Two stories published in the New York Times today underscore the importance of handwashing in preventing infection. First, from a public hospital in New York:
Timeouts to wash hands and put on hairnets, a simple checklist to ensure that such seemingly obvious precautions are done, and advertising campaigns directed at everyone from the most senior doctors to the poorest of patients have been credited with drastically reducing the number of serious infections at New York City's public hospitals.
Since 2005, central-line bloodstream infections, which stem from bacteria invading a catheter leading to the heart and can often be fatal, have fallen 55 percent in adult intensive care units at the city's 11 public hospitals, according to statistics released last week. Ventilator-associated pneumonia, caused by bacteria in breathing tubes and which also can be fatal, declined by 78 percent.
Before the hospital system began cracking down on them in late 2005, preventable infections were considered part of the collateral damage of advanced lifesaving techniques, such a routine occurrence that few people questioned their prevalence, or the deaths that resulted from them. In fact, there had been a perverse financial upside to hospital-based infections, since they filled beds that might otherwise be empty. But changes in government reimbursements have driven New York's public hospitals, which serve the city's poorest patients, to tackle the problem.
As part of a pay-for-performance plan, the federal government and many private insurers are planning to stop reimbursing hospitals for harm caused to patients by certain preventable errors.
In October, Medicare, the federal insurance program for the elderly, will no longer cover the additional cost of eight preventable complications, including central-line bloodstream infections. Some hospital administrators expect Medicaid, which covers health care for the poor, to follow suit. The government may also stop covering ventilator-associated pneumonia in 2009.
...A red binder at the nursing station at Woodhull contains dozens of forms, labeled "Central Venous Catheter Insertion Checklist," which instruct doctors to, first of all, make sure that they have the right patient and are planning the right procedure. The 14-item list goes on to include washing hands; putting on caps, masks, sterile gowns and gloves; draping the patient from head to toe; preparing the patient's skin with chlorhexidine antiseptic; maintaining a sterile field; and applying a sterile dressing.
One person, usually a nurse, acts as the referee by calling, "Timeout!" and checking off the "completed" or "not completed" columns on the list as each step is called out and performed.
Dr. Pronovost, who developed his checklist at Johns Hopkins in 2001 and tested it in more than 100 intensive care units in Michigan in 2003, found that the simple hygiene it takes to avoid many infections can seem like a low priority in the frenzied atmosphere of high-tech medical care.
At Woodhull last week, when the resident called timeout for hand-washing, he was interrupting a team focused on serious and complex issues like the woman's respiratory rate and ratio of body weight to medication.
"What's going on in the critical care units is so complicated that the simple things get overlooked," said Alan Aviles, president of the city's Health and Hospitals Corporation, which administers the 11 municipal hospitals.
Dr. Pronovost, testifying before Congress last month, estimated that infections acquired during treatment affect 1 in 10 patients nationally and kill about 90,000 people a year, costing the health care system $5 billion to $11 billion.
Actually, Pronovost's cost estimate is probably off by, umm, $30-50 billion (not to criticize him; he's done tremendous work saving lives).
Then there's this op-ed about basic sanitation (italics mine):
There's no place for squeamishness when -- even without complicated and difficult disasters like Myanmar's -- diarrhea trails only pneumonia as the biggest killer of small children in the world, greater than tuberculosis, AIDS or malaria, in numbers equivalent to a jumbo jet crashing every hour....
Celebrities like Matt Damon and Jay-Z line up to talk about water. Shiny taps and clean water make good pictures. I've never seen a movie star pictured in front of a new latrine, though it can double its user's life span.
Of course food and water are crucial. But feces can undermine both. If people are eating fecal particles, no amount of high-energy biscuits will make them well. In poor countries, diarrhea is the reason you find malnourished children in well-fed families. It's why millions of girls drop out of school, and why millions of dollars' worth of productivity is lost from workers sick with this week's bout of dysentery.
Good disposal of human excreta can reduce diarrhea by 40 percent. Washing hands reduces it still further. Health economists reckon that every dollar invested in sanitation can save $7 on health costs and lost productivity.
I've mentioned before how it's the boring bacteria that kill you. What connects these two stories is that very simple, low-tech innovations, such as yelling at people to wash their damn hands and not putting shit on food, can have tremendous effects on illness and death rates. Unfortunately, these aren't 'sexy' activities, so very little is done in these areas, even though these are the quintessential 'low-hanging fruit.'
Laurie Garrett in her excellent book 'Betrayal of Trust: The collapse of global public health' makes precisely this point in her introduction (If I recall correctly). Extremely basic measures including basic sanitation and clean water have prevented more illness and saved more lives than most modern medical advances that we think of as integral to our health today (i.e. the development of antibiotics).
Still, it is very hard to drive the message home. Check out as many hand-washing stations as you can and count how many are equipped with fingernail brushes.
What would help is TV and movies. They were great for promoting smoking.
Why not get screenwriters to join in on this? Everything somebody washes their hands, they scrub under their nails with a brush. And they protect their clean hands by not touching knobs with newly-clean hands. And not just hospital shows, all shows. Make smart handwashing look cool and people will copy what they see.
Check out as many hand-washing stations as you can and count how many are equipped with fingernail brushes.
I understand that brushing under your fingernails is important. How would you keep fingernail brushes clean? I suppose they make disposable brushes?
Seems to me, a brush left at a sink would be a great place for bacteria to grow.
It is obvious to all associated with healthcare that handwashing may be the single important procedure to reduce infection. My question is more to the monitoring aspect of this issue. Is there any publication that identifies what constitutes an effective hospital-based handwashing monitoring policy? Is there any publication that shows significant improvement to hospital infection rates due to monitoring handwashing?