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Monday, March 8, 2010

One Hospital's Simple Measure
to Defeat Infections

By Michael Vitez, Inquirer Staff Writer

One in an occasional series.

See related photos taken by
Philadelphia Inquirer staff
photographer and Pulitzer-prize
winner Tom Gralish.

Catherine "Pat" Zakrzewski of Roxborough was her family's matriarch, hosting 90 people – including 23 grandchildren and five great-grandchildren – every Easter, her favorite holiday.

But arthritis was crippling her – she could barely walk – so she decided four years ago to have her knees replaced at Abington Memorial Hospital.

"She sailed through surgery, rehab, and went home," said Kevin Zakrzewski, her son, a primary-care physician who practices at Abington.

But at home, a kneecap split, which happens from time to time, requiring more surgery.

Back in the hospital, Pat Zakrzewski acquired an infection, one of the worst kinds, MRSA, resistant to antibiotics.

What followed was a nightmare: removal of her new knee, amputation of a leg, and, ultimately, after a combination of 20 surgeries and hospitalizations, her death April 13 at age 77.

The hospital infection led to her death.

And "almost certainly," said John J. Kelly, the hospital's chief of staff, that infection was carried to her bedside "on the hands of someone in the hospital."

"She was a lovely woman, vibrant and energetic," said Kelly, who said he was at times in tears as he left her hospital room. "We failed in our ability to protect her from infection."

One could argue that the infection also killed Pat's husband of 58 years, Henry, who was holding her hand as she took her last breath.

"He died two months after his wife of a broken heart," Kelly said. "There wasn't anything wrong with him."

What happened to Pat Zakrzewski has happened at virtually every American hospital.

Nearly 100,000 patients die every year in the U.S. from infections they get in hospitals, according to the federal Centers for Disease Control and Prevention.

"None of us likes to believe these things happen in our hospital," said Kelly, Abington's top doctor. "And any hospital that says, 'It doesn't happen here,' is not being honest. . . . Our goal is to continually push down the risk of preventable harm."

A major cause of hospital-acquired infections, remarkably, is poor hand-washing.

Bacteria can travel from one room to the next on the hands of doctors, nurses, and technicians, much like bees carrying pollen. And weakened patients are vulnerable.

More than 150 years ago – before anyone understood germ theory – a Hungarian doctor, Ignaz Semmelweis, showed how washing hands in a Vienna hospital cut down dramatically on the frequency of infection.

Washing hands saved lives.

U.S. hospitals didn't forget that lesson from Semmelweis, but in the last few decades, with the increase in high-technology medicine, nurses and doctors came to regard infections as inevitable.

Tubes entering the body are ideal vessels to carry infection past the skin and the body's normal defenses.

"We used to accept infections as the result of medical progress," Kelly said. In the last few years, however, there has been a complete "frame change," he said. "We've moved away from this notion of inevitability."

A landmark Michigan study published in December 2006 in the New England Journal of Medicine showed the world that hand-washing and other safety efforts could nearly eliminate infections.

In 2005, Pennsylvania became the first of 27 states to require hospitals to report rates of hospital-acquired infections. (The health bills stalled in Congress would require it of all states.)

Pennsylvania's most recent report, covering half of 2008, shows Abington was in the normal range.

Hospitals are trying to reduce infection not only to save lives. In 2009, Medicare stopped reimbursing hospitals for some costs resulting from infection, deciding that because hospitals caused the additional expense, they should pay for it.

This trend will continue no matter what happens now in Congress. Hospitals know they will be paid less in years to come for their errors.

Hand-washing spies

About two years ago, Abington dispatched "spies" to observe and report how often doctors and nurses washed their hands when entering and leaving patients' rooms.

The idea was not dreamed up in Abington, but was promoted by national groups and adopted by many hospitals. Using spies is a resource-heavy task and considered evidence of high-level commitment by hospitals to improve hand hygiene.

Abington's policy is clear: Everyone involved in patient care must wash hands before entering and after leaving every patient's room.

Collette Hendler, an infection-control nurse in epidemiology, was asked to form the team of spies.

Hendler hated the assignment at first because she had trouble recruiting; nobody wanted to be a spy. But she has grown to like the job because she sees the value and results.

"It's interesting how something so basic can help so much," she said. "I worked in intensive care for 20 years. After patients were there for a while, you just expected them to get infected. Now I see infections can be prevented."

Hendler assembled a team – staffers whose identity will be protected here – who began recording the number of times hospital staff washed with soap and water or "gelled," hitting the Purell wall dispensers outside each room and rubbing hands with the alcohol-based sanitizer.

Most of the time, one form of handwashing is as good as the other, but after touching blood or feces, one must wash with soap and water.

Washing only on the way in or out was a "No."

One had to wash going in and coming out to be a "Yes."

"When the first survey came out and compliance was 34 percent, there was a lot of pain," said Peachy Viviano, a nurse.

She said the reaction was just like the five stages of grief that Elisabeth Kübler-Ross described in her book On Death and Dying.

She explained: "First, denial ('We wash our hands, that's not us'); then anger ('Who's gathering that info?'); then bargaining ('We could do it better'); then sadness, and finally acceptance."

Todd Groeber, nurse manager on the Medical Intensive Care Unit, didn't believe the numbers at first, and Hendler told him he could do the observations himself.

"Honestly, everyone was disputing the numbers at the beginning," Groeber said. "I think it was because no one wanted to believe they were that bad." He tried collecting data and discovered that "the numbers were as bad as they were originally reporting."

