 Next speaker in our quality series is Emily Landon, an assistant professor of medicine here at the University of Chicago in infectious diseases and global health and also a faculty member in our McLean Center. She's a hospital epidemiologist and serves as medical director for the infection control program. She leads the infection control program here and is medical director for our Ebola treatment center. Her research is focused on health care provider behavior, specifically behavioral modification for reducing the risk of health care associated infections. Dr. Landon is currently working on innovative ways to use technology to improve hand hygiene compliance and reduce health care associated infections. During the Ebola scare last year, she emerges a national expert on the ethics of Ebola management but not Ebola today. She's going to talk to us about the ethics of hand hygiene. Emily, please. This is the talk I was supposed to give last year and I'm so pleased that I'm not doing Ebola all the time these days, although it is quite fun. So today we're going to talk about the one thing that I care most about in the world except for that little guy sitting down in the third row who is not paying any attention at all and that is hand hygiene. So I don't know how to make this go forward. Oh, there we go. I have no disclosures other than I work as a consultant and a speaker for Gojo Industries that make Pure Out, which is what we use at the University of Chicago and we used it for many years before I got here. So many, many years ago in 1846, many of you know the story of Selen Weiss who figured out or decided that he thought that it was possible that physicians doing autopsies were bringing cadaveric particles on their hands to the women who were delivering babies and if they just cleaned their hands with a chlorinated lime solution, perhaps more of those cadaveric particles would not make it to the women who were in labor and then they wouldn't die. It turns out he's right. However, no one bought it and the reason no one bought it then was because no doctor wanted to be told that it was their fault that a patient was getting perperal sepsis and this idea of cadaveric particles sounded kind of fishy even then it turns out the name bacteria goes over better with people but otherwise they just didn't want to believe that either. This was before the germ theory so you know it's a little confusing. Since then many, many people have proven again and again that hand hygiene does in fact reduce infections in hospitals and I could go through all of this data but then we would never have time for the rest of the speakers and yet we still don't seem to be able to do it. It's become one of the most stubborn problems we have in American medicine especially in quality. There are 1.7 million health care associated infections every year, 99,000 results in deaths. That's more than breast cancer, motor vehicle accidents and HIV combined and yet no one is having a walk in Grant Park with colored t-shirts to prevent health care associated infections. They cost us a ton of money and some mathematical modeling suggests that University of Chicago could save $1.2 million a year in MRSA costs alone for every 10% improvement in hand hygiene compliance. Now I don't know if that's real or not because no one's been ever able to really show that we can improve hand hygiene on a large scale. Many of you know that direct observations, secret shoppers are not ideal because they are, there's a problem with the Hawthorne effect. Hand hygiene is usually 30 to 60% higher when it's measured by people who are out on the wards just checking once in a while. So at the University of Chicago we now have this comprehensive aggregate monitoring system. It involves, oops that's not what I wanted to do. One of these is probably supposed to work for that, oh here we go. Dispenser modules have counters in them so that each unit knows exactly how many times someone has put soap or Purell into their hands. Each doorway has one of these little things that's like the thing outside of the grocery store that when you walk up to it the door opens infrared sensor that says how many times someone enters or exits. It doesn't know who, it just knows for a unit this is how many times people entered and exited this is how many times they used the Purell or the soap and put those two together and send them off to a software program that can then put this kind of graph, a real-time graph on the unit and available to people outside the unit like me to see what the hand hygiene compliance is. Now I wish we could do this on a more individual level but I get that that makes people feel a little bit big brotherish. Some people feel a little bit big brotherish about what we've already done and I want to make just a quick moral argument about that as well. You know there are a lot of things that we have to give up as health care providers and in our jobs that we wouldn't necessarily want to give up in terms of liberties in our everyday life because of professionalism and yet we do it like being immune to measles, being immune to varicella, you can't work in our hospital without being immune to those things if you aren't immune you get you get vaccinated again. I've had like six MMRs because I never show up as immune to measles and that's just how it works. So this is something that actually Dr. Siegler and Dr. Rubin who talked earlier this morning and Lydia Dougdale wrote years ago, physicians must