Hand Hygiene Reduces Multidrug Resistance

Daniel M. Keller, PhD

November 02, 2012

SAN DIEGO, California — Hand hygiene in hospitals actually does something beneficial. Whereas many studies have gauged compliance with hand hygiene policies, Yoko Furuya, MD, assistant professor of clinical medicine in the Division of Infectious Diseases at Columbia University Medical Center and Medical Director of Infection Control and Hospital Epidemiology and Director of Antimicrobial Stewardship for New York–Presbyterian Hospital (NYP) in New York City, showed that improvements in hand hygiene can actually reduce the incidence of methicillin-resistant Staphylococcus aureus (MRSA) and other multidrug-resistant organisms (MDROs), such as vancomycin-resistant enterococci (VRE) and carbapenem-resistant Klebsiella pneumoniae (CRKP).

Speaking here at IDWeek 2012, Dr. Furuya described her study at NYP, which is affiliated with both Columbia University and the Weill Cornell Medical College in New York City. Consisting of 4 acute care hospitals, NYP comprises 2000 beds and 18 pediatric and adult intensive care units and employs 13,000 staff and 2000 physicians, plus students and house staff.

The NYP hand hygiene program began in 2007. Six impartial observers provided direct observation of compliance in all patient care units. Between 2007 and June 2012, many changes were made to the program, including how hygiene was accomplished, how it was monitored, and how it was reported and publicized.

Key Program Components

Key components of the program were leadership engagement, by which the program was discussed at all key hospital and departmental meetings; monthly feedback by unit, discipline, and department, which was prominently posted; real-time interventions; and individual accountability.

Over the 5-year period of the program, there were 169,000 observations of hand hygiene opportunities in 11 units of the hospitals. Initial compliance was 55%, and by 2011, it was 95% (P < .001).

"The greatest improvement really happened between 2007 and 2008...but there were small but significant improvements that continued from year to year thereafter," Dr. Furuya reported.

"We did see a significant decrease in MRSA incidence from the beginning to the end [2007-2011], relating to a 30% relative reduction [P = .006]. And interestingly, the greatest reduction happened, again, between 2007 and 2008, which is the same period of time where we saw the greatest improvement in our hand hygiene compliance," she said.

The investigators saw a very similar trend for VRE, and although the incidence of CRKP was overall lower than that of the other organisms, it, too, showed a significant decrease.

Correlation of Hand Hygiene Compliance and MDRO Rate

For MRSA, VRE, and CRKP combined, "We did see a significant correlation relating to every time hand hygiene compliance went up by 10%, the combined MDRO rate came down by 9.2%," Dr. Furuya said. "And this is really notable in the setting of the fact that the prevalence of these organisms has actually been increasing over the same period of time, so the burden in the hospital has been going up, but the incidence rate has been coming down."

Clostridium difficile was an exception. There was an observed 40% increase in C difficile during the study period. In 2007, there was a median of 0.58 hospital-onset cases/1000 patient-days, which increased to 0.81 hospital-onset cases/1000 patient-days in 2011 (P = .0014). However, this observation is muddied by the fact that the hospital laboratory switched from an enzyme-linked immunoassay for diagnosis to polymerase chain reaction during the period of the study, which may have resulted in greater diagnostic sensitivity. Or it is possible that the hand hygiene program is insufficient and that other measures need to be instituted, such as antimicrobial stewardship or better environmental cleaning.

Dr. Furuya concluded that the multifaceted program improved hand hygiene from 55% to 95% over 4 years, and the improvement correlated with a significant and sustained decrease in MRSA, VRE, and CRKP despite the increasing prevalence of these organisms in general. Measuring pathogen rates such as MDRO incidence was a useful way of assessing the efficacy of the hand hygiene program, not just compliance.

Strengths of the study are the large sample size involving hospital-wide data and the sustained correlation of hand hygiene with several MDROs. However, a limitation of the study is that it measured only correlation, and therefore one cannot infer causality. Furthermore, there are many possible unmeasured confounders.

Lower Compliance Rates Measured Elsewhere

Session cochair Elaine Larson, RN, PhD, associate dean for research at the Columbia University School of Nursing and professor of epidemiology in the School of Public Health at Columbia University, commented to Medscape Medical News that Dr. Furuya reported hand hygiene compliance rates above 90%, but "when we've done checks with different observers, we find much lower rates."

Nonetheless, she commended the many staff members involved in the program for their ongoing efforts, which seem to have paid off. "It's clear that none of the hand hygiene interventions works in the short term.... And there are a number of others around that are good examples of how long it takes to have a sustained change in behavior," she said.

Dr. Larson also pointed out, as did Dr. Furuya, that the study showed only a correlation and not causality of the hand hygiene intervention in lowering the prevalence of some of the MDROs. "So it's hard to tease out because for something like what they did, which involved really changing behavior in a sustained way, you end up not only changing 1 thing. You end up changing a lot of things at the same time," she said.

She also noted that hand hygiene programs can have positive and negative effects. One good thing is "it focuses on infection prevention in general and gives other alternatives besides more pharmaceuticals and antibiotics," Dr. Larson said. "The bad thing is that if an institution is in it for a quick fix in order to meet the requirements of the Joint Commission or whatever, they run the risk if there isn't a concomitant reduction in infection of actually losing credibility, and staff are going to say, 'See, it doesn't do any good'.... Then we are really in trouble because we are going to reinforce the lack of correlation between hand hygiene and no infections."

Healthcare Workers Doubt Hygiene Data

Session cochair and medical anthropologist Heather Reisinger, PhD, assistant professor in general internal medicine at the University of Iowa and the Veterans Affairs Health Care System in Iowa City, who was not involved in the study, commented to Medscape Medical News that in choosing to give staff feedback about infection rates, "you have to be prepared for when they're not going the way you want them to be.... Healthcare workers want you to be very honest with them when you're displaying the data, and they often question the hand hygiene rates because they don't trust whether they're accurate and who's actually observing and whether they're observing the right thing."

She said that if hand hygiene gets good compliance but infection rates are still too high, "It would definitely trigger, I think, to look deeper into what's going on with infection [control] in general in the hospital."

On this point, Dr. Larson advised that hand hygiene and infection control in general are not problems just for the infection control professionals in a hospital, but everyone must take responsibility. "The issue is, how does the system support people to do the right thing? The theme to me at this conference is systems. It takes a systems change from the leader down," she said.

Dr. Reisinger said that she was curious to know what were the interventions between 2007 and 2008 that caused such a large increase in hand hygiene compliance and that she would like to see the work published soon "so that people can look into it more, and...see how the hand hygiene program and campaign evolved, because I think we forget that it's an evolving process."

Dr. Furuya has disclosed no relevant financial relationships. Dr. Larson was not involved in the study, but she and Dr. Furuya work on grants together, and Dr. Larson is on the NYP Infection Control Committee. Dr. Reisinger has disclosed no relevant financial relationships.

IDWeek 2012. Abstract 583. Presented October 18, 2012.