Kathryn Bowsher, a medical solutions professional for more than 20 years, is CEO of PurThread Technologies, which develops antimicrobial technology intended to help hospitals reduce the bioburden on hard-to-clean soft surfaces in the patient environment. She discusses horizontal versus vertical strategies to reduce the frequency and costs of healthcare-acquired infections.
Q: With organizations paying significant attention to hand hygiene, do you think organizations are overlooking or neglecting other HAI prevention methods?
Kathryn Bowsher: I don't think 'neglect' or 'overlook' are really the right words. Hand hygiene is fundamental. There's probably nothing more important to infection prevention efforts than hand hygiene. At the same time, it's insufficient to the challenge. If healthcare workers washed their hands between every touch … between the door knob and the privacy curtain, the curtain and the bed rail, the bed rail and the monitor, etc., they would have no time for patient care. That's the fundamental problem. Anything less than handwashing between each touch makes hand hygiene inadequate as a standalone solution to infection prevention.
As a result, hospital administrators, physicians, nurses, infection preventionists and researchers are all looking for new solutions they can implement with minimal training, routine or behavioral changes. One of the growing trends is a renewed focus on improving the hospital environment since it is much easier to reengineer the system than to change human behavior. Hand hygiene, while a critical practice, is challenging as a standalone solution both because it requires so much healthcare worker time and because hospitals cannot count on perfect compliance from everybody, not just the healthcare workers.
Adding up hand hygiene moments from the various guidelines such as CDC, The Joint Commission, etc., there are 16 different hand hygiene trigger events possible in one patient interaction. Most people work hard at hand hygiene but most often think about it as in and out of the patient room and before or after an obvious high risk event … not after every touch.
Unless everyone — healthcare workers, visitors, delivery people — is performing hand hygiene after every touch, hand hygiene alone is probably insufficient to the challenge of reducing the spread of hospital infections overall. Moreover, expanding hand hygiene surveillance and other interventions can be costly and management intensive. We also need to look at horizontal approaches that are likely easier to implement and potentially more cost effective.
Q: What do you see as some of the areas where organizations need to step up their prevention efforts?
KB: The answer is both a matter of opinion and specific to an individual hospital. In my opinion, there is a growing focus on the question "what next?" As I read the literature and listen to the dialogue, it appears that the infection prevention community is leaning towards an answer of "cleaner patient environment." This past fall I attended the Interscience Conference on Antimicrobial Agents and Chemotherapy, and I heard a speaker make the point that "hospitals need to do more cleaning and less screening."
I'm not in the position to say you shouldn't screen, but at the same time it's important to ask if you get more bang for your buck focusing on a cleaner patient environment versus screening and isolating carriers of a particular pathogen. That would be a classic horizontal-versus-vertical choice. Different people are looking at this kind of relative value question in different ways. For instance, there's a large federally funded study going on right now looking at universal gown and glove in ICUs versus contact precaution protocols.
Increasingly, cleaner patient environments are being looked at as a way of reducing the overall bio-burden. APIC and others have recently launched "Clean Spaces, Healthy Patients."
We need to do more. We are still seeing a flat national infection rate after eight years (pdf). The good news is that hospitals are keeping infection rates from climbing in the face of a hospital population that is older and sicker each year. At the same time, overall infection rates in hospitals are not declining, which means our efforts are inadequate.
Right now there are 1.7 million infections a year nationally, causing more deaths per year than AIDS and car accidents combined. This is not due to a lack of commitment. Nobody, no matter what their role, goes into healthcare because they want to see patients get sicker than they were before they entered a hospital. We just have to keep working at it.
Q: What are some critical steps organizations need to take to identify such areas in need of improvement?
KB: I tend to think of it as an issue of identifying "what next" to strengthen the impact of the overall effort. I like horizontal approaches that focus on reducing the bio-burden in a patient environment.
However, hospitals face a challenge in both identifying this need and measuring the impact of a horizontal intervention because they do most of their infection tracking on a vertical or silo-specific basis. Most HAI tracking is done by pathogen type such as MRSA or by related intervention such as catheter associated urinary tract infection. This sort of segmented tracking makes it harder to both identify horizontal needs and measure the impact of a horizontal intervention.
