>> GOOD MORNING, EVERYONE.

MY NAME IS DR. PATRICIA GRADY,

DIRECTOR OF THE NATIONAL

INSTITUTE OF NURSING RESEARCH.

IT'S MY PLEASURE TO WELCOME YOU

TO 2012 NATIONAL INSTITUTE OF

NURSING RESEARCH DIRECTOR'S

LECTURE.

THIS IS AN ANNUAL EVENT WE HAVE

IT DESIGNED TO BRING THE NEIGH'S

TOP SIEBTISES TO THE NIH CAM --

SCIENTISTS TO SHARE THEIR WORK

AND INTEREST TO A

TRANS-DISCIPLINARY AUDIENCE.

THIS LECTURE WAS INITIATED LAST

YEAR AS PART OF OUR 25th

ANNIVERSARY CELEBRATION AND WE

CONTINUE IT BECAUSE WE HAD SUCH

A WONDERFUL KICK OFF LAST YEAR.

IT IS AN OPPORTUNITY TO BRING

PEOPLE HERE TO THE CAMPUS SO

THAT WE CAN LEARN MORE FROM THEM

AND THEY CAN EXPERIENCE SOME OF

THE THINGS GOING ON HERE.

SO IT DOES PROMOTE COLLABORATION

AND WE'RE VERY PLEASED TODAY

WITH OUR SPEAKER.

FOR ABOUT -- A QUARTER CENTURY

NOW OUR OVERARCHING MISSION IS

TO HEALTH AND PROMOTE -- PROMOTE

THE HEALTH OF FAMILIES AND

COMMUNITIES AROUND THE COUNTRY

AND THE GLOBE BY BRINGING THE

SCIENCE WE DO INTO THEIR DAILY

LIVES.

IN THIS CONTEXT NURSING SCIENCE

PLAYED A PIONEERING PIVOTAL ROLE

IN BIOMEDICINE LEADING THE WAY

IN THE INTEGRATION OF BIOLOGICAL

BEHAVIORAL SCIENCES.

HIGHLIGHTING THE IMPORTANCE OF

PERSON-CENTERED FAMILY AND

COMMUNITY-BASED POINT OF CARE

PRACTICE.

AS SCIENTISTS CLINICIANS POLICY

LEADERS AND EDUCATORS, NURSES

INTRINSICALLY UNDERSTAND

RESEARCH POLICY PRACTICE AND

EDUCATION ARE INTEGRALLY LINKED.

EVERY DAY NURSE SCIENTISTS ARE

MAKING A DIFFERENCE AND

DISCOVERIES AT THE BENCH,

TRANS-LATINGING -- TRANSLATING

DISCOVERS INTO EVIDENCE BASED

PRACTICE AND POLICY INTEGRATING

INTO THE EDUCATION AND TRAINING

OF THE NEXT GENERATION OF HEALTH

AND SCIENCE LEADERS.

TODAY'S SPEAKER, DR. ELAINE

LARSON EXEMPLIFIES THIS EVIDENCE

BASE AND INTERDISCIPLINARY

APPROACH TO RESEARCH, PRACTICE,

POLICY AND EDUCATION.

ONE CANNOT OVERSTATE THE

IMPORTANCE OF DR. LARSON'S WORK

WHICH HAS USING A VARIETY OF

INNOVATIVE APPROACHES SOUGHT TO

IDENTIFY, PREVENT AND CONTROL

INFECTION.

A MAJOR DRIVER OF MORBIDITY AND

MORE TAIL IN THIS COUNTRY AS

WELL AS THROUGHOUT THE WORLD.

OF EQUAL IMPORTANCE TO HER

SCIENTIFIC RESEARCH PER SE IS

THE TIME AND CONSIDERATION

DR. LARSON HAS GIVEN TO

DEVELOPING SUCCESSFUL

COLLABORATIVE MODELS TO CONDUCT

THAT RESEARCH.

DR. LARSON IS THE ASSOCIATE DEAN

FOR RESEARCH AND PROFESSOR OF

PHARMACEUTICAL AND THERAPEUTIC

RESEARCH COLUMBIA UNIVERSITY

SCHOOL OF NURSING, DIRECTOR OF

THE CENTER FOR INTERDISCIPLINARY

RESEARCH TO PREVENT

ANTI-MICROBIAL RESISTANCE AT

COLUMBIA UNIVERSITY AND THE

PROFESSOR OF EPIDEMIOLOGY AT

COLUMBIA SCHOOL OF PUBLIC

HEALTH.

SHE RNED HER BACHELOR, MASTER

AND Ph.D. DEGREE UNIVERSITY OF

WASHINGTON SEE WATT L AND --

SEATTLE AND MEMBER OF NUMEROUS

ORGANIZES INCLUDING THE

INSTITUTE OF MEDICINE, ACADEMY

OF NURSING, AMERICAN NURSING

ASSOCIATION, SIGMA THETA TAU.

SHE'S ALSO AS YOU'LL HEAR DURING

HER TALK TODAY ONE LEADING

INVESTIGATOR FROM OUR ROADMAP

EXPERIMENT, THE NIH ROADMAP TO

IMPROVE MEDICAL RESEARCH DURING

THE PREVIOUS ADMINISTRATION.

AND SOME OF THE WORK SHE WILL

PRESENT TODAY DOES DATE BACK

FROM THAT.

AND SO WE'RE VERY EXCITED TO

HEAR ALL THE WORK FUNDED THROUGH

OUR INSTITUTE AND OTHERS AS

WELL.

DR. LARSON IS ALSO A FORMER DEAN

OF THE GEORGETOWN UNIVERSITY

SCHOOL OF NURSING SO AS AN ALUM

I'M PROUD OF WHAT SHE DID THERE

AND HAS BEEN A MEMBER OF THE

BOARD OF DIRECTORS OF THE

NATIONAL FOUNDATION FOR

INFECTIOUS DISEASE AND REPORT

REVIEW COMMITTEE OF THE NATIONAL

ACADEMY OF SCIENCES, A MAJOR

HONOR AND VERY LARGE

RESPONSIBILITY.

IN ADDITION SINCE 1995 SHE

SERVED AS EDITOR OF THE AMERICAN

JOURNAL OF INFECTION.

INFECTION CONTROL.

SHE'S PUBLISHED NUMEROUS MORE

THAN 250 PLUS JOURNAL ARTICLE,

BOOK, NUMBER OF BOOK CHAPTERS,

ET CETERA.

VERY WELL REPRESENTED IN HELPING

TO SHAPE THE NEXT GENERATION.

SO THE TITLE OF DR. LARSON'S

TALK THIS MORNING IS INFECTION

PREVENTION AND INTERDISCIPLINARY

TEAM APPROACH.

SHE WILL SPEAK FOR APPROXIMATELY

30 MINCE AND THEN THE FLOOR WILL

BE -- MINUTES AND THEN THE FLOOR

WILL BE OPEN FOR QUESTIONS SO

YOU WILL HAVE A ADDRESS THINGS

IN HER TALK OF PARTICULAR

INTEREST TO YOU.

SO LET ME VERY ROUNDLY WELCOME

DR. ELAINE LARSON, WE'RE PLEASED

TO HAVE YOU HERE WITH US TODAY.

[APPLAUSE]

>> THANK YOU, DR. GRADY, I'M

DELIGHTED TO BE ABLE TO PRESENT

AND SHARE WITH YOU A LITTLE BIT,

A SAMPLING OF SOME OF THE

INTERDISCIPLINARY RESEARCH I

HAVE BEEN PRIVILEGED TO BE PART

OF OVER THE YEARS.

THESE ARE MY DISCLOSURES, I

DON'T KNOW IF NIH DOES IT BUT

ERYBODY DOES IT.

THESE ARE ANYMY DISCLOSURES.

WHAT I WANT TO DO TODAY IS TALK

ABOUT SOME OF THE RESEARCH

RESULTS IN THREE PHASES.

FIRST OF ALL SORT OF THE

DESCRIPTIVE CORRELATIONAL STAGE,

THEN THE INTERVENTIONAL STAGE

THEN PROBABLY MOST IMPORTANTLY

IS THE STAGE WHERE WE TRY TO

ACTUALLY HAVE AN IMPACT ON

CLINICAL PRACTICE AND ON POLICY.

