Is This the Answer to Hospital-Acquired Infections?

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

DESCRIPTIONTable: 2009 National Healthcare Quality Report

Why 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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  1. Mike says:

    I’ve often been irritated with the multitude of tests required that seem to be CYA for doctors when I visit them. Yet, the same doctors should be subjected to at least a high-level screening on a monthly or weekly basis for ‘skin associated’ bacteria or other easily communicable diseases.

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  2. Esther says:

    My friend got MRSA in a top hospital in California after open heart surgery from a catherer resulting in redoing the aortic valve–infections go directly to the wound–her heart is permanently damaged.

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  3. Mike B says:

    In defense of doctors having to decontaminate one’s self between every patient interaction becomes a major undertaking with significant costs once a person realize how many different patient interactions there are. While practical in theory, washing one’s hands hundreds of times a day not only takes a lot of time, it also has damaging side effects on one hands, which a doctor needs to do his job properly.

    The solution here needs to be technological, not just procedural. Enforcing hand washing compliance might have an unintended consequence of doctors avoiding patient interactions. Disinfection needs to be made nearly costless to drive up use of the service.

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  4. Anon says:

    Hospital I work at has slashed blood-culture contamination rates by doing similar. ID who signed for and took the blood sample and then retrain them once it’s found to be a contaminate (i.e. taken wrong).

    The externalities are that not only does the doctor signing the form have to take responsibility for their action (even if they got a junior to take the sample) and their peers will see, but they have to get retrained. Multiple times if necessary.

    Word gets around, rates and numbers taken both fell.

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  5. Kevin says:

    I think you just like saying the name Ignatz Semmelweis.

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  6. Rosewood says:

    Don’t you know that Doctors are gods, walking amongst us mortal men? If you get infected and die from a Doctor not washing his hands, it is because the all-mighty deemed it time for you to pass. Dare yee not question the wisdom of the all knowing Doctors!

    (Thank you for the article; Passed it along to all of my nursing friends and family who know all too well the problems of physician hand washing.)

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  7. Ford says:

    Infections are caused by a small subset of the microbes on a doctor’s hands, so your proposed approach wouldn’t work to track an infection to an individual doctor. If hospitals were penalized strongly enough to infections, though, I bet they would come up with ways of increasing hand-cleaning, including making it easier.

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  8. Daniel Wagner MD says:

    Identifying whose hands touched an object using a signature bacterial community is an interesting accomplishment. It would be quite another matter to find that same entire community in or on a patient with an infection so as to associate it with a source. In addition, even if you could do so with any sort of accuracy, how would you know that the source (Dr, nurse, etc) hadn’t passed it inadvertently and unintentionally to a colleague who had just sanitized their hands and then touched the chart or computer keyboard that had been used (up to 2 weeks ago) by the source. Couldn’t the colleague then temporarily become a surrogate source and be the one who actually infected the patient. While no one would argue that we don’t need to do something about HAIs, implementing a system of culturing all hospital personnel and the hundreds of objects they touch on a daily basis in order to MAYBE find the source of a patient’s infection would be a very costly exercise in futility.

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