I have written quite a bit — probably far too much for the average person’s taste — about the poor state of hand hygiene in hospitals, and the resulting proliferation of bacterial infections. I often think I should shut up already about this problem. After all, it’s been 10 years since the Institute of Medicine’s damning report “To Err Is Human.”
Well, after taking at look at the latest National Healthcare Quality Report, I think I won’t be shutting up any time soon. Despite a lot of effort and innovation, despite a wise checklist approach, the problem doesn’t seem to be getting better:
Infections acquired during hospital care, also known as nosocomial infections, are one of the most serious patient safety concerns. It is unfortunate that HAI [hospital-acquired infection] rates are not declining. Of all the measures in the NHQR measure set, the one worsening at the fastest rate is postoperative sepsis (Table H.3). The two process measures related to HAIs tracked in the NHQR, both covering timely receipt of prophylactic antibiotics for surgery, are improving steadily. However, HAI outcome measures are lagging; only one shows improvement over time while three are worsening and one shows no change. This may, in part, reflect improving detection of HAI’s.
Table H.3. Measures of health care-associated infections, annual rates of improvements
Table: 2009 National Healthcare Quality ReportWhy is it so hard to get hospital personnel, doctors in particular, to do a better job with hand hygiene?
My belief, and as we wrote in SuperFreakononomics, is that it’s a question of externalities: the bacteria that a doctor may pass along via poor hand hygiene do not typically damage the doctor him/herself, but rather the next patient down the line. In this sense, deadly bacteria are a lot like our daily pollution: we do not personally pay the cost of our actions, so we have weak incentives to change our behavior.
I have often thought that if only individual doctors could be held accountable for their poor hand hygiene — if, say, an individual’s bacteria could somehow be tagged so that if a patient died from a hospital-acquired infection, the source of those bacteria could be determined — that would radically adjust the incentives at work here.
Well, the first step toward such a system may be on the way. A study published in the Proceedings of the National Academy of Sciences called “Forensic Identification Using Skin Bacterial Communities” argues that:
Recent work has demonstrated that the diversity of skin-associated bacterial communities is far higher than previously recognized, with a high degree of interindividual variability in the composition of bacterial communities. Given that skin bacterial communities are personalized, we hypothesized that we could use the residual skin bacteria left on objects for forensic identification, matching the bacteria on the object to the skin-associated bacteria of the individual who touched the object. Here we describe a series of studies demonstrating the validity of this approach. We show that skin-associated bacteria can be readily recovered from surfaces (including single computer keys and computer mice) and that the structure of these communities can be used to differentiate objects handled by different individuals, even if those objects have been left untouched for up to 2 weeks at room temperature.
If such identification worked for nosocomial infections, life would surely become more complicated for doctors (and their malpractice lawyers). And it might be one of the best things to happen for patient safety since a fellow named Ignatz Semmelweis came along.
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Instead of a doctor washing hands every time he/she moves from patient to patient, why not just carry a box of surgical gloves and wear/change them for each patient?
Seems pretty easy to me.
You provide no evidence that the increase in postoperative sepsis or catheter infections are due to lack of hand washing. On the contrary, surgery and catheter insertions are about the only times in medical care when hands are ALWAYS washed meticulously. These bacteria are everywhere, including all over the patients own skin, their GI tract, etc. The increase is more likely due to increasing prevalence of resistant bacteria and increasingly older/sicker patients who are less able to fight off bacterial infections.
How about requiring doctors to wear a badge with the number and percent of their patients who have HAIs?
It could be attached below their hospital namebadges, and updated daily. Bingo, externalities brought home. The doctor needs to justify his number to his patient and colleagues.
Take a complex issue such as infection with bacterial and viral agents that have had millions of years of natural selection and evolution to perfect their survival skills, and attack it with a popular economist’s simplistic solutions and miraculously another problem is solved.This is another example of the self-proclaimed Best and Brightest actually being the Worst and Dimmest.
Have you ever lived with a doctor? Looked at his hands? I have. The doctor’s hands were in constant pain, rough and dry from all the hand washing he did. Using rubber gloves throughout the day didn’t help. It just made it worse; even the hypoallergenic gloves didn’t help.
Sadly I hope some of us know how Semmelweis ended up.
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Mike B:
Your analysis might have some legs were it not that Docs are less likely to wash than RN’s. RN’s have much more patient contact and, to the extent that time and hand damage were the issue, we should expect the same poor hygiene. In fact, it is a cultural issue. Docs are high status and can get away with not washing RN’s, not so much.
An alternative approach would be an accountable care organization where doctors work together as a team and the results of one doctor are closely identified with those of all the other doctors.
As someone once said about Kaiser Permanente: Here their doctor’s name is Kaiser.
Not surprisingly everyone works just a little harder to keep things clean and the results for hospital borne infections show it.