BUT AS MANY THINGS IN LIFE ARE,

THE WAY A CAREER STARTS IS OFTEN

SERENDIPITOUS.

AND I WANTED TO START WHEN I WAS

A CRITICAL CARE NURSE IN THE ICU

MANY YEARS AGO.

THE ICU WAS TYPICAL FOR THAT

TIME FIVE BED UNIT WITH TWO

SINKS IN THE BACK, ONE OCCUPIED

BY THE DIALYSIS EQUIPMENT, WE

HAD ONE SINK AROUND NURSES

STATION IN THE CENTER.

THE PLAN AT THE HOSPITAL, THIS

WAS IN SEATTLE, WAS TO HAVE AN

ARCHITECTURAL CHANGE AND OPEN A

NEW ICU WITH 12 BEDS, EACH BET

SEPARATE WITH A SEPARATE ROOM

AND TWO SINKS, ET CETERA, SO AN

EPIDEMIOLOGY COLLEAGUE OF MINE

AND I DECIDED TO DO A

LONGITUDINAL STUDY FOR TWO YEARS

TO LOOK AT THE IMPACT OF THIS

ARCHITECTURAL CHANGE ON

HEALTHCARE ASSOCIATED INFECTION

RATES.

WE COLLECTED SAMPLES FROM EVERY

ICU PATIENT FOR A YEAR IN THE

OLD UNIT AND THEN IN THE NEW

UNIT.

AND THAT STUDY WAS PRESENTED AT

AN INTERNATIONAL MEETING AND

PUBLISHED IN THE AMERICAN

JOURNAL OF MEDICINE.

WHAT WE FOUND AND WHILE WE WERE

DOING IT WE ALSO WERE DOING AIR

SAMPLING BECAUSE THAT'S WHAT YOU

DID IN THOSE DAYS.

WE DON'T DO TOO MUCH OF THAT ANY

MORE.

WE WERE REPORTING ALL THE

ACTIVITIES THAT WENT ON AROUND

PATIENTS AND WHAT WE FOUND

THOUGH IT WASN'T PART OF OUR

INTEREST OR OUR HYPOTHESIS OR

ANYTHING, WAS THAT PEOPLE IN THE

OLD UNIT AND NEW UNIT DID NOT

INCREASE THE FREQUENCY OF THEIR

HAND HYGIENE.

SO THE CONCLUSION FROM THIS

PAPER WAS BASICALLY TWOFOLD,

THAT FIRST OF ALL THE ISOLATION

ROOMS AND THE NEW ARCHITECTURAL

CHANGE WAS NOT ASSOCIATEDDED

WITH ANY REDUCTION IN

ACQUISITION OF ORGANISMS AND

ALSO WE SAW THAT HAND WASHING

DID NOT INCREASE.

EVEN THOUGH WE WENT FROM ONE

SINK FOR FIVE PEOPLE TO TWO

SINKS PER PATIENT.

SO I WENT TO THE -- AFTER THIS

WAS PUBLISHED, I WENT TO THE

DIRECTOR OF THE ICU AND SAID WE

REALLY SHOULD DO SOMETHING ABOUT

HAND WASHING IN THIS UNIT.

HE SAID TO ME, WHAT IS THE

EVIDENCE THAT THERE'S ANY

RELATIONSHIP BETWEEN HAND

WASHING AND INFECTION?

AT FIRST I WAS SHOCKED.

THEN I THOUGHT WHAT IS THE

EVIDENCE?

I'M NOT REALLY SURE MYSELF.

SO THAT WAS A BIT OF A WAKE-UP

CALL FOR ME.

FIRST OF ALL THE HEALTHCARE

ASSOCIATED INFECTIONS ARE COMMON

AND THE QUESTION IS, HOW

PREVENTABLE ARE THEY, IN THOSE

DAYS WE WERE TOLD BY CDC THAT

ABOUT 30% OF INFECTIONS WERE

ACTUALLY PREVENTABLE.

SINCE THEN LOOKS MORE LIKE 95%

ARE PREVENTABLE BUT IN THOSE

DAYS THAT'S WHAT WE WERE TOLD.

AND THE OTHER WAKE UP CALL FOR

ME IS HAND HYGIENE IS SUPPOSED

TO BE A PRIMARY PREVENTION

STRATEGY BUT NOT EVERYONE

BELIEVES IN IT AND NOT EVERYONE

DOES IT.

SO THAT SORT OF WAKE-UP CALL

SERVED AS A LITTLE BIT OF AN

UNDERPINNING FOR THE PROGRAM OF

RESEARCH OVER THE YEARS WHICH

I'LL TALK WITH YOU ABOUT.

SO THE FIRST PHASE OF THE

RESEARCH THAT WE BEGAN TO DO,

WAS TO ANSWER SOME OF THESE

QUESTIONS.

FIRST OF ALL, IT DOESN'T MATTER

IF YOU DO HAND HYGIENE, IF YOUR

HANDS ARE OKAY.

WHAT'S ON THE HANDS OF

HEALTHCARE PROFESSIONAL?

WHAT ARE HAND HYGIENE PRACTICES

OF HEALTHCARE PROFESSIONALS AND

WHAT IS THE EVIDENCE OF A LINK

BETWEEN HANDS AND INFECTION?

SO FOR THAT, I HAD SOME CLINICAL

SKILL BUT I CERTAINLY NEEDED

MICROBIOLOGY AND EPIDEMIOLOGY.

SO OUR COLLABORATIVE TEAM WAS

THE SURGEONS, THE

EPIDEMIOLOGISTS, THE STAFF,

MICROBIOLOGISTS, STATISTICIAN

AND A DERMATOLOGIST.

ONE OF THE THINGS WE FOUND IS

ACTUALLY FROM MY DOCTORAL

DISSERTATION I SAMPLED THE HANDS

OF A LITTLE UNDER A THOUSAND

HEALTHCARE PROFESSIONALS AND

FOUND THAT YES, INDEED, THE

HANDS ARE -- AFTER HAND WASHING,

STILL HIGHLY COLONIZED WITH

POTENTIAL PATHOGENS.

IN ONE STUDY THAT WE DID, WE

FOUND THAT IN THE ICU STAFF THEY

PERSISTENTLY CARRIED ON THEIR

CLEAN HANDS ONE OR MORE OF 22

SPECIES OF GRAM NEGATIVE

BACTERIA CONSIDERED TO BE MORE

ENTERIC ORGANISMS BUT THEY'RE ON

THE HANDS.

21% OF 541 HEALTHCARE ASSOCIATED

INFECTIONS OVER A 7 MONTH PERIOD

DOING THE STUDY ARE CAUSED BY

THE SAME SPECIES THAT WERE FOUND

ON PERSONNEL HANDS.

SO WE STARTED TO LOOK AT THE

HAND WASHING BEHAVIOR IN A MORE

SYSTEMATIC WAY.

THIS IS ACTUALLY, WE STOOD AT

THE DOORWAY OF PATIENTS KNOWN TO

BE INFECTED AND HAD AN ISOLATION

SIGN ON THE DOOR.

WE HAD A CLIP BOARD.

WE WEREN'T HIDING.

PEOPLE KNEW WE WERE OBSERVING,

THEY DIDN'T KNOW WHAT WE WERE

OBSERVING BUT THEY KNEW WE WERE

OBSERVING BEHAVIOR.

EVEN AMONG PATIENTS KNOWN TO BE

INFECTED, 55% OF THE TIME THE

STAFF AFTER TOUCHING THAT

PATIENT DID NOT DO HAND WASHING.

THIS IS THE SAME DATA BY TYPE OF

UNIT ONCOLOGY.

THEY HAD 80% HAND WARK RATE BUT

LOOK AT RENAL TRANSPLANT LESS

THAN 20%, ABOUT 17% OF RENAL

TRANSPLANT STAFF WHEN AFTER

TOUCHING PATIENT KNOWN TO BE

INFECTED WASH THEIR HANDS.

NURSING 50%, PHYSICIANS 35% AND

OTHERS SUCH AS RESPIRATORY

THERAPISTS, ET CETERA, LESS THAN

20%.

WE DID ANOTHER STUDY AT ANOTHER

HOSPITAL LOOKING AT THE

ANTIBIOTIC RESISTANCE OF THE

SKIN FLORA, THE STAFL COKAL

NORMAL FLA RA ON THE HANDS OF

FOUR GROUPS.