recognize that actions such as hand washing or being vaccinated accomplish more than simply minimizing nosocomial spread of disease rather through these simple actions. Physicians demonstrate their beneficence and non-maleficence toward patients essential components of professionalism and that is a very succinct way of arguing that hand hygiene is more than just doing the right thing because there's evidence that it helps patients. But I want to talk a little bit more about how it works that we come to this point where we think that everyone has to wash their hands. So let's start with a health care facility right that there are rights and obligations in every part of this trio the facility the health care worker in the patient. A health care facility expects employees to follow the rules that they set for safety. They also know they have a duty to provide safety for the patients that come to their hospital and good care and they have a duty to support employees in being able to provide good care and safe care. That means putting up in terms of hand hygiene that means putting up cural dispensers means making sure that nurses aren't completely overloaded and have time to wash their hands although to be honest with you using Purell has reduced the amount of time it takes or Purell or any sort of alcohol based hand sanitizer reduces the amount of time it takes to perform hand hygiene so as to make it largely negligible since it can be done as one is entering largely. Health care workers really have the right to expect a supportive environment to follow the rules. That means alcohol based hand sanitizer and sinks where they're needed reminders feedback whatever it takes to help get your behavior to where it needs to be. Think about all the meaningful use reports you get. I'm not sure if that's quite as important as this but it is good duty. They know they have a duty to protect patients and they have a duty to follow the organizational rules. Now patients have an expectation of safety and they expect a minimization of harm. Now what is their duty? I'm not sure in this little trifecta what exactly their duty is. Some would say that they have a duty to speak up and remind their physicians and nurses to wash hands. I don't tend to agree with that. I think that we don't ask our patients to do double checks of the interactions in their drugs. We don't ask them to make absolutely certain that their creatinine is acceptable before they have a dye study. That's our job and while we want them to be good advocates for themselves we really do need to be responsible for the safety. So with all of these things in favor of hand hygiene why is it that we don't do it all the time? And so let's explore a little bit more about why we should do it. The consequentialist might say that if you don't clean your hands you'll result in harm to patient and sometimes that's what I use as an argument. Other people respond better to the idea that hand hygiene is the rule, the policy and you have to follow the rules if you want to work here. Some people respond well to the idea that this is the right thing to do. It's virtuous. It is correct because of all the reasons that Dr. Siegler wrote in his quote earlier. Others believe that it's a duty. We owe it to our patients. Regardless of the reasons that you individually choose, it checks all the boxes, whatever box system you want to use. Aside from occasionally people having a little bit of eczema to certain hand gel sort of brands, there's really no downside to washing one's hands and cleaning one's hands. So why is it that the compliance in my hospital looks like this? This is one of our hospitals. This is the last 30 days and you can see that the compliance isn't really above 30%. And another important thing to notice is this number here. 1.4 million opportunities in 30 days in one of our three facilities. That's really hard to understand. In fact, in the first quarter of fiscal year 2015, University of Chicago healthcare workers cleaned their hands 3.6 million times. That is a lot of safe patients. That is enough to make everyone feel like they are doing the right thing. It didn't do it 6.5 million times. This is a catastrophic and consistent failure to meet a very basic professional and ethical standard of every single person that goes into or out of a patient's room. Whether they are an EBS worker or they are a nurse or they are a doctor, it doesn't matter. And yet we can't seem to get that to work. And I wish that my talk had a lot more answers. I get my five minute marker here, and maybe someone's concerned that I have a lot more to say. But the truth is we don't have a lot of answers to this question. So when I ask people why they don't clean their hands, they tell me they forget. We don't forget to leave the ventilator on. There's not enough accountability. So no one's making me do it. So no one just walks around, you know, map back to the ventilator, unplugging ventilators because no one told them to keep it on. There's not enough time. The dispensers aren't really in the right place. I have to walk two steps to get to that dispenser, Dr. Landon. I love that one. And my favorite one is, it's not me, it's everyone else. I'm washing my hands, but no one else is. I'm not touching anything when I go into the room. Forget the fact that you really need to be prepared to provide care to the patient when you walk into the room, because that's your job. And if the patient asks for water, more likely than not, you're