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Special report: New infection control standards call for high-tech approaches

July 20, 2012
by Loren Bonner, DOTmed News Online Editor
This article first appeared in the July 2012 edition of DOTmed Business News

Today, hand sanitizer dispensers are familiar to anyone who’s visited a hospital in the last few years. In most cases, if these identifiable, easy-to-use devices aren’t inside a patient’s room, they can be located right outside the door. Universally referred to as “gelling in” and “gelling out,” a caregiver is supposed to sanitize their hands upon entering and exiting a patient’s room.

The reason for the sanitizer’s ubiquity is simple: getting providers to clean their hands between contact with patients has been proven time and again to be an effective means to reduce health care-associated infections (HAIs), a leading cause of death in the U.S.

New standards
In fact, the Joint Commission changed its hand hygiene standard as a result of a project the Commission’s Center for Transforming Healthcare developed in 2008. Previously, the standard called for hospitals to demonstrate hand hygiene compliance at a rate greater than 90 percent. But findings from the project, published in 2010, proved that was difficult to do. Today, the Joint Commission asks that hospitals provide proof that the facilities have a plan in place to improve compliance.

Four of the eight hospitals that participated in this study to improve hand hygiene capitalized on real time locating technology to play detective. This is where Michigan-based Versus Technology Inc.—a real time locating systems company — entered the picture. For the study, Versus worked with Cedars-Sinai Medical Center in California and Johns Hopkins Hospital in Maryland to monitor hand washing using its RTLS technology.

“We made a preliminary decision with the Joint Commission that we could just focus on gelling of inbound compliance and then compliance coming out,” says Henry Tenarvitz, chief of intellectual property at Versus.

The World Health Organization has identified the Five Moments for Hand Hygiene: Before patient contact, before an aseptic task, after body fluid exposure risk, after patient contact and after contact with patient surroundings. Tenarvitz says to address all of those points technologically was a big challenge, which is why he set up the Versus’ system on the universal “gelling in” and “gelling out” policy for patient caregivers. Health care workers wear a Versus real time location system badge that’s activated when it’s triggered. It picks up a signal and reports the activation from hand motion to the dispenser — also tagged with Versus technology — and reports the activation to the facility’s system.

“What was obvious to me was the natural place for the compliance system: the nurse call system as opposed to the back of the IT department or biomed department. The nurse call system is mandated and you already have the infrastructure in place to care for and service it,” says Tenarvitz.

CenTrak, another RTLS company headquartered in Newtown, Pa., which offers a hand hygiene compliance system—part of its “open infrastructure”— connects to the nurse call system and can automatically cancel a call when the nurse enters the room. CenTrak’s president and CEO, Ari Naim, says that’s important for workflow, but also for infection control because workers don’t have to put their hands on a button.

AeroScout, which is now a part of Stanley Healthcare Solution (a division of Stanley Black & Decker), introduced its Wi-Fi based RTLS system with hand hygiene monitoring capabilities at HIMSS 2012.

“We were getting customers saying, ‘Can you help us?’” says Charlotte Miller, director of nursing informatics for AeroScout.

According to Miller, facilities were asking for a way to merge the technology offered for nurse call integration with hand hygiene monitoring.

A new agenda for hospital infection control
Although hospitals across the country have made concerted efforts to decrease incidents of HAIs in recent years, key components under health care reform are forcing many hospitals to refocus their strategies.

“In some cases, hospitals are prepared for this. Infection control was an area where they felt they were doing quite well. But now it’s about putting stringent protocols and processes in place to ensure that everyone is marching on the same path,” says Lisa Fox, vice president of strategic syndicated research and data audits for Healthcare Research & Analytics.

The health care marketing firm’s most recent study looked at how hospitals are preparing for certain provisions under the 2010 health care law.

“Although the legislation is under debate, you still have a number of requirements hospitals have been forced to adhere to starting now,” says Fox. “We looked at hospitals as the channel that are going to get hit first and in some ways hardest by a lot of the changes under the Affordable Care Act, including penalties for HAI readmission and value-based purchasing.”