WE DID THESE CULTURES AFTER HAND

WASHING IMMEDIATELY.

THESE ARE ON CLEAN HANDS.

WE WANTED TO SEE WHAT WAS ON THE

HANDS WHEN WE TOUCH THE NEXT

PATIENT.

THE FIRST LAVIN DAR BAR -- LA

INVENTORY DAR BAR, -- LAVIN DAR

BAR -- SOME OF THE ANTIBIOTICS

WE TESTED AND THE VERTICAL IS

THE PRERS OF STAFF COCAL FLORAL

ON THE ANTIBIOTICS.

THE SECOND BAR IS A DERMATOLOGY

OUTPATIENT STAFF, THIS IS

PHYSICIANS, NURSES, UNIT

SECRETARIES, RESPIRATORY

THERAPISTS, ET CETERA.

THE THIRD BAR IS PATIENTS WHO

HAD BEEN IN THE HOSPITAL 30 DAYS

OR MORE, HALF OF WHOM ON

ANTIBIOTICS.

AND THE FOURTH BAR WAS THE

NORMAL CONTROLS CONSTRUCTION

WORKERS, SECRETARY, PEEPED WHO

HAD NOTHING TO DO WITH THE

HOSPITAL.

AND WHAT YOU SEE IS THAT FOR

EVERY ANTIBIOTIC WE TESTED T

NORMAL COLONIZING FLORA OF THE

BONE MARROW TRANSPLANT STAFF WAS

SIGNIFICANTLY MORE RESISTANT

THAN ANYBODY ELSE INCLUDING

PATIENTS WHO HAD BEEN ON

ANTIBIOTICS.

THIS WAS VERY CONCERNING BECAUSE

WE ALSO STUDIED THIS STAFF OVER

A PERIOD OF ABOUT 12 MONTHS, AND

THAT COLONIZING FLORA REMAINED

WITH THEM.

IT WASN'T JUST TRANSIENT.

SO JUST TO SUMMARIZE THIS,

PHYSICIANS HAD HIGHER COUNTS

THAN NURSES OF STAFL COKAL FLORA

BUT SECRETARIES HAT HIGHER

RESISTANT THAN FE SITION.

THE RANK ORDER OF RESISTANCE,

BONE MARROW TRANSPLAN STAFF,

PATIENTS HOSPITALIZED 30 DAYS OR

MORE, DERMATOLOGY STAFF AND

NORMAL CONTROLS.

ALSO AROUND THE SAME TIME

BECAUSE THE QUESTION OF THE

DIRECTOR OF THE SURGICAL ICU WAS

STILL HAUNTING ME AND STILL DOES

OVER THE YEARS, WHAT'S THE

EVIDENCE?

WE PUBLISHED WHAT I THINK IS

PROBABLY THE FIRST SYSTEMATIC

LITERATURE REVIEW LOOKING AT THE

CAUSAL LINK BETWEEN HAND WASHING

AND RISK OF INFECTION.

THE QUESTION TO ANSWER WAS DOES

HAND HYGIENE MAKE A DIFFERENCE

IN INFECTION RATES?

HOW CAN WE IMPROVE HAND WASHING

PRACTICES?

AND WE NEEDED TO ADD BEHAVIORAL

SCIENCE, CHANGE THEORY,

BEHAVIORAL EXPERT, CLINICAL

TRIAL EXPERTS AND SYSTEMS

THEORY.

ONE OF THE EARLY STUDIES WE DID

ADDING INDUSTRIAL ENGINEERS,

PSYCHOLOGISTS, ET CETERA, WAS A

STUDY THAT WAS SUBSEQUENTLY

PUBLISHED IN BEHAVIORAL MEDICINE

BUT FOR -- WE WORKED IN THIS

STUDY WITH SOMEONE WHOSE

EXPERTISE WAS IN ORGANIZATIONAL

CLIMATE AND SYSTEMS CHANGE AND

DECISION THEORY.

AND WHAT WE HYPOTHESIZED WAS

THAT ANY TIME ANYBODY TRIED TO

IMPROVE HAND HYGIENE BEHAVIOR,

WITH EDUCATION OR WITH OBSERVING

AND FEEDBACK AND SO FORTH, IT

USUALLY GOES UP FOR ABOUT TWO

DAYS AN BACK DOWN.

TO BASELINE.

OUR HYPOTHESIS WAS IF WE WANT TO

MAKE A DIFFERENCE WE NEED TO

CHANGE THE COACHER -- CULTURE

AND WE NEED TO CHANGE THE SYSTEM

OF CARE SO IT'S NOT LIKE THE

DOCTORS DON'T WASH THEIR HANDS

OR NURSES DON'T WASH THEIR HANDS

BUT AS A TEAM THIS IS SOMETHING

WE OWN AND BELIEVE IN.

OUR HYPOTHESIS, IF WE DO USE

MORE BEHAVIORAL SCIENCES, THEN

WE WOULD NOT SEE AN IMMEDIATE

CHANGE UP.

BUT WE WOULD SEE A SLOW GRADUAL

CHANGE OVER TIME THAT WOULD BE

PERSISTENT.

SO WE DID THE STUDY FOR EIGHT

MONTHS AND WHAT WE DID IS WE HAD

TWO HOSPITALS, ACTUALLY IN D.C.,

AND WE RANDOMIZED ONE TO THE

INTERVENTION AND THE OTHER WAS A

CONTROL, OBVIOUSLY A VERY WEAK

DESIGN BECAUSE THE SAMPLE SIZE

WAS TWO BUT NEVERTHELESS.

THEN WE INSTALLED ELECTRONIC

COUNTERS INSIDE THE SOAP

DISPENSER SO WE COULD COUNT HOW

OFTEN THE SOAP DISPENSER WAS

USED.

AND THESE ARE JUST THE NUMBERS

THAT WE HAD THIS IS THE

INTERVENTION HOSPITAL AND THE

CONTROL HOSPITAL.

SO WE OBSERVED QUITE A FEW HAND

HYGIENE EPISODES.

WE OBSERVED IN THE INTERVENTION

HOSPITAL 110,000 PATIENT DAYS

AND 240,000 PATIENT DAYS IN THE

COMPARISON HOSPITAL.

WHAT WE FOUND, FIRST OF ALL,

THIS IS THE STUDY HOSPITALS IN

THE DARKER GREEN AND THE CONTROL

HOSPITAL IN THE LIGHTER GREEN.

THIS IS THE HAND HYGIENE MEAN

HAND WASHES PER PATIENT CARE DAY

IN THE TWO HOSPITALS, AND AT

BASELINE THERE WAS A LITTLE

HIGHER BY CHANCE, NOT

STATISTICALLY BUT A LITTLE BIT

HIGHER RELATIVE RISK OF HAND

HYGIENE EPISODES IN THE STUDY

HOSPITAL.

DURING THE INTERVENTION WE DID

NOT SEE A BIG DIFFERENCE IN HAND

HYGIENE BUT AFTER THE FOLLOW-UP

AFTER EIGHT MONTHS WE SAW A HUGE

INCREASE IN HAND HYGIENE

CONSISTENT WITH OUR HYPOTHESIS

THAT CHANGING THE CULTURE TAKES

TIME.

SO WE ALSO LOOKED AT RATES OF

METHSILLAN RESISTANT STAFF ORIUS

PER PATIENT DAYS.

CONTROLS AT BASELINE, NO

SIGNIFICANT DIFFERENCE, NO

SIGNIFICANT DIFFERENCE DURING

THE INTERVENTION PERIOD NOR

EIGHT MONTHS LATER.

BUT WHAT WE DID SEE, WHEN WE

COMPARED THE HOSPITAL, THE STUDY

HOSPITAL, BASELINE TO FOLLOW UP

PERIOD, THERE WAS 33% DECREASE

IN MRSA RATES IN THE

INTERVENTION HOSPITAL AND 31%

INCREASE MR GNA RATES IN THE

HOSPITAL.

FOR VANCOCOCCIN RESISTANT, THESE

ARE THE TWO MAJOR ANTIBIOTIC

RESISTANT ORGANISMS CAUSING

HEALTHCARE INFECTIONS TODAY IN

HOSPITALS.