going to hand them their cup, whether or not your hands were clean when you did. Not understanding or believing the numbers we show them. Or there are so many patients and visitors, it's their fault. That's why we're not doing it. And they don't have to wash their hands. So why should I have to wash mine? Well, it turns out that hand hygiene is a habitual behavior and changing habits is really hard to do, even when they're important and virtuous and good. Like smoking, overeating, some of you might bite your fingernails or keep checking your Facebook, how many of you have had multiple diet cokes already today? So you know how many, how important it is and how difficult it is to break these habits. It also turns out that changing these habits is a lot like what Elizabeth Kubler-Ross described in terms of the stages of grief. I have health care workers tell me I don't believe those numbers. That's not what's really going on. Those dispensers are in the wrong place. I don't really want to do this. But I just wash my hands. I just left one room. I'm going into the next room. I'm not touching anything. And then the nurse manager from the unit after I've been bothering them to improve their hand hygiene calls me up and says, we can't do this. It's impossible. And eventually some of our units get to this place called Acceptance where we do see some improvement. But unfortunately that is really not the majority of the units in our hospital. And I think some of that has to do with this culture of keeping quiet. People get impolite reactions when they're reminded to clean their hands. They're not necessarily seen as a team player if they call out another nurse or a doctor. There's this subtle or systematic retribution for filing incident reports if you catch someone not washing their hands. There's no real training in assertive communication how to tell colleague you think they're doing something wrong. How many of us feel comfortable doing that? We don't feel good about giving feedback up the ladder. Imagine a new nurse trying to tell a senior transplant surgeon that he forgot to clean his hands. And a lot of times people feel outnumbered if they're the one cleaning their hands and no one else is, then maybe they're in the wrong. The herd idea gets along with us. There are union rules that prevent nurses from reminding one another in some cases and there's often a focus on other tasks. So things that might help, accurate monitoring, accountability either on an aggregate or unit team based scale or individual scale support for speaking up, listening to frontline providers about what they need to be supported in order to do these things and commitment to change. And this isn't just true of hand hygiene, right? There are thousands of other habits that healthcare workers have to do every day in order to provide optimal care to patients. And these things are going to be needed to change all of those behaviors to what we would consider to be virtuous, ethical and good. Now at the University of Chicago, I'm pleased to say we have all of these things in place, including a commitment to change. And yet we still find ourselves blazing new trails because this is one of the most difficult things. Since 1840, we haven't moved from that 30% compliance range. And I think that any hospital that uses similar monitoring has found the same thing. So we're all working together. I think ethics can have a bigger role in this. I think that we need to think about ethics as more proactive instead of just reactive when there's some complaints. And so I'm going to continue to work to make that happen. And that's all I wanted to say except for please clean your hands. Time for perhaps one question. Lydia, yes. Emily, great talk. Thanks so much. Has there been any conversation about making these dispensers or rather the sensors at the doors to patients rooms able to detect a chemical in the Purell itself? So right now this system can't tell whether or not you an individual actually washed their hands when they went into the room, right? And there are a lot of ways that we can tie hand hygiene more closely to the entries and exits. There's a lot of different technologies out there. We pilot some of these in different places. So far, the one that I described to you is the best, most functional, most accurate system available. I think that those kinds of ideas are great. And there are some people that have alcohol sensing technologies. But what we really need is behavior change. Dr. Seaton has a question. The hospital has made flu shots mandatory or required. You didn't suggest that hand washing? It is mandatory. It is a requirement. It's absolutely the policy. Anyone can be fired for not washing their hands. But we don't do it. It's not monitored. It's not monitored. And flu shots are not at the University of Chicago are not technically mandatory. You can't actually have a higher or fire decision based on that. They are much more strongly mandatory. I know there's like degrees of mandatory. Who thought that was the case? For physicians, then they are for nurses because of union issues at University of Chicago. But our influenza vaccination with sort of a positive proactive campaign is much higher than it has been. But I think that everyone will end up with mandatory influenza vaccines in short order if they don't already have them. Thank you. Thank you very much. I think we all recognize that the main reason to wash your hands is to do with avoiding the ire of Dr. Landings.