easily remove their coats before entering a room.

(…) By bundling supplies and tasks, health care personnel have fewer opportunities to be in patient rooms and fewer opportunities when they need to wash their hands, likely increasing compliance. “We looked at workflow and how to standardize it, so we decreased ins and outs of patient rooms,” said Miller. Changing the location of dispensers to fit in people’s workflow also increased compliance.

(…) Since June 2010, Virtua has been piloting technology and sensors worn by all health care providers. “Technology is making us look at our process,” said Kate Gillespie, RN, Six Sigma black belt. Though the hospital is still fine‐tuning that technology, Gillespie believes that in the long term, using technology will be helpful. “We cannot sustain secret observers,” she said. But having the technology has shown them their observations were “not that far off.” “We can see a correlation,” she added.

WFUBMC also focused on using an electronic method to monitor and increase compliance for hand hygiene. Health care personnel wear a real time location system tag equipped with infrared recognition that is activated when entering a patient care area. The tracker on the hand sanitizers, sinks, or pumps reads the tag and reports the activation. Tony Oliphant, RN, nurse manager, emphasized that the goal for the technology is that it does not interfere with the workflow. The badges are being modified so as not to hinder work. “We didn’t want to change the way people enter and exit rooms,” Oliphant said.

The new technology and its possibilities are “monumental in nature,” said Shayn Martin, MD, WFUBMC. “We are creating a system to track providers to perform hand hygiene on a scale that is substantially greater than our existing systems. It is continuous. It allows us to build reports for individual compliance.” He added, “We should be 100 percent compliant with hand hygiene. We want to be sure the system is highly accurate, does not give false data and does not impose on workflow.” Though using this technology “sounds big brother‐like,” Martin acknowledged, “the last thing we want is to create an environment that makes people nervous and makes it harder to do their job….[The technology] is a way to approach 100 percent [compliance].”

(…) Johns Hopkins Hospital also used red lines at the thresholds to all patient rooms to serve as a reminder to “wash or don’t cross,” said Kulik. At Memorial Hermann The Woodlands, the door thresholds in the ICUs have red tape that goes up the side of the door with an arrow pointing to where the hand sanitizer is located. That area is marked “patient zone” to remind health care personnel and all visitors that they are crossing this threshold and should clean their hands. “We know hand hygiene has become a habit when a serious situation develops in the ICU and we see health care providers pause in the doorway to get hand sanitizer,” said Parks. “It is the last point at which a health care worker can get it right and prevent infection,” observed Rob Morehead, RN, infection control practitioner. “If we wash hands, we can still get it right,” he added.

How to Get Doctors to Wash Their Hands, Visual Edition

This photo is one of several developed for the Cedars-Sinai hand-hygiene campaign. There is an excellent, short Freakonomics podcast on the topic — highly recommended. And 25 January there is a brief update with links to some of the humorous Cedars-Sinai campaign materials. This campaign is directed by their “Zero Hospital-Acquired Infections Task Force”.

This is such a critical topic — a topic that hospitals largely do not wish to discuss. Few hospitals are as serious as Cedars-Sinai. Few hospitals know how many of their doctors practice adequate hand-hygiene. As patients how do we protect ourselves from the dirty doctors and all the other hospital pathways to infection?

In our latest podcast “What Do Hand-Washing and Financial Illiteracy Have in Common?,” we revisited a topic we wrote about a few years back: how one hospital (Cedars-Sinai Medical Center in Los Angeles) has tried to increase the rate of hand hygiene among its doctors. In the podcast, chief medical officer Michael Langberg regretfully reported that his doctors, like many doctors, routinely failed to wash their hands. Cedars-Sinai came up with a series of computer screensavers and posters that, along with some other creative measures, significantly jacked up the hand-hygiene rate.

Read the whole thing »

There are a few public documents coming out of Cedars-Sinai, though I’ve not found any publications on their current infection control performance, or policies/procedures (other than OR surgical hand scrub, but I don’t think the OR is where the problem is). In one of their pubs on MRSA, Super Staph, on the effects of anti-cholesterol drug BPH-652, there is a sidebar outlining the hand-washing campaign:

The Best Weapon, Hands Down.