CERTAINLY NOT THE ONLY ONES BUT

TWO OF THE MAJOR ONES.

AND AGAIN, WHAT WE SEE HERE IS

BASELINE, NO SIGNIFICANT

DIFFERENCE, THE ERE RATE WAS

HIGHER IN THE CONTROL HOSPITAL

BUT NOT SIGNIFICANTLY.

BY THE INTERVENTION PERIOD YOU

CAN SEE IN THE INSTITUTION GOING

DOWN, ONE PROBLEM AS YOU KNOW

WITH FIELD RESEARCH IS YOU CAN'T

CONTROL EVERYTHING AND THERE WAS

AN OUTBREAK IN THE STUDY, IN THE

CONTROL HOSPITAL.

SO IN A WAY I WOULDN'T LOOK AT

THAT BECAUSE THAT REPRESENTS AN

OUTBREAK.

BUT AT FOLLOW UP 568 MONTHS

THERE WAS A SIGNIFICANT

REDUCTION IN BRE RATES

CONSISTENT WITH NOT CAUSAL YOU

CAN SAY BUT CONSISTENT WITH THE

CONCOMITANT INCREASE IN HAND

HYGIENE.

ANOTHER STUDY WE DID AT ABOUT

THE SAME TIME OF FUNDED BY NINR

WAS A RANDOMIZED CLINICAL TRIAL

ON -- IT WAS ACTUALLY A

CROSS-OVER DESIGN LOOKING AT THE

EFFECT OF STAFF HAND HYGIENE ON

HEALTHCARE ASSOCIATED INFECTIONS

IN THE NEONATAL INTENSIVE CARE

UNIT.

WE STUDIED THE FINAL SAMPLE WAS

ABOUT 2600 NEONATES.

374 OF THOSE NEONATES BECAME

INFECTED AND 114 OF THOSE HAD

MORE THAN ONE INFECTION.

IN THIS STUDY THIS WAS A TWO

YEAR CROSS OVER DESIGN.

SO WE WERE COMPARING AN

ANTI-BACTERIAL SOAP CONTAINING

(INDISCERNIBLE) WP ALCOHOL BASED

HAND SANITIZER WHICH IS THE

THING YOU USE NOW ADAYS IN

HOSPITALS.

THAT'S PARTLY BECAUSE OF THE

RESEARCH THAT WE AND OTHERS HAVE

BEEN DOING OVER THE YEARS.

SO WHAT WE FOUND IS THE

HEALTHCARE ASSOCIATED INFECTION

RATE WHEN THEY WERE LOW NURSE

HOURS THE HAZARD RATIO IS 1.75

CONJUNCTIVEITIS, HIGH TOTAL

NURSING HOURS, THERE WAS

SIGNIFICANTLY LONGER TIME BEFORE

BABY GOT CONJUNCTIVEITIS.

THE LENGTH OF STAY WAS SHORTER

WHEN THERE WAS A HIGH RN SKILL

MIX, AND DURING LOW TOTAL

NURSING HOURS, THE RISK OF

BLOODSTREAM INFECTION IN THE

BABIES WAS 2 AND A HALF TIMES AS

COMPARED WITH THE NORMAL NURSING

HOURS.

LOW RN HOURS WAS ALSO ASSOCIATED

WITH A HIGH RELATIVE RISK OF

BLOODSTREAM INFECTION.

THE OTHER THING WE FOUND IN THIS

STUDY, WE WERE INTERESTED TO SEE

BECAUSE WE HAD LOOKED AT HAND

FLORA OF FAST WE WERE INTERESTED

TO SEE IF, ARE THESE PEOPLE

COMING IN WITH RESISTANT

ORGANISMS OR ACQUIRING THEM IN

THE COURSE OF THEIR WORK?

WE FOUND -- WE TOOK A GROUP OF

NEW VIRGIN NURSES, WHO HAD NEVER

WORKED EXCEPT DURING STUDENT

NURSES TIME, THEY NEVER WORKED

IN THE CRITICAL CARE AREA.

WE CULTURED THEIR HANDS EVERY

WEEK FROM THE TIME THEY STARTED

FOR A FEW MONTHS.

WHAT WE FOUND IS WITHIN 4 TO 12

WEEKS YOUNG NURSES WHO HAD COME

IN WITH ANTIBIOTIC SENSITIVE

STAPHYLCOCCAL FLORA ACQUIRED THE

SAME CLONE OF RESISTANT FLORA IN

THE UNIT.

AND KEPT THAT CLONE FOR THE NEXT

YEAR.

WHAT'S HAPPENING IS HEALTHCARE

PROVIDERS ARE ACTUALLY TAKING ON

AND ACQUIRING THE SKIN FLORA OF

WHAT'S GOING ON, PREVALENT IN

THE UNIT.

WE ALSO FOUND AS I SAID, HIGHER

NURSE STAFFING WAS ASSOCIATED

WITH FEWER INFECTIONS AND

SHORTER LENGTH OF STAY AMONG

NEONATES IN THE ICU.

WE DID A COUPLE OF STUDIES I'M

GOING TO HIGHLIGHT FOR YOU.

IN THE COMMUNITY YOU NEED TO

WORK CLOSELY WITH THE PUBLIC

HEALTH DEPARTMENT, SOAP

MANUFACTURERS BECAUSE FOR THESE

RANDOMIZED CLINICAL TRIALS WE

GOT PROCTER & GAMBLE TO BLIND

REPACKAGE ALL THEIR PRODUCTS SO

WE DIDN'T KNOW WHICH ONES WERE

CONTAINED ANTI-BACTERIAL AGENTS

AND WHICH WERE JUST PLAIN.

BECAUSE WE LIVE IN A COMMUNITY

WHICH IS 90% HISPANIC AND 50%

IMMIGRANTS WE HAD BILINGUAL

COMMUNITY HEALTH WORKERS.

BACK TO OUR ANSWERING THE

QUESTION ABOUT CAUSALITY, WE DID

A META ANALYSIS THAT WAS

PUBLISHED IN AMERICAN JOURNAL OF

INFECTION CONTROL TO ASK

OURSELVES IN THE COMMUNITY NOW,

NOT IN THE HEALTHCARE SETTING,

IS THERE SIGNIFICANT REDUCTION

RELATED TO HAND HYGIENE DISEASE

OR NOT?

WHAT WE FOUND IN OUR META

ANALYSIS, THAT IT RESULTED IN

31% REDUCTION IN GI INFECTION,

IN DEVELOPING COUNTRIES AND THE

U.S. AND 21% REDUCTION IN

RESPIRATORY ILLNESS.

YOU CAN SEE THE CONFIDENCE

INTERVALS THERE.

IN THE COMMUNITY STUDIES

ANTI-BACKBACTERIAL SOAPS SHOW NO
ADD

BENEFIT AT ALL.

THE DATA ON ALCOHOL BASED HAND

SANITIZERS WERE LIMITED AND

WEAK.

BECAUSE YOU SEE NOW

ANTI-BACTERIAL LABELS OF

PRODUCTS LIKE HAND SOAP, LAUNDRY

SOAP, ET CETERA, ARE UBIQUITOUS,

IT'S HARD TO FIND SOAPS THAT

DON'T HAVE ANTI-BACTERIAL AGENTS

IN THEM.

I WAS VERY CONCERNED ABOUT

WHETHER WE'RE RAISING A WHOLE

GENERATION OF KIDS WHO ARE

EXPOSED TO ANTI-BACTERIAL AGENTS

AND WHETHER THAT HAD ANY

PROBLEMS.

NINR FUNDED A STUDY, DOUBLE

BLIND RANDOMIZED CLINICAL TRIAL

OF THE EFFECT OF ANTI-BACTERIAL

HOME PRODUCTS ON INFECTIOUS

DISEASE SYMPTOMS IN THE

COMMUNITY.

WE RECRUITED FOR THIS STUDY

ABOUT 300 HOUSEHOLDS.

I THINK IT WAS 300.

AND WE RANDOMIZED THEM TO ALL

ANTI-BACTERIAL CLEANING PRODUCTS

INCLUDING LAUNDRY, SOAP, HARD

SURFACE CLEANERS, HAND WASHING

SOAP, ET CETERA.

AND THE EXACT SAME PRODUCT WITH

AN ANTI-BACTERIAL INGREDIENT IN

IT.

