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More stick, less carrot: Hand hygiene fines
Docs face $1,000 fine, lost credentials
Money talks when it comes to infection prevention, particularly if it's coming out of your purse or wallet. That appears to be the lesson thus far of an infection control policy taken to an unusual extreme.
As of this writing, a punitive policy in place at the University of Pittsburgh Medical Center (UPMC) a vanguard institution in infection prevention calls for fines of up to a $1,000 for physicians who ignore a hand washing edict. Second offenses could mean a temporary loss of hospital privileges. With varying fines for other health care workers, the policy was enacted amid a persistent outbreak of multidrug resistant Acinetobacter baumannii (MDR-Ab).
How did we come to such a place, we ask rhetorically, knowing full well many infection preventionsts will answer, "Well, we've tried everything else!" But are such punitive approaches counterproductive, breeding worker resentment in the name of patient safety? Surprisingly there has been little "pushback" thus far, in part because no fines have had to be levied, explains Carlene Muto, MD, MS, UPMC's medical director for infection control.
"We've had the support of our entire team our physicians, our nurses, our [administration] and medical executives," she tells Hospital Infection Control & Prevention. "I think people want to do the right thing. They intend to do the right thing, but for lots of reasons they don't. They are in a hurry; they didn't see the sign, whatever. But they get it they know these organisms are very problematic and that patients can die from them. We just needed something to bring it home."
And make no mistake, the system was set up with every intention of follow-through on the first offense.
"This fine thing there's been a lot of talk over the years about whether the carrot or the stick is better," she says. "We've tried a lot of things with rewards, and I do think it gets you some improvement in behavior. But the bottom-line is we want the right behavior every time."
Like brushing your teeth
Thus, hand hygiene and other infection control measures must become as natural as routinely brushing your teeth, a habit so engrained it prompts the memory immediately if forgotten, she notes.
"If you think you could even be potentially fined, or more so, lose your privileges at the hospital where you work that's enormous," she says. "It tells our employees this is so important to who we are to our culture here, to our patient safety efforts that we will do anything to ensure the right behavior occurs."
That behavior includes hand hygiene and contact precautions as indicated in designated areas of the hospital dealing with clusters of MDR-Ab, a notoriously difficult bug to contain and eradicate. Becoming increasingly prevalent since many early cases were linked to the Iraq War, MDR-Ab is no bug to take lightly. In addition to some strains being practically pan-resistant, a study published last year found that gowns, gloves and the unwashed hands of health care workers were frequently contaminated with MDR-Ab, suggesting it persists in the environment and is more easily transmitted than other resistant bacteria.1
"We had some clustering of MDR-Ab in the hospital that we identified," Muto notes. "So as usual, we made the staff aware of it and did everything we normally do: contact precautions and all of the things we would do for MRSA or any other epidemiological significant organism."
However, as cluster reports and suspected transmission sporadically continued, Muto and her top administrators felt it was time to take it further.
"It was really through the support of our administrative and medical staff," she says. "They said, 'You know what we really mean it this time. Everybody has to do the right thing.' So they actually came up with what they thought would be the appropriate fines for each of the services and divisions."
In addition to the physician fines, fellows and residents on house staff face fines of $250 and they have to go through their program director with a disciplinary action plan. "For our non-physician staff, those folks will be immediately dismissed for the day and sent home without pay," she says. "So the fines are not the same, but we thought that each of them would have meaning to each of the different health care worker types. Believe me, everybody is aware. Everybody is willing to comply."
Seeking a 'Just Culture'
The policy is part of UMPC's "Just Culture" approach to patient safety, she explains.
"Our mission statement is 'Your care: Our commitment,'" she says. "We have decided to do whatever it takes to make sure health care workers have the right behavior every time. The systems are perfected now. There's hand hygiene dispensers everywhere, and [infection control] garb and signs on every door. The last piece is accountability."
The policy was adopted with full transparency and clear notice that there would be infection prevention observers in the designated areas to monitor compliance. In addition to the standard contact isolation signs, a strip of blue tape was placed above the designated room doors to prompt workers.
"It was never really our intention to fine people," Muto says. "It was our intention to get them to uphold the right behavior. People are very busy and might be heading into a room without the appropriate garb on. They would be stopped and reminded, and we have not had to issue any fines."
The blue tape also prompts housekeeping to do rigorous environmental cleaning upon patient discharge. "We wanted to make sure that the curtains were changed and the extra things were done for contact precaution rooms," Muto says.
The outbreak peak was in the third week of January, and since then has decreased steadily.
"We also did active surveillance on all of the clustered areas to see if there was reservoir that was undetected," she says. "That is not normally done here for that organism."
In addition, workers' hands were cultured, not so much to find MDR-Ab as to educate them about the persistence of germs and the value of hand hygiene.
"We did their hand cultures both before and after hand hygiene to show them and prove to them its importance," she says. "We did a lot of things, and the number of new cases has significantly decreased. We're almost there."