Value-based purchasing under health care reform, which kicks in this October, is a top concern for hospitals, according to the study. The reimbursement scheme rewards or penalizes hospitals across 12 key quality measures, four of which focus on HAIs. For example, Medicare will reduce payments to hospitals with poor infection rates in their intensive care units, beginning this year.

“That goes into their performance score and will start to form that pool that everyone will be a part of. Hospitals will either gain or lose reimbursement based on how they are performing on all 12 clinical processes of care measures,” says Fox.

New Medicare rules that went into effect in early 2011 already require hospitals to report infections or pay a penalty.

In addition, reductions in payments will happen in 2015, based on any acquired condition. Regardless of whether it’s an HAI or a blood clot as a result of surgery, the hospital will have to eat that cost.

Although well-intended, some experts have mixed feeling about the new rules.

Xenex PX-UV Disinfection System

“It’s good for our cause in that it raises awareness and leadership roles, but it could have unintended consequences and it’s really hard to link hand washing all the way through,” says Dr. Lisa Maragakis, senior hospital epidemiologist and director of hospital epidemiology and infection control at Johns Hopkins Hospital.

HRA’s study results show that hand washing as well as isolating and monitoring Methicillin-resistant Staphylococcus Aureus (or “superbugs”), were hospitals’ biggest focus as far as controlling infection. Specifically, the study found that 94 percent of hospitals already had hand washing initiatives in place.

But companies like AeroScout believe technologies that can monitor compliance are the only way to reduce HAIs and comply with what’s in store under health care reform.

“It shows the Joint Commission that they have a program and what those compliance rates are,” says Miller.

The data accrued from the systems can also help management see where certain areas in a health care facility might have low compliance rates, and what staffing or workflow changes might be necessary.

“You can see we have problems on Wednesday nights on this particular floor. And people start to look at the process and they see that every Wednesday evening these guys get flooded with 20 to 30 surgeries. It’s not that staff don’t want to wash their hands, it’s probably that they are just running ragged with too many demands,” says Miller.

CenTrak is also a firm believer in using RTLS to improve efficiency because of the data it can generate.

“Unless you have an army of people with clipboards looking at things 24 hours a day, RTLS is the only thing that can provide visibility and that’s a fundamental component to get [HAIs] numbers down,” says Naim.

By tracking employees and engaging with data, facilities can also link up which employees might have come in contact with an infected patient, giving them better tools to manage infection control.

Miller also adds that this technology has direct and indirect cost savings for health care facilities.

“To do it manually requires nurses to be secret shoppers. That’s an added expense and it still tends to be subjective. Plus, nurses need to be doing direct patient care.” Nurse to patient ratios, or the number of patients a nurse cares for, are already a problem for hospitals, and taking away critical staff from their jobs to an even greater degree could interfere with good patient outcomes.

“Any time we can automate a process that is taking nurses away from patient care, I want to be part of that solution,” says Miller.

Easy integration
RTLS, already in place in many health care facilities, tracks equipment, as well as hospital personnel, through a network that detects tags attached to equipment or badges worn by employees. Hand washing monitoring is easily integrated into such a system and most RTLS companies market hand washing compliance as one component of a bigger package.

“It’s really just another case use for our system. So while we provide tags for staff workflow, this is another add-on feature in the overall system that allows us to monitor staff interactions with patients,” says Tuomo Rutanen, senior vice president for worldwide marketing and business development at Ekahau, an RTLS company headquartered in Virginia.

Although hand washing can be singled out of the package for a company, Rutanen says that his company’s strategy is to market the system for these other things because it’s financially difficult to justify a dedicated solution for hand hygiene alone.

An RTLS is expensive for a hospital no matter how it’s broken down. So to be able to leverage many disciplines over them—like hand hygiene—makes the system much more attractive.

“One investment can be used for many different things,” says Naim. CenTrak aims to brand itself as vendor-neutral, and in doing so, broaden its portfolio to give customers flexibility. CenTrak provides the infrastructure, and various CenTrak certified applications running in the hospital can connect to its server.

“Recently, we found a way to integrate our CenTrak Gen2IR tags with existing Wi-Fi infrastructure. Our tags can roam around from place to place and be seen under Wi-Fi or not, so it all works together seamlessly,” says Naim.