NONE WERE EXPERIMENTAL PROJECTS,

THEY WERE ALL ON THE MARKET AND

PROCTER & GAMBLE BLINDED THEM

AND REPACKAGED SO WE DIDN'T KNOW

WHAT SO IT WAS A DOUBLE BLIND

STUDY, WE STUDIEDED THEM FOR 14

MONTHS.

DID HAND CULTURES AND WE HAD

THEM TWICE A WEEK WE GAVE THEM A

CELL PHONE AND HAD THEM CALL IN

WITH ANY SYMPTOMS IN THE FAMILY.

WE TRACKED SEVEN SYMPTOMS OF

INFECTIOUS DISEASES, 1, 2, 3, 4,

5, -- YEAH.

THOSE ARE THE SYMPTOMS WE

TRACKED.

WHAT YOU SEE HERE IS THE

ANTI-BACTERIAL GROUP RANDOMIZED

VERSUS THE NON-ANTI-BACTERIAL

GROUP.

THIS WAS THE RATE OF ONE

SYMPTOM, ANY OF THESE SYMPTOMS

PER HOUSEHOLD MONTH.

THE IMPORTANT THING HERE IS

ADJUSTED RELATIVE RISK AND WE

ADJUSTED FOR PROPER CONFOUNDERS,

ET CETERA.

EVERY RELATIVE RISK INCLUDES

ONE.

THAT IS THERE WAS NO IMPACT AT

ALL OF ANTI-BACTERIAL PRODUCTS

COMPARED TO PLAIN PRODUCTS IN

TERMS OF INFECTIOUS DISEASE

SYMPTOMS.

WHAT WAS INTERESTING IS THAT WE

WENT INTO THE HOMES AND CULTURED

THEIR HANDS EVERY MONTH.

THESE ARE THE TWO BASELINE

RATES, THE YELLOW BAR IS THE

GROUP THAT WAS RANDOMIZED TO

ANTI-MICROBIAL HAND SOAP AND THE

BLUE BAR IS THE GROUP THAT WAS

RANDOMIZED TO THE PLAIN SOAP.

WHAT WE SEE HERE IS BEFOREHAND

WASHING, PRE, POST IS AFTER HAND

WASHING, THIS IS A YEAR LATER.

PRE-HAND WASHING AND POST HAND

WARVING, THE SAME GROUP.

WHAT YOU SEE IS THERE'S NO

SIGNIFICANT DIFFERENCE

WHATSOEVER IN THE COLONY COUNTS

ON THE HANDS WITH ANTI-BACTERIAL

OR PLAIN SOAP.

EITHER BEFORE OR AFTER HAND

WASHING.

AFTER A YEAR EVERYBODY HAD

CLEANER HANDS.

WHY IS THAT?

THAT'S JUST THE HAWTHORNE

EFFECT.

PEOPLE KNEW THEY WERE IN A

STUDY, WE WERE PROVIDING THEM

WITH FREE SOAP AND FREE PRODUCTS

AND I THINK P PEOPLE WERE JUST

-- THEY KNEW WE WERE COMING, WE

HAD APPOINTMENTS SO THEY WERE

CLEANER.

THE SPOINT WASH WITH ANYTHING

AND YOU'LL BE FINE.

AFTER HAND HYGIENE NOTICE THE

COUNTS ON THE HANDS OF THOSE

WITH ANTI-BACTERIAL SOAP WERE

HIGHER.

AND SOMETIMES THAT HAPPENS AS

WELL.

SO UNLESS YOU HAVE HIGH RISK OR

WHATEVER DON'T MESS WITH

ANTI-BACTERIAL PRODUCTS.

ANOTHER STUDY WE DID IN THE

IMMUNITY WAS A RANDOMIZED TRIAL

THE STUFFFY TRIAL, STOP IN FLUS

AND FAMILIES FUNDED BY CDC.

THIS WAS A STUDY IN WHICH WE

ENROLLED 509 HOUSEHOLDS TO A

LITTLE OVER 2700 MEMBERS IN THE

HOUSEHOLDS TO ONE OF THREE

INTERVENTION GROUPS.

THE COMPARISON OR CONTROL GROUP

RECEIVED EDUCATION AB WHAT IS

FLU COMPARED TO A COLD.

AND YOU'RE NOT SUPPOSED TO USE

ANTIBIOTICS, THINGS LIKE THAT IN

SPANISH, MOST ENROLLEES WERE

SPANISH SPEAKING.

SECOND GROUP, THEY ALL HAD

EDUCATION.

THE SECOND GROUP WAS PROVIDED

WITH ALCOHOL HAND SANITIZER AND

THE THIRD GROUP WAS WITH FACE

MASKS AND FACE MASKS WHEN THERE

WAS AN INFLUENZA LIKE VIRUS IN

THE FAMILY, WE EXPLAINED TO THEM

THEY WERE TO WEAR WITHIN THREE

FEET OF EACH OTHER.

YOU CAN GUESS THE RESULTS ON

THAT ONE.

HERE IS SOME OF THE SYMPTOMS BY

YEAR AND I'M SHOWING YOU THIS,

FOR EXAMPLE, THIS IS RUNNY NOSE

SO YOU SEE THERE'S A SUMMER

DECREASE BECAUSE MOST VIRAL

UPPER RESPIRATORY INFECTIONS

OCCUR IN THE WINTER AND THE NICE

THING WAS THIS WAS A TERRIFIC

GROUP, 90% DROP OUT RATE AND

THEY KEPT REPORTING ALL THE WAY

THROUGH THE STUDY.

IT WAS A TERRIFIC GROUP TO WORK

WITH.

THIS IS THE PEOPLE WITH

INFLUENZA LIKE ILLNESS DEFINED

BY CDC AS A FEVER OF 100

FAHRENHEIT OR HIGHER WITH EITHER

SORE THROAT OR COUGH.

WE HAD 669 REPORTS OF ILI.

FROM THEM WE TRIED TO GET

SAMPLES FROM EVERYBODY BUT ONLY

GOT 234 NASAL PHARYNGEAL SAMPLES

TO TEST INFLUENZA.

SOME WE MISSED, SOME WE COULDN'T

REACH AND SOME WHEN WE WENT TO

VISIT THE HOUSE WAS NOT AN ILI,

IT WAS AN INACCURATE REPORT.

SO AMONG THOSE WHO SAMPLES WE

COLLECTED WE FOUND ONLY 78 WITH

INFLUENZA, THIS WAS THE YEAR

BEFORE H1N1.

MOST WERE NEGATIVE BUT THEY HAD

A VARIETY OF OTHER VIRUSES SUCH

AS RESPIRATORY, ET CETERA.

OF THOSE WITH THE FLU, HALF WERE

INFLUENZA A AND B.

SO BY STUDY GROUP, THE CONTROL

GROUP YOU CAN SEE SPECKLED BAR

WE DIDN'T GET THE SAMPLE.

THE FULL PART IS ONES FOR THE

SAMPLE, WHAT YOU SEE IS NO

SIGNIFICANT DIFFERENT IN

INFLUENZA LIKE ILLNESS, AMONG

THE THREE GROUPS, INTERVENTION

GROUPS.

NOFER WAS THERE A SIGNIFICANT

DIFFERENCE IN THE ACTUAL LAB

CONFIRMED INFLUENZA AMONG THE

THREE GROUPS.

HOWEVER, USING OUR EDUCATION

GROUP AS THE REFERENCE, THERE

WAS A SIGNIFICANT REDUCTION IN

SECONDARY TRANSMISSIONS AMONG

THOSE WHO HAD THE HAND SANITIZER

AND THE MASK.

ONLY 20% OF THE PEOPLE WHO WERE

ASSIGNED TO THE MASK GROUP

ACTUALLY WORE THE MASK.

WE DID INTERESTING STUDIES

QUALITATIVE ANALYSES LATER WHY

PEOPLE WOULDN'T WEAR MASKS.

SO IN THIS STUDY THERE WERE NO

SIGNIFICANT DIFFERENCES BETWEEN

THE INTERVENTION GROUPS IN TERMS

OF NUMBERS OF URIs OR FLU BUT

SECONDARY TACK RATES WERE LOWER

IN THE MASK GROUP.

