Monday, November 19, 2007

"Don't worry about it"

I have written before about hand hygiene and the inexplicable difficulty of getting people who are trained in medicine to be attentive to this most basic infection control method. (For BIDMC's latest compliance with this and other clinical safety and quality metrics, you can check our website.)

I am still not pleased with our progress, but this is not just our problem. It appears to pervade medical centers. Here's a true story about a recent example at another place in town.

A friend of mine (let's call her "Mary") was accompanying a friend of hers (let's call him "Sam") to a visit with his doctor's office. Sam has Parkinson's disease and needs help getting around. Sam also needs to be accompanied through his office visit because he takes lots of medications, and the doses and frequency of them are changed from time to time, and he gets confused unless there is someone to help him keep track.

At this visit, several dosages and frequencies were changed, and it became Mary's job to unload and reload Sam's medication dispenser box so he would have the right pills for the right days of the week. As she was moving pills around, and breaking some of them in half, she suddenly realized that she had spent the whole day opening doors for her friend and touching all kinds of surfaces in the hospital and had neglected to wash her hands before handling his medications. Mary blurted out, "Gee, I forgot to wash my hands."

The nurse responded, "Don't worry about it." Now, because of all the medications he already takes, Sam is prohibited from taking any other medications if he catches a cold or gets a sore throat or any such problem. So, for him, a cold is a particularly uncomfortable event. Mary, who therefore was worried about it, temporarily put aside the nurse's comment and looked for a disinfectant dispenser somewhere in the exam room. There was none.

Mary, not being the shy type, made clear to the nurse that she was not pleased with either her comment or this situation. But how many of us would have the nerve to do that? Probably not many. I fear, though, that unless we as patients take it upon ourselves to remind our providers, progress in this arena will be all too slow.

P.S. When Mary told me about this story a few days later, she had a cold . . . .

13 comments:

Anonymous said...

http://www.ama-assn.org/amednews/2007/11/26/prsd1126.htm

Maybe a good way to get people to participate in these quality improvement and safety initiatives is to give the staff bonuses related to compliance and improvement in care, not you.

I harrass staff people, especially doctors, to wash their hands constantly. I zap vap all night long. I can honestly say that I personally have saved this hospital tens of thousands of dollars on the front line preventing nosocomial infection. Why are you the one getting the bonus for it? That's rediculous. I have a great deal of respect for you and what you've done with this hospital. You saved my mother's career here before I worked here myself - and I appreciate that. But I'm not quite sure that your salary is reasonable. I know you've discussed this matter on your blog before, and I know improvements come from the top, but don't you think a little kick-back to the staff might improve compliance?

Paul Levy said...

Thanks, anon.

We did issue bonuses to all employees in September. They were not related to quality metrics, but that is certainly worth thinking about for the future.

Doctors were not included in that bonus because they are not employees, and I don't set their salaries. I will raise that issue with the Chiefs of the various department.

Are you suggesting differential bonuses based on each floor's compliance with hand hygiene? We do measure this metric by floor. Is that what you had in mind?

nonlocal M.D. said...

Well, there's an excellent argument for the existence of this blog right above - that idea and response; a dialogue between staff and CEO. What a novel idea - not that I am taking sides, but it just proves that "many heads are better than one" when it comes to idea-generating.

John Norris said...

I understand that hospitals swab and do cultures of various things in the hospital to see if they are clean. (Correct me if I am wrong.)

They could do it to people's hands. Or have them wear a bracelet and turn that in to be swabbed. I'm thinking of something like the process they use with x-ray techs and those badges.

Naomi said...

It's not just the medical community that is having these issues. I used to work with special needs children in an integration program in a local elementary school. Not only were the kids hand hygiene challenged, but it was amazing how many of the teachers, admin staff, ect, were lacking in hand washing. No wonder so many adults and kids get sick during cold and flu season.

Anonymous said...

(anon)
To reply to your reply, I don't think necessarily that a bonus program for calstat use would work very well. The data collection on that measure is less than perfect to start. If you wanted to do a straight up monetary reward to staff for reducing infection, perhaps the VAP program would be a good place to start. I don't want to give you the wrong impression -- I didn't become a nurse for the money. Our jobs are fundamentally different, but we do work at the same place and essentially have the same mission. I never have nor will I ever complain about the money I make. We do deserve every cent we make, and if you want to retain nurses you have to pay them well. The dilemma which touched off this conversation is that you are getting rewarded for the work that we do - and your salary is already beyond what ANY person needs. Don't get me started on my feelings regarding social class.

I really would like to touch on the fact that our benefits are quite dismal compared with other industries and even within the Boston hospitals. I understand that it is a national crisis, but healthcare employees should be getting the best and cheapest health insurance that exists. Even if it means we have to come to this hospital for our care. I already do, for reasons I've mentioned before. Everyone saw right through the email that said "congratulations -- we're only increasing your insurance by 7% this year, not 14!". I'd rather see you take the money we save by reducing iatrogenic medical problems and their subsequent costs and pouring it into the health insurance you give to the employees. That'd be an excellent locally driven stab at the global healthcare crisis. If anyone should get the best, it should be us. I've said this to you on here before -- the biggest gun the union has revolves around our benefits.