Ekahau’s system can also work with a hospital’s Wi-Fi network. “We look at our approach as a cost-effective solution. The wireless reader is already there and it’s just a question of software and tags and then the dispenser that can be retrofitted with an Ekahau component to capture the hand hygiene event,” says Rutanen.

Sonitor Technologies Inc., based in Seattle, specializes in ultrasound RTLS for health care to track movement, assets as well as hand hygiene compliance. “Its accuracy is the highest of any of the technologies because of the fact that it’s not affected by windows, bright lights or clothing,” says Dick Tabbutt, executive chairman of Sonitor.

He says that other common location technologies, like infrared light, are affected by these things; and the downside to Wi-Fi is its inability to track more than 50 to 110 feet.

AeroScout licenses Sonitor’s technology in its system.

Striving for perfection
Versus originally based its hand hygiene monitoring systems on the universal “gelling in” and “gelling out” concept practiced by patient caregivers. But based on feedback from caregivers at Johns Hopkins and Cedars Sinai—the two hospitals that tested the system for the Joint Commission’s study—Versus ended up adjusting some parameters. In addition to tracking every time a caregiver hits the dispenser, being “compliant” in a hand washing event also means the caregiver must perform the action within a certain amount of time.

“Basically, they can set the rules depending on room set up, like if they gel inside or outside the room,” says Tenarvitz. “The customer could decide [to allow] a window of 10 seconds in the hallway after leaving the room.”

Changes like this were established on the third generation of Versus’ system—mostly as a result of feedback.

“People don’t really want to be tracked. But if you go talk to them about what the system is actually doing and get their input and how it would make their lives easier and get those things in the system, then they will support it,” says Tenarvitz.

AeroScout’s Miller, a nurse herself, says there’s been a real shift in how nurses view technology in their workflow. “They are asking for it and are more receptive to it,” she says.

Nonetheless, integrating a fully capable and 100 percent accurate RTLS is easier said than done.

“Nurses are very fast people. They are smacking the dispenser at lightning speed, so we’re trying to pick up a very fast event and track if they are approaching a patient. We have to do the location within seconds,” says Naim.

One size doesn’t fit all
Decreasing incidents of HAIs is a multi-component effort. Although hand hygiene is important, and at the top of many institutions’ priority lists, it’s just one way hospitals are working toward reducing infections.

Eckard Gesell, regional director of marketing for Lifecycle Solutions at the Lübeck, Germany-based company Dräger, says they have created a line of disposable accessories and consumables in response to the growing market demand for disposable products and infection prevention solutions. One example is Dräger’s ECG lead system intended for single-patient use, which the company launched in February.

“Even a product as simple as an ECG lead cable can contribute to the entire chain of patient safety, hygiene and comfort,” says Gesell.

The risk most commonly associated with an ECG is a nosocomial infection. Studies have shown that ECG leads can be a pathway for antibiotic-resistant pathogens, even after disinfection.

Philips resells a UV room sterilizer called Tru-D from Lumalier Corp. The device is automated, no-touch, portable and helps control pathogens known to contaminate environmental surfaces.

Another portable cleaning device, the Xenex PX-UV Disinfection System, uses pulsed xenon ultraviolet light to destroy viruses, bacteria and bacterial spores in patient areas. Cone Health in North Carolina began using the system last year and reported a 42% decrease in MRSA in just six months.

Despite an abundance of technology available to help keep hospitals germ-free, not all epidemiology departments are convinced it’s the way to go.

“We have to follow state guidelines, but we have our own infection control approach that’s quite simple,” says Alfonso Torress-Cook, director of epidemiology and patient safety at Pacific Hospital Long Beach.

Instead of focusing completely on caregiver hygiene, Pacific makes sure every patient that’s admitted into the hospital is cleaned. “What about the patient washing their hands? We make sure to clean their hands and fingernails and give them a shower from head to toe,” he says. Combined with staff protocols, Torress-Cook says his hospital has virtually eliminated methicillinresistant staphylococcus aureus and surgical infections, and can boast of being a hospital with a low incidence of infection.