EVERYBODY KNEW MORE.

THAT'S NOTHING TOO EXCITING.

YOU CAN SHOW THAT WITH ALMOST

ANY STUDY.

THERE WAS LOW COMPLIANCE.

WE ALSO FOUND THE RAPID TEST FOR

FLU WERE ONLY 38% ACCURATE.

AND WE PUBLISHED A PAPER ON THAT

AS WELL.

THIS IS OUR TEAM FROM THAT

GROUP.

THEN PHASE 3 TALKING IMPACT OF

CLINICAL PRACTICE AND POLICY, TO

ME THAT'S THE MOST IMPORTANT

PART OF ANYBODY'S WORK.

HERE WE'RE ASKING HOW STANDARDS

FOR TESTING OF PRODUCTS AND

PERFORMING AND STANDARDS FOR

PERFORMING HAND HYGIENE BE

CHANGED.

AND FOR THIS WE NEEDED MORE

COLLEAGUES, WE NEEDED TO KNOW

ABOUT THE POLITICAL PROCESS,

RULES AN REGULATIONS.

GRANTSMANSHIP, ET CETERA.

NINR FUNDED ANOTHER STUDY RIGHT

AFTER IN 2002, THE CDC BASED ON

RESEARCH, CHANGED THE GUIDELINES

FOR HEALTHCARE PERSONNEL HAND

WASHING FROM SOAP AND WATER, TO

USING ALCOHOL HAND SANITIZERS.

IN THE CLINICAL CENTER ANYWHERE

YOU HAVE THESE HAND SANITIZERS

AROUND.

SO WE WERE SO EXCITED BECAUSE I

WAS ONE OF THE AUTHORS OF THAT

GUIDELINE AND I THOUGHT THIS IS

THE PANACEA.

THIS IS GOING TO DO IT.

IT'S CHEAP, EASY, YOU DON'T HAVE

TO HAVE A SINK, YOU DON'T HAVE

TO DRY YOUR HANDS, YOU CAN DO IT

WHILE YOU'RE WALKING ALONG, SO

THIS RESOLVES OUR PROBLEMS ABOUT

HAND HYGIENE.

SO WE DID A STUDY TO LOOK AT THE

IMPACT OF THE CDC GUIDELINE FOR

SEVERAL YEARS BEFORE AND SEVERAL

YEARS AFTER.

WE DID SITE VISITS TO 40

HOSPITALS WHO WERE ENROLLED IN

THE CDC PROGRAM, THE NATIONAL

INFECTION SURVEILLANCE PROGRAM.

AND WHAT WE FOUND IS THE STAFF,

THE INTENSIVE CARE STAFF, 90%

KNEW ABOUT THE GUIDELINE, THEY

KNEW WHAT IT SAID AND THEY KNEW

WHERE TO FIND IT.

ALCOHOL PRODUCTS WERE

EVERYWHERE.

IN THE HALLWAYS, EVERYWHERE.

JUST LIKE YOU SEE THEM NOW.

BUT THE HAND HYGIENE RATES HAD

NOT CHANGED.

57% ACROSS THE COUNTRY.

BUT WE DID FIND THAT IN THOSE

ICUs, AND HOSPITALS WHERE

THERE WAS HIGHER RATES OF HAND

HYGIENE, THERE WERE

SIGNIFICANTLY LOWER RATES OF

CATHETER-ASSOCIATED BLOODSTREAM

INFECTION.

SIMILARLY THESE ARE RESULTS FROM

THE STUDY EARLIER DID PEOPLE --

STAFF WASH HANDS AFTER SEEING A

PATIENT, TOUCHING A PATIENT IN

ISOLATION, THIS IS FROM 1983

PUBLICATION.

WE REPEATED THAT IN 2010 WITH

ONE OF OUR STUDENTS AND FOUND

IT'S ACTUALLY STAFF HYGIENE HAND

HYGIENE WAS ACTUALLY WORSE.

SO BEFORE TOUCHING A PATIENT WHO

WAS ISOLATED, IT WAS LESS THAN

20%.

AFTER IT WAS A LITTLE OVER 40%.

BECAUSE OF GLOVES.

SO PEOPLE ARE WEARING GLOVES

NOW.

THEY WEREN'T WEARING GLOVES IN

1983.

EVEN AS GUIDELINE SAYS YOU'RE

SUPPOSED TO DO HAND HYGIENE

AFTER GLOVING, PEOPLE DON'T.

SO JUST THE RESULTS AREN'T

ENOUGH.

THAT'S WHY WE NEED THE TEAM.

CDC FOR THE GUIDELINES, WHO FOR

GUIDELINES.

THE FDA FOR MAKING SURE THAT THE

PRODUCT TESTING IS AS IT SHOULD

BE, THE NEWS MEDIA, AND IN THE

LAST FIVE YEARS I'M SURE YOU

NOTICED AS I HAVE, THERE'S MORE

ATTENTION, PART LAY LIVE BECAUSE

OF H1N1 BUT BECAUSE OF

ANTIBIOTIC RESISTANCE AND

CONCERNS ABOUT CONTINUED

HEALTHCARE ASSOCIATED INFECTIONS

IN HOSPITALS SO THE MEDIA IS

HELPING US BECAUSE NOW WE HAVE

MANDATORY REPORTING OF

HEALTHCARE INFECTION RATES IN 27

STATES.

AND PROBABLY IT WILL BE MORE.

LOBBYING GROUPS AND THE JOINT

COMMISSION REQUIRES EACH

HOSPITAL MONITOR HAND WASHING AN

PROVIDE FEEDBACK AND REPORT.

NOT SURE THAT'S ALL GOOD.

BUT THAT'S ANOTHER TALK.

SO STANDARD-SETTING, YOU NEED

THE PROFESSIONAL ORGANIZATIONS,

TESTING YOU NEED FDA, THE

NATIONAL RESEARCH AGENDA.

AND THE IOM REPORT CAME OUT

RECENTLY WITH THE TOP 100 KINDS

OF INFECTIONS AND ADVERSE EVENTS

THAT ONE NEEDS TO STUDY AND

PUBLIC PRACTICE.

IN 2009 AMONG MANY OTHER AUTHORS

I WAS ONE OF THE AUTHORS OF THE

WORLD HEALTH ORGANIZATION

GUIDELINE FOR HEALTHCARE

PERSONNEL HAND HYGIENE.

BETTER THAN THE CDC BECAUSE IT'S

SEVEN YEARS NEWER AND THERE ARE

NEW DATA OUT THERE BUT ALSO IT

WAS WRITTEN FOR THE WORLD.

SO IT WAS WRITTEN FOR COUNTRIES

THAT ARE LOW RESOURCED, ET

CETERA.

AND THE FIVE MOMENTS AT HAND

HYGIENE HAS NOW BECOME SORT OF

THE WAY THAT WE TEACH HAND

HYGIENE.

BEFORE TOUCHING THE PATIENT,

AFTER TOUCHING THE PATIENT,

BEFORE ASEPTIC TECHNIQUES, AFTER

BLOOD AND BODY FLUID EXPOSURE OR

TOUCHING THE PATIENT'S

ENVIRONMENT, THE FIVE MOMENTS.

NOW THERE ARE 86% OF THE WORLD

HAS ADOPTED THIS WHO GUIDELINE.

THAT DOESN'T MEAN THAT IT --

THERE ARE -- THEY ARE DOING HAND

HYGIENE BETTER THAN WE ARE.

BUT THESE ARE THE ORANGE AND THE

PURPLE ARE THE COUNTRIES IN THE

WORLD THAT OFFICIALLY ADOPTED

THE WHO GUIDELINE FOR HAND

HYGIENE.

JUST TO END, I WANTED TO TALK A

LITTLE BIT ABOUT OUR CENTER FOR

INTERDISCIPLINARY RESEARCH TO

PREVENT ANTI-MICROBIAL

RESISTANCE THAT DR. GRADY

MENTIONED.

WE WERE VERY FORTUNATE AND SO

GRATEFUL TO HAVE GOTTEN A

PLANNING GRANT FOR THE CENTER.

WE DID NOT GET A FULL PROGRAM

BUT WE GOT THE PLANNING GRANT

AND THE CENTERS STILL CONTINUES

WITH SOME SUPPORT FROM OUR

SCHOOL NURSING AND ALSO SOME

INDIRECTS FROM THE VARIOUS

AFFILIATE GRANTS WHICH ARE

WITHIN THE CENTER.