The rule is clear: Doctors and nurses are supposed to wash their hands or use a Purell® dispenser before they enter and leave a patient room. For various reasons—not only at Cedars-Sinai but at hospitals everywhere—compliance with this rule falls short of the 100 percent goal. Sometimes, in the rush to get to the next patient, healthcare professionals simply forget to wash their hands. Or they might figure it’s not necessary because they were only in a patient’s room briefly and didn’t touch anything.

Making sure everyone complies with hand-washing guidelines without fail is the goal of a hospital-wide campaign at Cedars-Sinai that involves educating all employees, as well as patients and visitors, about the fact that hand hygiene can, indeed, save lives. New custom-designed kiosks in visitor waiting areas provide Purell® dispensers, masks and tissues and display the message, “The power is in your hands. Please help us protect our patients’ health.”

Erica Palys, MD, an infectious disease fellow who helps lead the hospital’s hand hygiene task force, says trying to get people to change their routine is a challenge, especially when they can’t directly see the results of their actions. “If you don’t wash your hands, there is no visible consequence—you don’t see that person down the line who could get sick or die. We’re making hand hygiene as convenient as possible so that it becomes easy to do the right thing without even thinking about it.”

In the same bulletin see also the informative “Staff vs. Staph” sidebar which closes with this:

“It all comes down to a common goal,” notes Dr. Langberg, who devotes five to 10 hours a week to the task force. “We realized that if anyone of us is a patient coming to the hospital we shouldn’t walk out with a bug we didn’t have. It’s a priority for all of us.”

Could technology help us overcome this human-social challenge? I think so, read on…

Infection control: could hospital real time location tracking (RTLS) help (part 1)

A little bit of followup on our previous post on hospital hand-hygience. Eliminating hospital-acquired infections requires achieving a nearly perfect performance on many different fronts. From quarantine of suspect new admissions (e.g., nursing home patients), staff hand-hygiene, to efficient forensic analysis when the presence of an infection is discovered. The latter case illustrates to me the potentially enormous impact that technology might have on the infection control and the larger issue of medical errors.

The Freakonomics podcast that motivated my little bit of research mentioned the potential application of automated location tracking. First, imagine that every patient, every staff member, every piece of equipment, every parcel of drugs or apparatus is identified and real-time located by an RFID tag. An almost trivial application of that real time information is described in this vendor promotion Elpas Hand Hygiene Compliance Monitoring Solution:

(…) Each caregiver is issued an Elpas Active Identity Badge. So when the caregiver uses a hand washing station or sanitizer, a nearby Elpas LF Exciter triggers the personal badge tag worn by the caregiver to transmit hand washing event messages that identifies the caregiver and the time that the specific dispenser was used.

Elpas RTLS Readers relay this time-critical hand hygiene data over the hospital’s Ethernet network to the Eiris Command & Control Server that provides hand hygiene compliance reporting and alerting.

Hospital administrators can use the Elpas Hand Hygiene Solution to generate detailed compliance reports per caregiver or per examination room. This documentation can be beneficial in monitoring staff compliance with hospital hand hygiene policies and to trace the source of infection transfers.

The Elpas Hand Hygiene Solution can also alert administrators of non-compliance incidents in real-time as well as alerting those caregivers to their non-compliant status prior to providing care.

So the system can alert the doctor that they need to rectify their hygiene before contacting this patient; and of course can perform logging of compliance exceptions. With this feedback, and the appropriate hospital administration priorities, soon there won’t be any un-corrected exceptions.

Now, imagine a hypothetical infection case: a patient is discovered to be infected with MRSA. Besides quarantine and treatment, one would expect the hospital staff to urgently want to know “How did this happen? “. Who and what has been in contact with this patient during the time window of possible infection? The imagined RTLS system will “know” the time-location web of interactions involving this patient. Just one of the more obvious questions comes back to the hand-hygiene topic: were there compliance exceptions for any of the staff interacting with the infected patient? That knowledge would at least guide us to give high priority to those staff (I have no idea what best practice reactions are to this sort of case).