Clearly targeted interventions help. Many hospitals have had success in reducing their CLABSI rates by implementing the Johns Hopkins' checklist procedure in their ICUs. Given the multi-factorial nature of the HAI problem, you're not going to see a meaningful delta in an individual sub-rate by doing a broad based intervention. For instance, increased hand hygiene compliance is not likely to cause a clear — let alone associated — reduction in the ICU's ventilator-associated pneumonia rate. However, we need to figure out which additional, broader approaches are the best bets to drive down the overall rate in the coming years.
A cleaner patient environment seems like a good place to start. Our goal should be to find practical ways to reduce the risk that a freshly cleaned hand picks up a pathogen from the environment on its way to the patient. Refining the cleaning protocols is one approach to reducing bio-burden in the patient environment.
While more rigorous cleaning will help, it is limited to being one point in time over what is usually about a 24-hour window. Therefore, I think continuously active surfaces are going to be a key to cleaner patient environments in the coming years.
Q: What barriers should organizations be aware of that can stand in the way of effective HAI prevention?
KB: There are really two things — human nature and bureaucratic inertia.
Change is a little counter to the human experience. People are more comfortable doing things the way they've always done them. This is all the more true when it comes to healthcare.
Change is slower in medicine because of the informal understanding that your first goal in life is to do no harm. If what you're doing today works okay, what you're doing next could be better but it could be worse. So … are you going to take that risk? That fear slows down change.
I'm not arguing you should necessarily throw that caution to the wind, but being aware of that and how that impacts change is very important. If you're implementing a new solution and the risks are relatively limited, you should make a special effort to articulate that fact.
The other big issue I see as a barrier to success is what I think of as the budget bucket problem. Essentially infection prevention is a cost center … spending money that is not matched against revenue. If an individual unit gets cost savings from reduction in infection rates, that credit goes to the individual unit. At budget time, who is more likely to get a scarce $150,000? Is it cardiac surgery, which is a profit center, or is it infection prevention? Leadership needs to think about how this issue impacts progress in infection prevention.
Management needs to be conscious of that when making choices about allocation of resources. It's rational to say the people who make money should get more investment, but if you're not tracking your infection rate on a hospital-wide basis, if you're not crediting reductions in infection to the cost of reduction efforts, then you're not really focusing on the full benefit.
Lowering infections saves money as well as lives. HAIs add an average of 19 days to a hospital stay, with an average cost of about $43,000 (Healthcare Cost and Utilization Project - 2010). It is important that the cost savings be factored into the overall spending priorities at budget time. Most hospitals do this to a certain extent, but the broader based the intervention and the more multifactorial the problem, the easier it is for cost and benefit to become disconnected as an idea works its way through the system.
Everyone wants to reduce the infection rate. Everybody is committed philosophically to reducing this risk, but between that emotional commitment and the practical reality of implementing a change that costs money, a lot of things can go wrong in the details.
These days, patients can easily go online to check out the infection rates for their local hospitals, and in many cases patients have a range of hospital options to choose from. In that environment, a lower than average infection rate can give a hospital a competitive edge, and an effective infection prevention team becomes an asset, not a cost.
Q: Who needs to be involved in developing an effective strategy to combat HAIs across an entire organization?
KB: At individual levels, infection preventionists tend to be highly respected by the doctors and nurses they work with. Unfortunately, they are not always empowered to participate in strategic discussions about changes to the hospital and patient environment. That needs to change.
It's similar to developing a product like a medical device. End users need to be involved in the design up front so that the end result is something that actually works and meets their needs. In this case, infection preventionists need to be involved with discussions of purchasing and asset allocation early on in order to ensure that hospital departments and staff will have the tools they need to drive their infection rates to the lowest possible level.
While it may not be possible to achieve perfect sterility in a hospital, it is vitally important to have more dialogue between general clinical staff, management and the infection prevention team about broader-based solutions to lower the overall risk of infection in the hospital environment.
Learn more about PurThread Technologies at www.purthread.com.
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