"Since then," he added, "we have had great success in our unit. Numbers that everyone can be proud of."

"Does anybody walk in and say, 'I'm not washing my hands. This is overrated?' Absolutely not," Viviano said. "It was never that people didn't buy in. It was that we're running in and running out. You can say to yourself, 'Well, maybe I didn't touch that patient.' "

Doctors were the worst, the spies said.

Geetika N. Sood, medical director of epidemiology, had to call her colleagues who were chronic offenders. "Most of the time, they just weren't thinking about it," Sood said. When a doctor goes into a patient's room, she said, "you're thinking, 'these are the medical problems, these are the drugs they're on, these are the things I have to do,' so you're not thinking, 'I have to wash my hands.' "

Screensavers on every Abington computer promote hand hygiene. Some of the images used at first were jarring. One was of a young boy in a hospital bed with the caption: "What's on your bare hands could kill him." Another was of an elderly woman alone in a room with the caption: "She had three million visitors today. Most were deadly germs."

"People got very upset," Hendler said. "They were afraid families would be offended. But I saw it as it got people talking, which is what I wanted to do."

One spy – "I call myself a mole," she said – is a 30-year veteran nurse. One afternoon, she sat in a corner of one unit giving her a view down two hallways, and pretended to be charting on a computer. She watched who was washing.

But she does have regular duties and was often interrupted from spying by others asking her to do her job. That prevented her from completing some observations. Unless she could see entry and exit, she couldn't count it.

One nurse asked the mole for help with a patient. They were longtime friends. But when the nurse left a room and didn't gel, the mole recorded a "No."

One doctor filled out a patient's chart book in the hallway, put the chart away, put on gloves and a gown, and entered a room. But he didn't wash before he put on the gloves. The mole was busy working at that point and didn't see this sequence. But it would have been a "No."

"Docs were the hardest sells," said the mole. "But I see them doing it. They're getting good with it."

Spies do between 800 and 1,400 observations a month. Kelly wants to create a culture where every employee down to housekeeping takes ownership of every patient and feels comfortable, regardless of position, asking doctors and nurses, "Did you wash your hands?"

Abington has tried to make washing easy by putting dispensers outside every room.

Several months ago, Viviano came out of radiology and couldn't find a dispenser. "I was like an alcoholic looking for a drink," she said. "I couldn't find my alcohol."

She called housekeeping and a dispenser was put up the next day.

A compelling story

In the first several months, with the hospital's mission so clear, hand-washing compliance reached the 60 percent range.

But Kelly realized he needed to make it personal, so he began telling the hospital's 5,700 employees the story of Pat Zakrzewski.

A year before Zakrzewski died, Kelly got her permission to use her story.

Kelly presented a slide show, first at the management meetings to get the executives on board, then at staff meetings to get physicians to buy in, then at all departmental meetings and at every new-employee orientation.

Meghan Patton, vice president of human resources, said Kelly's decision to share Zakrzewski's story is what really changed the culture at Abington and got the rank-and-file to buy in.

"To me, that's what made the difference, when he started telling stories," she said.

Years ago, hospitals would have been much more likely to conceal what happened, never admit a mistake or error.

But Kelly contends "there can never be trust without transparency." He wants errors and preventable harm caused by the hospital disclosed to families immediately.

"Will this provide an invitation to sue for damages? Perhaps," he said. "But I am confident that the long-term and deep trust that will be established in the community for the hospital and its professionals will be ultimately a much greater strength."

Friends had encouraged Pat and Henry Zakrzewski to sue, but they refused, their son said. She loved her surgeon and thought he had done his best.

As a result of all of Abington's efforts, the percentage of staff washing hands rose from a dismal 31 percent in December 2007 to 88 percent in September 2009, Kelly said.

"You really deserve to congratulate yourselves," Kelly told employees in the fall. "It's really wonderful for patients because it's not just hand hygiene alone, but it's the commensurate decrease in infections in the hospital.

"We have had dramatic reductions in central-line-related bloodstream infections, ventilator-associated pneumonias, and surgical-site infections," he said. "We are still working on urinary-tract infections and I'm certain they're going to come down."

Kelly said last week there was only one central-line bloodstream infection hospital-wide in February – a first – and no hospital-acquired infection after a total knee replacement in one year.

In the last few months, however, the hand-hygiene rate has plateaued around 80 percent.

So, beginning later this month, those seen washing will be given index cards making them eligible for a prize raffle. Those seen not washing will get the same size and color cards with a different message.

Three infractions and the offender will get a letter saying reappointment – required every two years to keep one's job – is conditional.

Kelly says poor hand-washing truly could cost doctors and nurses their jobs.

"What's more serious than somebody dying from a hospital-acquired infection you could prevent?" he asked.

Virtually everyone at Abington knows of Kevin Zakrzewski, whose medical office is across the street and who is on the hospital's safety committee.

The personal anguish caused by his mother's death was immense and complex. He loves and believes in Abington hospital. He has devoted his professional life to the place. He urged his mother to have her surgery there.

As hard as the death of his mother was for him and his family, the idea that good has come from it, that Kelly used her story to change behavior, has helped in his own healing and in his family's.

"Infection is personal," Zakrzewski said. "We can't just think of this as 'infection out there.' To really create change, we had to understand this. That's what my parents' story did for the staff. It gave them a picture."

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