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Comment regarding “Electronic hand hygiene monitoring as a tool for reducing health care–associated methicillin-resistant Staphylococcus aureus infection”

      To the Editor:
      The article by Kelly et al
      • Kelly J.W.
      • Blackhurst D.
      • McAtee W.
      • Steed C.
      Electronic hand hygiene monitoring as a tool for reducing health care-associated methicillin-resistant Staphylococcus aureus infection.
      reported the results of an electronic hand hygiene monitoring system in the reduction of methicillin-resistant Staphylococcus aureus (MRSA) infections at Greenville Memorial Hospital. They found that the system prevented 24 MRSA infections, which represented a 42% decrease from the baseline, a reduction of 0.114 infections per 1,000 patient days. A calculated postintervention MRSA rate of infection would equal 0.1574 per 1,000 patient days. This is an excellent rate of control, especially when compared with the postintervention results by Jain et al,
      • Jain R.
      • Kralovic S.M.
      • Evans N.E.
      • Ambrose M.
      • Simbartl L.A.
      • Obrosky D.S.
      • et al.
      Veterans affairs initiative to prevent methicillin-resistant Staphylococcus aureus infections.
      who reported postintervention rates of 0.26 infections per 1,000 patient days for nonintensive care unit beds and 0.62 infections per 1,000 patient days for intensive care unit beds.
      However, as shown in Table 1, the reported MRSA infection rates during the study's time frame (July 1, 2012-March 31, 2015) approximate the values of bloodstream infections as reported for the institution on Hospital Compare (https://www.medicare.gov/hospitalcompare/). MRSA infections reported to Hospital Compare are primarily laboratory identification events of bloodstream infections and do not include MRSA soft tissue infections. This raises the question as to whether the authors are actually reporting MRSA bloodstream infections and not all MRSA infections.
      Table 1Methicillin-resistant Staphylococcus aureus bloodstream infections reported on Hospital Compare from Greenville Memorial Hospital
      Data acquisition periodSIRObserved casesPredicted casesPatient daysCases per 1,000 patient days
      January 1, 2013-December 31, 2013
      Data form Hospital Compare (https://data.medicare.gov/data/hospital-compare).
      1.1821916.075202,9800.094
      July 1, 2013-June 30, 2014
      Data form Hospital Compare (https://data.medicare.gov/data/hospital-compare).
      0.7851215.278206,4670.058
      October 1, 2013-September 30, 2014
      Data form Hospital Compare (https://data.medicare.gov/data/hospital-compare).
      0.7581114.506211,3580.052
      January 1, 2014-December 31, 2014
      Data form Hospital Compare (https://data.medicare.gov/data/hospital-compare).
      0.8271315.725217,0450.060
      April 1, 2014-March 31, 2015
      Data form Hospital Compare (https://data.medicare.gov/data/hospital-compare).
      1.2362016.183220,2100.091
      July 1, 2014-June 30, 2015
      Data form Hospital Compare (https://data.medicare.gov/data/hospital-compare).
      1.5382516.255217,5170.115
      January 1, 2015-December 31, 2015
      South Carolina Department of Health and Environmental Control.
      23208,5740.110
      NOTE. National average hospital SIR equals 0.93 (data acquisition dates July 1, 2014-June 30, 2015)
      SIR, standardized infection ratio.
      * Data form Hospital Compare (https://data.medicare.gov/data/hospital-compare).
      South Carolina Department of Health and Environmental Control.
      Assuming that the study is actually reporting bloodstream infections and not all MRSA infections, then the baseline rate of infections must have been very high. By calculation, this rate would be 0.271 bloodstream (laboratory identification) infections per 1,000 patient days.
      Hospital Compare data at the time of our letter's submission (acquisition dates July 1, 2014-June 30, 2015) described the facility's MRSA infections as worse than the U.S. national benchmark, with a standardized infection ratio (SIR) of 1.538 (0.115 cases per 1,000 patient days) (Fig 1). Hospital Compare data corresponding to the last year of the study had an SIR of 1.236 and were designated as no different than the national benchmark. Because the study did not appear to be registered on ClinicalTrials.Gov, a pretrial specified data collection time frame could not be found.
      Fig 1
      Fig 1Methicillin-resistant Staphylococcus aureus blood laboratory identified infections reported on hospital compare for data acquisition dates July 1, 2014-June 30, 2015. GHS, Greenville Health System.
      Adapted from Hospital Compare (https://www.medicare.gov/hospitalcompare)
      This high infection rate might partially be explained if there was a high environmental presence of MRSA carriers in Greenville, South Carolina. A 2012 Greenville Health System quality and safety report described the screening of all chronically ill patients on admission to Greensville Memorial Hospital and reported an MRSA carrier rate of 11%. The MRSA SIR risk adjusts for facility bed size, medical school affiliation, and community-onset MRSA bacteremia. Community-onset MRSA is not determined by the use of the present on admission indicator, but instead if the blood specimen was collected ≤3 days after admission.
      • Dudeck M.A.
      • Weiner L.M.
      • Malpiedi P.J.
      • Edwards J.R.
      • Peterson K.D.
      • Sievert D.M.
      Risk adjustment for healthcare facility-onset C. difficile and MRSA bacteremia laboratory-identified event reporting in NHSN.
      The article by Kelly et al
      • Kelly J.W.
      • Blackhurst D.
      • McAtee W.
      • Steed C.
      Electronic hand hygiene monitoring as a tool for reducing health care-associated methicillin-resistant Staphylococcus aureus infection.
      also stated that the “institution has been involved in developing and deploying such a system” since 2009 and references DebMed. This begs the question regarding a potential relationship with DebMed, and a statement to clarify whether or not a relationship exists, even if nonfinancial, should optimally be included in the disclosure of conflicts of interests. In addition, a clear statement of research study support should also be made in the article. Such a disclosure was made by a news release from the Electronic Hand Hygiene Compliance Organization regarding this study, which stated “The study was supported by Deb Worldwide Healthcare, Inc…
      • Sherrer K.
      • Electronic Hand Hygiene Compliance Organization
      Electronic monitoring system for hand hygiene reduces MRSA rates.
      The significance of this study has been reported by the news media, and its results appear to represent an improvement over the results the U.K.'s Cleanyourhands campaign had on decreasing methicillin-sensitive S aureus infections.
      • Dancer S.J.
      Response to: evaluation of the national Cleanyourhands campaign to reduce Staphylococcus aureus bacteraemia and Clostridium difficile infection in hospitals in England and Wales by improved hand hygiene: four year, prospective, ecological, interrupted time series study.
      It would be important for Kelly et al to clarify exactly what was measured, the baseline infection rate, and if known, the MRSA carrier rate in patients admitted to the facility.
      Postintervention, the institution's SIR (1.538) was substantially higher than the national baseline (SIR, 1.0) for MRSA bloodstream infections. The national average hospital SIR for data acquisition dates July 1, 2014 to June 30, 2015 is 0.93. The national baseline should be viewed as the starting point for reduction, not the goal. The national goal was to decrease MRSA bloodstream infections by 25% to an SIR of 0.75 by the end of 2013.
      • National Targets and Metrics
      Office of disease prevention and health promotion.
      Even with an extensive hand hygiene program, spread of pathogens and outbreaks can still occur. For example, this happened at Greenville Memorial Hospital in 2014, with an outbreak of a rare atypical mycobacterium causing infections in 15 surgical patients. In this case, the infection was believed to have come from water used in the facility and demonstrates the importance of indirect and environmental spread of pathogens. Hand hygiene should be viewed as an integral part of a bundle necessary to prevent MRSA infections, not as a sole solution.