AND I JUST WANTED TO MENTION A

STUDY THAT'S NOT YET, IT'S UNDER

REVIEW IN JAMA, I THINK THEY'RE

AT LEAST REVIEWING IT, THEY HAVE

HAD IT SINCE NOVEMBER SO WE

DIDN'T GET IT BACK QUICKLY.

THIS IS ONE OF OUR LATEST

STUDIES.

WE GATHERED A DATABASE OF ABOUT

320,000 HOSPITAL DISCHARGE FROM

FOUR HOSPITALS.

WE EXAMINED ADDITIONAL COST OF

INFECTIONS THAT WERE ASSOCIATED

WITH RESISTANT STRAINS OF A

BACTERIA, AS COMPARED WITH THE

SAME STRAIN OF BACTERIA WHICH

WAS NOT ANTIBIOTIC RESISTANT.

MRSA VERSUS STAFF ORIOUS OR

PNEUMONIA RESISTANT VERSUS

SENSITIVE.

AND AFTER CONTROLLING FOR THE

THINGS YOU'RE SUPPOSED TO

CONTROL FOR AND MATCHING BY

PROPENSITY SCORE, WE FOUND FOR

HEALTHCARE ASSOCIATED

INFECTIONS, IF YOU HAVE A

RESISTANT ORGANISM COMPARED TO A

SENSITIVE, YOUR CHARGES ARE ON

AVERAGE ABOUT $19,000 MORE PER

HOSPITAL STAY.

YOU STAY AN AVERAGE OF 2.2 MORE

DAYS.

AND INCREASE RISK OF DEATH OF

ABOUT 4%.

COMMUNITY ASSOCIATED INFECTIONS

EVEN MORE SO.

AND THAT'S BECAUSE A LOT OF THE

THINGS CALLED COMMUNITY

ASSOCIATED INFECTIONS ARE

ACTUALLY FROM NURSING HOMES AS

THEY COME INTO THE HOSPITAL.

$32,000 MORE FOR RESCISSION

STANT INFECTION -- RESISTANT

INFECTION, 4.2 MORE DAYS IN THE

HOSPITAL AND SLIGHTLY INCREASED

DEATH RATE.

SO NOW IN 2007 AND 8, WE HAD

FIVE PROJECTS FUNDED BY NINR AND

TWO BY CDC.

IN 2009 WE HAVE FOUR ADDITIONAL

PROJECTS FUNDED.

WE DIDN'T -- DID AN AHRQ

CONFERENCE WHICH WE DEVELOPED A

RESEARCH AGENDA TO IDENTIFY WHAT

THE IMPACT OF CMS CHANGES IN

REIMBURSEMENT MIGHT HAVE ON

INFECTION RATES.

WE HAVE DONE AN INTERNAL CTSA

PILOT AND SEVERAL OTHER GRANTS

WHICH YOU CAN SEE HERE.

WE ALSO CONTINUE TO PREPARE

BIOMEDICAL RESEARCHERS AND

OTHERS IN INTERDISCIPLINARY

RESEARCH.

WE HAVE HAD 13 PRE-DOCS AND POST

DOCS.

AND THEY'RE NOW GOING OUT AROUND

THE WORLD, WE HAVE MICHIGAN,

SOME IN OHIO, SOME IN

CALIFORNIA.

WE TEACH A COURSE IN

INTERDISCIPLINARY RESEARCH

MODELS.

I TEACH IT WITH A

BIOSTATISTICIAN.

IT'S OFFERED ACROSS COLUMBIA

UNIVERSITY TO ANYBODY AND ANY

SCHOOL, THE FIRST COURSE AT

COLUMBIA, TOOK US TWO YEARS TO

GET THROUGH THE BUREAUCRACY.

THAT'S OFFERED TO ANY STUDENT IN

ANY OF THE SCHOOLS.

SO WHAT NEXT?

WELL, WE CLEARLY NEED MORE

BEHAVIORAL INSIS STANCE

INTERVENTIONS TO MAKE IT EASIER

TO DO THE RIGHT THING AND MORE

DIFFICULT TO DO THE WRONG THING.

THINGS LIKE ELECTRONIC

MONITORING OF PRACTICE SO YOU

CAN GET IMMEDIATE FEEDBACK ON

HOW YOU'RE DOING.

ALIGNING INCENTIVES WITH

BEHAVIOR AND WHAT IMPACT THAT

WILL HAVE.

THEN WE CAN'T CONTINUE TO DO

EXPENSIVE MANY, MANY YEAR

RANDOMIZED CLINICAL TRIALS.

WE NEED MORE FLEXIBLE AND

EFFICIENT RESEARCH METHODS AND

THAT'S WHY WE'RE MOVING INTO

COMPARATIVE EFFECTIVENESS

RESEARCH MAYBE RELABELING

RENAMING OF WHAT'S BEEN THERE

BEFORE BUT NEVERTHELESS,

PRACTICE-BASED EVIDENCE AND

MODELING AND SIMULATION.

SO HERE IS WHY WE DO IT.

I WANTED TO POINT OUT THAT THESE

TWO HEALTHY CHILDREN, BOYS, DIED

OF MRSA.

AND THEY WERE COMPLETELY

HEALTHY, THEY HAD NO RISK

FACTORS SO IT'S NOW SPREAD INTO

THE IMMUNITY.

THIS LITTLE BOY BRYCE HAD MRSA.

HE DIDN'T DIE BUT HIS MEDICAL

BILLS WERE OVER $500,000.

THIS IS MY GRANDCHILDREN.

AND MY GRANDCHILD NATHAN ALMOST

DIED OF RESPIRATORY VIRUS WHEN

HE WAS TWO WEEKS OLD.

HE SPENT TWO WEEKS IN THE

PEDIATRIC ICU AT THE NATIONAL

CHILDREN'S MEDICAL CENTER HERE

IN DC.

SO HERE IS WHY WE DO IT.

I WANT TO THANK YOU ALL FOR --

AND ALL MY COLLEAGUES AND

COLLABORATORS AND PARTICULARLY

TO NINR.

SO THANK YOU VERY MUCH, THAT

ENDS THE TALK BUT WE HAVE TIME

NOW FOR QUESTIONS FOR AB FIVE OR

TEN MINUTES SO MAYBE WE CAN HAVE

THE LIGHTS UP.

(OFF MIC)

>> VERY INTERESTED HERE AT THE

NIH BECOME VERY INTERESTED IN

INFECTION CONTROL PRACTICES AND

PROCEDURES IN OUR RESEARCH SITES

AND THE INTERNATIONAL SETTING.

I'M STRUGGLING WITH HOW TO

MEASURE END POINTS.

WHAT MEASURES DO YOU USE, YOU

TALK ABOUT AN ELABORATE AND

CLEARLY GOAL STANDARD HAND

WASHING -- CULTURING PEOPLE'S

HANDS BEFORE AND ANSWER SPECIFIC

INTERVENTION.

BUT IN THE AMBULATORY CARE

SETTING IT BECOMES MORE

DIFFICULT.

YOU HAVE ALSO TALKED ABOUT

CATHETER ASSOCIATED BLOODSTREAM

INFECTIONS AND BLOODSTREAM AND

ALSO BLOODSTREAM INFECTIONS AN

THESE ARE HARD END POINTS BUT IN

THE OUTPATIENT IT'S A MUCH MORE

DIFFICULT PROPOSITION.

SO WONDERING SOME OF OUR

OUTPATIENT SETTINGS SOME

RESEARCH SITES ARE VERY --

THEY'RE VERY BASIC.

AND WE'RE -- AND ALTHOUGH MANY

OF THE COUNTRIES IN WHICH WE DO

RESERK HAVE ADOPTED THE --

RESEARCH HAVE ADOPTED THE WHO

HAND HYGIENE RECOMMENDATIONS

THEY REALLY AREN'T THERE.

IN FACT THERE AREN'T -- THE

PHARMACIES DON'T ACTUALLY MAKE

THE BY -- THERE'S A RECIPE FOR

ALCOHOL-BASED SCRUB.

THEY'RE NOT ABLE TO MAKE IT.

