Managing Chaos

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January 15, 2007

Germs, Germs, Germs...

(Cross-posted from HedgeStop.com)

Doctors are smart people. They save lives, improve the general wellbeing of a population, and even get to wear cool white lab coats.

Washing hands is common sense. You get rid of germs and dirt. When you were little, your mother probably told you to do it a dozen times a day. It’s an easy way to avoid passing germs around.

It wasn’t until 1850 that people realized that germs caused infections and illness. A Hungarian doctor, Ignaz Semmelweis, was working in a Viennese hospital with two maternity wards. In one, midwives delivered babies. In the other, doctors did. The doctors had a mortality rate three times higher than the midwives. It turns out that the doctors would deliver babies immediately after working on cadavers, and didn’t wash their hands between medical acts. They were transferring the germs from the dead bodies to the mother and the newborn child. When the doctors started washing their hands, the mortality rate plummeted.

So how come so many doctors—smart people in cool white lab coats—don’t wash their hands between seeing patients? Do they not understand the benefits? Have they never seen an episode of ER or Chicago Hope, and never learned that it’s what you’re supposed to do? Did they not teach this in medical school?

Amazingly, even today, some doctors don’t do it enough.

According to “To Err Is Human,” the Institute of Medicine reports that each year, between 44,000 and 98,000 American die because of hospital errors, and one of the leading errors is bacterial infections.

Researchers at Johns Hopkins Medical School took this a step farther. From the Baltimore Sun:

A study by Johns Hopkins researchers offers strong evidence that careful adherence to a few simple and cheap procedures - as basic as hand-washing - can drastically reduce the spread of infection in hospitals.

The Hopkins researchers tracked infection rates in Michigan hospitals that had agreed to institute strict safety practices for catheters, which are small tubes inserted into patients' veins. Used to administer medication and nutrients to some patients, the tubes can also be the source of life-threatening infections.

“The results are pretty breathtaking,” said Dr. Peter Pronovost, the lead author and a professor of anesthesiology and critical care medicine at the Johns Hopkins University's School of Medicine. “The numbers of infections went down quickly and they stayed down.”

(The report, “An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU,” was published in the New England Journal of Medicine.” The abstract is available here, and the full report here.)

Do doctors realize they’re not washing their hands? Yes and no. According to “Selling Soap: How do you get doctors to wash their hands?” a September 2006 article in the New York Times by Steven Levitt and Stephen Duber, “in one Australian medical study, doctors self-reported their hand-washing rate at 73 percent, whereas when these same doctors were observed, their actual rate was a paltry 9 percent.”

Now that we know they’re not doing it enough, how can we get them to change their behavior?

In “Selling Soap,” the authors demonstrated two attempts to improve hand washing rates at Cedars-Sinai hospital:

For the next six weeks, Silka and roughly a dozen other senior personnel manned the parking-lot entrance, handing out bottles of Purell to the arriving doctors. They started a Hand Hygiene Safety Posse that roamed the wards and let it be known that this posse preferred using carrots to sticks: rather than searching for doctors who weren’t compliant, they’d try to “catch” a doctor who was washing up, giving him a $10 Starbucks card as reward. You might think that the highest earners in a hospital wouldn’t much care about a $10 incentive — “but none of them turned down the card,” Silka says.

When the nurse spies reported back the latest data, it was clear that the hospital’s efforts were working — but not nearly enough. Compliance had risen to about 80 percent from 65 percent, but the Joint Commission required 90 percent compliance.

That got them part of the way there, but it wasn’t enough.

These results were delivered to the hospital’s leadership by Rekha Murthy, the hospital’s epidemiologist, during a meeting of the Chief of Staff Advisory Committee. The committee’s roughly 20 members, mostly top doctors, were openly discouraged by Murthy’s report. Then, after they finished their lunch, Murthy handed each of them an agar plate — a sterile petri dish loaded with a spongy layer of agar. “I would love to culture your hand,” she told them.

The administration then decided to harness the power of such a disgusting image. One photograph was made into a screen saver that haunted every computer in Cedars-Sinai. Whatever reasons the doctors may have had for not complying in the past, they vanished in the face of such vivid evidence. “With people who have been in practice 25 or 30 or 40 years, it’s hard to change their behavior,” Leon Bender says. “But when you present them with good data, they change their behavior very rapidly.” Some forms of data, of course, are more compelling than others, and in this case an image was worth 1,000 statistical tables. Hand-hygiene compliance shot up to nearly 100 percent and, according to the hospital, it has pretty much remained there ever since.

Interesting problems call for interesting solutions.

Bringing about change in an organization is never easy, and certainly harder in places like hospitals with highly-educated, highly-driven Type-A performers. The problem with not washing hands was clear: increased medical issues for patients. Rekha Murthy at Cedars-Sinai knew that, in addition to proving the problem, she had to show absolute proof that the doctors were the cause.

She did. There should be little doubt that she proved to the doctors that success or failure was… in their hands.

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