Wednesday, April 05, 2006

Doctors Beware: Wash well or else!

Now, another reason for doctors to stop touching their patients! First we have the Electronic Medical Record to keep health care providers banging on keyboards at the expense of more time with patients, careful critical physical examination, and individual assimilation and analysis of findings to communicate with our peers. Now it seems, the Big Brother administrators lead by eager infectious disease specialists have employed hall monitors to make sure we wash or hands, or else! What else? Well, it could go as far as revoking practice privileges. Laura Landro in the Health section of today’s (4/5/2006) Wall Street Journal reported:

In an effort to be launched this week, the Centers for Disease Control and
is collaborating with the nonprofit Institute for Healthcare
and two leading infectious control professional societies in a
program to boost compliance using behavior modification techniques, "best
practice" guidelines, and rigorous programs to monitor adherence.

“We are in an era of smarter bacteria and we need to be more aggressive in ensuring patient safety,” says Rebecca Shadowen, the infectious-disease specialist who led the study” that showed hand-washing reduced their “smart” bacteria infection rates. But more concerning was the attitude that the program implemented at Greenview Regional Hospital and Medical Center (Bowling Green, KY) “emphasized that the hospital’s top officials were monitoring compliance and prepared to take disciplinary action…”

Now, I’m no infectious disease expert, and I certainly understand the importance of careful hygiene and careful infection control strategies, but draconian measures like this are sure to fail. Education should be the cornerstone for health care workers and physicians alike. Rewarding good behavior rather than flogging bad behavior makes MUCH more sense. And let’s be real here. Taken to the next extreme (which was done at our hospital for a recent Joint Commission inspection), I would dare say that keyboards, like the one I’m typing on now, should be disinfected, too! (yes, we were supposed to wash our little mitts after every keyboard use, too!) And so should all stethoscopes be similarly disinfected? What about my tie? Who will monitor that I dry-clean it after each wearing (remember, those dirty hands and stethoscopes touch all of our ties!!!)? Should be implemented as well! Will hall monitors demand dry-cleaning receipts? Ridiculous? Yes! Worth revoking my privileges? Not!

Yet the drumbeat continues:

"It is no longer tolerable to accept (hand-washing) non-compliance rates of 50%
when we are dealing with critically-ill patients," says Don Goldman, MD, a
senior vice president of IHI and a professor of pediatrics at Harvard Medical
School, who notes that computer chip makers have better hand-cleaning standards
than most hospitals. While the IHI program emphasizes education and
positive feedback, "repeat violations in healthcare, or any industry, need to
have consequences, " Dr. Goldman says.

So can you see it now: clean rooms, laminar air flow, white bunny suits, and hand-washing like computer chip makers! And best of all, consequences if we don't comply!

Later in the article, a voice of reason existed:

John Boyce, and infectious disease specialist who helped write the CDC (Center for Disease Control) guidelines and runs a free instructional Web site,, says hospitals often view monitoring hand-hygiene compliance as time-consuming, tedious, and ineffective. “We need to come up with strategies that are believable,” Dr. Boyce says.

Please make it believable! (And along those lines, Dr. Boyce site quotes the statistic that 90,000 deaths (at the cost of 4.5 million per year) are caused by hospital-based infections, but how many of these were really caused by poor hand-washing technique? Are ventillator infections, GU infections and the like from handwashing infringements? - in my humble opinion and reading, patients themselves and the instruments we place in them are the most likely contaminants). If other sources of contamination are not just as important, then I’ll be first to develop contact dermatitis on weekends between the 25 or so patients I see each day. And hear me clearly: I do think there are data that hand-washing is helpful to decrease bacterial concentrations on my hands between patients. But I resent administrative personnel threatening to revoke privileges of a credentialed health care provider on the basis of failure to hand-wash. I would counter that the expense of administering this program unnecessarily drives the expense for health care delivery through the roof at way too little return on the investment and like all such rules, how exactly will it betracked, enforced, and most important accepted by doctors?

Another concern for our student physicians - what a way to further disempower them and ingender further dehumanization of the patient-physician encounter! If a monitor is near, and the credentials threat were clear, perhaps it will be perceived as "safer" just not to enter a patient's room - just keep typing at your contaminated keyboard since Big Brother is watching you.

None of us want patients to suffer such infections, and hand-washing is a relatively inexpensive way to, perhaps, reduce spread of resistant organsisms, but doctors should demand of administrators that they treat us as professionals as much as we desire to do the right thing for our patients. That way, everybody wins. My preference: remove bureaucracy in favor of good, prudent, touching care.


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