If Sebastian Thrun and colleagues can program a self-driving car, it won’t be long before the technical capability exists to produce in seconds an analysis of the time-location history, allowing hospital response staff to establish possible infection-sources ranked from most- to least-probable. Is it a fixed contamination (staff coffee maker, elevator); a staffer; a mobile blood-pressure monitor? How many hours/days does it take today when humans have to paw through reams of paper records to reconstruct the time-location history? The longer it takes to solve the puzzle the more infections.

There are already a number of competitors entering this field. Deployment seems to be starting with the easy and obvious: tracking hospital equipment and supplies, etc. – i.e., Walmart comes to hospital inventory control. Next seems to be error prevention priorities (is the correct patient about to get an amputation of the correct limb?; correct drug delivery?; etc.).

So far I’ve not found any public case study information demonstrating important successes in infection control or medical errors from an RTLS implementation – but I am hopeful. If not RTLS, then we need some another impartial technology to overcome our human fallibility. Meanwhile, more people will continue to die (in the US) from hospital-acquired infections than from AIDs.

A few other sources I noted:

Ekahau Infection Control and Prevention Solution

Ekahau RTLS and GOJO Dispensers Introduce Wi-Fi Hand Hygiene Monitoring Solution

Awarepoint Case Studies

Building a Smart Hospital using RFID technologies (2006, the obvious applications)

Wireless Automatic Tracking In A High Volume Emergency Department

Hospital infections & how you can reduce your risks

Betsy McCaughey is chairman of the Committee to Reduce Infection Deaths, a non-profit working on the critical problem of eliminating hospital infections.

…That is why RID was founded: to motivate hospitals to make infection prevention a top priority and to show them the financial benefits of doing so; to provide patients with information on how to protect themselves; and to educate future doctors and nurses on the precautions needed to stop bacteria from spreading patient to patient.

Many hospital administrators believe they can’t afford to take these precautions. They can’t afford not to! Infections erode hospital profits. When a patient contracts an infection and stays in the hospital weeks or even months longer, the hospital is seldom paid for the added stay and care. RID’s research provides compelling economic evidence that preventing infections can cost far less than treating them.

RID is also creating educational tools for medical and nursing schools. It’s hard to believe, but young doctors and nurses in training seldom have even one class session devoted to hygiene. Educating the future generation of caregivers about hygiene and making it a central part of medicine again may be RID’s most lasting legacy.

Finally, better infection control in hospitals is essential to prepare the nation for avian flu or bioterrorism. If hospitals have effective infection controls in place, they can prevent bird flu victims from infecting other patients who did not come in with it. If not, bird flu could sweep through hospitals. Right now, most hospitals are woefully under prepared.

How can hospitals that have failed to contain ordinary infections spread by touch control a flu virus that is communicated by droplets from coughing and sneezing as well as touch? Even more challenging would be small pox, plague, and other bioterrorism weapons that can travel through the air. Shoddy infection control is poor preparation for a flu epidemic and poor homeland security as well.

I recommend downloading and filing for reference the brochure “15 Steps you can take to protect yourself“. Why can’t you Google the score cards for hospitals’ infection rates?

Ideally, you would choose a hospital with a low infection rate. Good luck getting that information. It’s impossible. Many states collect data on infections that lead to serious injury or death, but nearly every state-with the exception of 6-has given into the hospital industry’s demands to keep the information secret. The federal Centers for Disease Control and Prevention also collect infection data from hospitals across the nation, but refuse to make it public. Government is too often on our backs, instead of on our side.

What’s the answer? Hospital infections report cards. Hospitals object that comparisons would be unfair because hospitals that treat sicker patients, such as AIDS, cancer, and transplant patients who have weakened immune systems, will have a higher infection rate. True, but the data can be risk adjusted to make comparisons fair. What is unfair is preventing the public from knowing which hospitals have infection epidemics. Keeping infection rates secret may help hospitals save face, but it won’t save lives.

Australia is taking some steps towards coherent surveillance, but AFAIK there is no state- or nation-wide database of hospital scores. Victoria’s VICNISS site has useful resources, and is expected to offer more, such as Aggregate Infection Rates for Victorian Hospitals.

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