      References

        • Kelly J.W.
        • Blackhurst D.
        • McAtee W.
        • Steed C.
        Electronic hand hygiene monitoring as a tool for reducing health care-associated methicillin-resistant Staphylococcus aureus infection.
        Am J Infect Control. 2016; 44: 956-957
        • Jain R.
        • Kralovic S.M.
        • Evans N.E.
        • Ambrose M.
        • Simbartl L.A.
        • Obrosky D.S.
        • et al.
        Veterans affairs initiative to prevent methicillin-resistant Staphylococcus aureus infections.
        N Engl J Med. 2011; 364: 1419-1430
      1. GHS quality and safety report.
        (Available from:) (Accessed July 23, 2016)
        • Dudeck M.A.
        • Weiner L.M.
        • Malpiedi P.J.
        • Edwards J.R.
        • Peterson K.D.
        • Sievert D.M.
        Risk adjustment for healthcare facility-onset C. difficile and MRSA bacteremia laboratory-identified event reporting in NHSN.
        (Centers for Disease Control and Prevention; Available from:) (Accessed July 25, 2016)
        • DebMed
        Hospital reduces MRSA rates by 42% with electronic hand hygiene measurement.
        (Infection Control Today; Available from:) (Accessed July 24, 2016)
        • Sherrer K.
        • Electronic Hand Hygiene Compliance Organization
        Electronic monitoring system for hand hygiene reduces MRSA rates.
        (Available from:) (Accessed July 23, 2016)
        • Sherrer K.
        Electronic monitoring system for hand hygiene reduces MRSA rates.
        (Healio Infectious Disease News; Available from:) (Accessed July 23, 2016)
        • Dancer S.J.
        Response to: evaluation of the national Cleanyourhands campaign to reduce Staphylococcus aureus bacteraemia and Clostridium difficile infection in hospitals in England and Wales by improved hand hygiene: four year, prospective, ecological, interrupted time series study.
        BMJ. 2012; 344: e3005
        • National Targets and Metrics
        Office of disease prevention and health promotion.
        (Content as of July 23; Available from:) (Accessed July 23, 2016)
        • Osby L.
        4th patient with GHS infection dies.
        (GreenvilleOnline; Available from:) (Accessed July 23, 2016)

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