Patient Dave said...

Re anon 3:14's "our benefits are dismal compared to other industries": I'm dyin' to know which industries are so much better that BID's look dismal. I can say from personal experience that benefits today ain't what they used to be. When I did an extensive job search a year ago, I was surprised at how much things had changed.

I also learned to be wary of firms that just say "We offer a competitive benefits package." Invariably that means "We've looked at what others offer, and we'll offer that much, sorta, i.e. pretty much as little as we can get away with."

Personally I wish I had all the benefits that are listed on the BIDMC site. (And I work for a good company, in my opinion.) But maybe I'm wrong...

Alexa Blue said...

Every 10,000th Purell dispenser should be implanted with some sort of pellet that can fit through the nozzle and be redeemed for $1000.

Mark Graban said...

I think you're right that not everyone has the nerve to speak up. I think it is very unreasonable when advocacy groups run ads saying that patients need to speak up and hound their medical providers about hand hygiene. That's an abdication of the hospital's responsibility. I respect that you are looking for creative solutions among your staff and physicians. Incentives might be part of the approach, but measuring adherence to hygiene standards is difficult. Since some hospitals have made dramatic improvements in nosocomial infection rates and the methods for doing so aren't secret, how about a hospital wide bonus or incentive system based on reducing HAI's? It's a team effort, so some team incentives might just help.

On a different note, do you have thoughts to share on the preventable heparin error involving Dennis Quaid's twins in L.A.? What steps is BIDMC taking to proactively prevent that same error from occurring in your hospital?


Good luck and, as always, thanks for your interesting blog.

Anonymous said...

Paul, transparency is your thing.
I am curious, why do you sometimes
write posts about problems at other
area hospitals? BIDMC has problems
and you are working on them. Other
hospitals have problems and "we" are working on them too. What is
your intention in this post?...was
it to say "BIDMC is working on a
problem but THEIR problem is worse?
It can seem that way.

Paul Levy said...

I think it helps to calibrate our own problems by comparing them with others'. Also, it sends a signal to our folks to focus on things that happen elsewhere, as a way to help our folks avoid them. And yes, it is a way of congratulating our folks when I see problems elsewhere that we used to have here.

You will note that I do not mention other places by name when I talk about their problems. I do, however, offer congratulations by name from time to time both here and in speeches.

But back to you. Why do you ask the question? Do you think it unusual or wrong that one organization would point out problems in another? I see it all the time -- and usually much more directly -- in American commercial and political life.

Paul Levy said...

Mark,

I asked our folks about the heparin question you raised. Here is part of the response from one of our pharamacists. As you can see, the staff is still working on other ideas.

"Please see the steps below that we put in place prior to the tragic September 2006 incident at Methodist Hospital in Indianapolis.

"1) Heparin Flush Syringes 10 unit/mL are stocked in the NICU Automated Dispensing Machine(ADM). These syringes are stored separately from adult heparin products in an area designated for "Neonate Use Only".

"2) All medications that are filled in the NICU ADM are checked by a pharmacist prior to delivery.

"3) All heparin containing intravenous fluids are prepared by the pharmacy.

"Additionally, the pharmacy does not stock the Baxter heparin products , which were involved in both the Indianapolis and the LA incidents.

"After the most recent heparin incident at Cedar Sinai, our Clinical Pharmacy Coordinator Medication Safety, we decided to evaluate utilizing the bar code technology as an added safety measure. The NICU/Pharmacy Committee will review this at this Tuesday's meeting.

"Providing medications safely and effectively for our NICU population is of utmost importance to our pharmacy."

And, a bit more explanation:

"The Methodist Hospital NICU stocked heparin flush 10 unit/mL in 1 mL vial. The pharmacy technician mistakenly delivered heparin 10,000 unit/mL vials which are used for SC injections for DVT prophylaxis(there are also 20,000 unit/ml vials). This is what caused the 1000 x overdose. The news stories do not say that a pharmacist checked the vials before they before they were delivered. We require all medications be checked by a pharmacist.

"I am comfortable that this could not happen here. We purchase pre-made 3 mL heparin flush 10 unit/mL in 12 mL syringes. These syringes are blue and stored in a special section of the pharmacy designated for NICU only. The adult heparin flush syringes are 100 unit/mL and in a yellow syringe. These are stored with the main inventory far away from NICU stock.

"In July, we began stocking the NICU with premix heparin IV solutions. This enabled us to remove the heparin 1000 unit/mL 10 mL vial that had been stocked for nurses to prepare initial IV bags for UAC and UVC lines. The RN would add 500 units to the 1 liter bag of fluid.

"We removed the heparin 1000 unit/mL vial in July and the only heparin in Omnicell now is the heparin flush syringe. This was a safety quality initiative that the NICU/Pharmacy committee had started a couple of years ago and finally implemented it this July."

Patient Dave said...

From today's Times - "Our Enemy Hands". By the author of The Dirt on Clean: An Unsanitized History.