SO --

>> WHY CAN'T THEY MAKE IT?

IT'S ALCOHOL AND GLYCERIN.

>> BUT THEY GET THE GLYCERIN

SUPPLY, THE OUTSIDE AND WHETHER

OR NOT -- IT'S THEY CAN BUT THEY

HAVEN'T TAKEN IT ON.

I RECOGNIZE IT'S MEANT TO BE

USER-FRIENDLY IN THOSE SETTINGS.

I WONDER IF YOU CAN GIVE

GUIDANCE ABOUT END POINTS YOU

MEASURE IN THAT SETTING IF YOU

WANT TO PUT SOME KIND OF

INTERVENTION INTO PLACE.

>> YEAH, YOU HINTED AT THE FACT

THE PROCESS VARIABLE SUCH AS HOW

MANY ORGANISMS ON YOUR HANDS ARE

ONLY USEFUL IF YOU ALREADY

ESTABLISH A CAUSAL LINK.

SO ONCE YOU DO, THEN IT'S OKAY

TO USE THOSE PROCESS VARIABLES

BUT I SPENT A LOT OF YEARS

SHOWING THE CAUSAL LINK ACROSS

FROM WHAT'S ON THE HANDS.

SO YOU COULD DO SOMETHING LIKE

THAT BUT EVEN THIS IS EXPENSIVE

IN DEVELOPING COUNTRIES.

I KNOW THE TIME I SPENT IN GHANA

AND PERU THERE'S NOT ALWAYS

RUNNING WATER.

SO YOU SORT OF HAVE TO INVENT

OTHER WAYS OF TESTING

INTERVENTIONS LIKE A PALE WITH A

SPICKET AT THE BOTTOM.

I HAVE A COLLEAGUE WHO DID A

STUDY LIKE THIS IN OUTPATIENT

SURGICAL CENTERS THAT TAKE CARE

OF VAGINAL FISSULAS IN OTHER

COUNTRIES.

A LOT COME BACK WITH INFECTIONS.

SO I GUESS ONE OF THE SIMPLEST

THINGS TO DO IS -- TO START WITH

IS TO KEEP RECORDS OF WHO COMES

BACK WITH INFECTIONS, BECAUSE IN

SOME OF THOSE SITES, THE

INFECTION RATE IS 30, 40, 50%.

SO THAT WOULD BE A SIMPLE WAY TO

START I GUESS.

BUT YOU ASK THE HARDEST

QUESTION, I WOULD SAY IF YOU

DON'T HAVE MANY RESOURCES YOU

CAN'T REALLY CULTURE BY -- SOME

PEOPLE USE PLACE WHERE YOU PUT

YOUR HAND ON A PLATE, THAT

DOESN'T WORK, IT'S TOTALLY

INSENSITIVE.

IF YOU PUT ALCOHOL ON YOUR HANDS

AND PUT IT ON A PLATE, YOU GET

NOTHING F. YOU CULTURE IN --

WITH THE JUICE TECHNIQUE YOU GET

10 TO 4TH OR 5TH ORGANISMS.

SO WISH I COULD ANSWER BETTER.

WE STRUGGLED ABOUT HOW TO DO

OUTPATIENT, YOU CAN DO IT EASIER

IN DEVELOPING COUNTRIES WHERE

THE INFECTION RATE IS HIGHER.

NOT SO MUCH IN THIS COUNTRY.

ONE MORE QUESTION.

>> I THINK TO BUILD ON WHAT WAS

SAID --

>> THANK YOU.

>> TWO THINGS WE GET AHEAD OF

OURSELVES.

IN OUR COUNTRY IT'S FINE TO BILL

THAT CAUSAL LINK.

WE KNOW THAT.

WHETHER WE HAVE TO RECREATE THE

RESEARCH MODELS IS A LITTLE

QUESTIONABLE.

I SAW AN OUTSTANDING EXAMPLE IN

JOHN F. KENNEDY SENOR IN

MONROEVIA, SIX YEARS POST

CONFLICT BUT AN AMERICAN

NEONATAL GIST CAME OVER AND THE

MORTALITY RATE WAS 8 INFANTS A

MONTH.

IT WAS UNACCEPTABLE TO MOST OF

US WHO WERE THERE.

HE SIMPLY TOOK THREE ROOMS THAT

THE BABIES WERE ALL IN, BRAND

NEW -- AND DIVIDED THEM TO SEEK

OUT THOSE BORN OUTSIDE SICK AND

WELL.

AND HE CUT IT TO TWO AND THREE

MONTHS.

HE WASN'T -- WE WERE IN NO SHAPE

TO MEASURE ANYTHING.

THEY WERE IN AND OUT OF JAIL

CONSTANTLY BUT SOMETIMES YOU

BACK UP AND YOU DO -- YOU LOOK

AT RESEARCH WE HAVE AND WHAT WE

HAVE DONE AND MOVE TO MORE --

AND ASSUME THAT SAME THING IF

ALL THE VARIABLES WERE THE SAME,

ET CETERA, ARE GOING TO WORK.

BUT THEN YOU -- YOU JUST CAN'T

WAIT.

YOU HAVE TO MOVE AND USE

SIMPLISTIC.

ON THE OTHER HAND MY WORK IN

KENYA TELLS ME ONCE WE GET THE

WESTERN COUNTRIES OVER THERE

BUILDING HOSPITALS AND LABS AND

DOING ALL KINDS OF THINGS, THOSE

ENVIRONMENTS MOVE VERY RAPIDLY

SO I THINK IT'S JUST -- AND THEN

SOMETIMES YOU CAN DO RESEARCH AT

SOME OF THE MORE BASIC LEVELS.

WE CULTURED HANDS OF STAFF AND

PEOPLE IN THE COMMUNITY WHEN WE

WERE IN PERU.

WHAT WE PUBLISHED A PAPER ON

THIS, I DIDN'T TALK ABOUT IT,

THE ANTIBIOTIC RESISTANCE IN THE

HANDS FLORA OF STAFF STAFF IN

PERU WAS HUGE.

HUGE.

BECAUSE IN MANY COUNTRIES YOU

CAN GO TO THE PHARMACY AND GET

ANTIBIOTICS OVER THE COUNTER.

THERE WASN'T ANY PRESCRIPTION

NEEDED OR WHATEVER.

OUR COMMUNITY IN NEW YORK WE

ACTUALLY FOUND THAT YOU CAN BUY

ANTIBIOTICS IN OUR NEIGHBORHOOD

BODEGA, A DELI, FOR A QUARTER

EACH.

AND YOU CAN MIX AND MATCH IF YOU

WANT.

SO A COUPLE OF AMPICILLIN AND

AND DO WHATEVER YOU WANT.

AND PEOPLE WHO COME FROM

COUNTRIES WHERE YOU CAN BUY OVER

THE COUNTER CAN EXPECT TO HAVE

THAT AS PART OF THE SERVICE.

SO MANY MANHATTAN, THERE'S 7,000

BODEGA WHICH SELL ANTIBIOTICS.

THE POLICE KNOW ABOUT IT, IT'S

ILLEGAL, THE HEALTH DEPARTMENT

KNOWS ABOUT IT AND WHEN I TALKED

TO THEM ABOUT IT THEY SAY IT'S

LIKE THE -- HIT THE MOLE GAME

WHERE YOU HIT ONE AND ANOTHER

POPS UP AND THEY STOP BUT IT'S

WHAT THE CUSTOMERS EXPECT.

IF THEY DON'T PROVIDE THAT

SERVICE, THEN THEY LOSE

CUSTOMERS.

THE ANTIBIOTICS THAT WE HAVE

FOUND IN THE BODEGAS ARE

IMPORTED, BROUGHT OVER

ILLEGALLY, FROM OTHER COUNTRIES.

>> DR. LARSON, I HAVE A QUESTION

AND IT HAS TO DO WITH EDUCATION.

AFTER OVER A HUNDRED YEARS

ROBERT COX ESTABLISHED HIS

POSTULATE, I FIND IT EXTREMELY

DISTURBING THAT WHEN THE PUBLIC

IS AT ITS MOST VULNERABLE STATE,

WHICH IS WHEN THEY GET SICK,

THEY GET TO THE HOSPITAL AND

THEY GET THERE AND THEY ARE

STILL PEOPLE OPERATING ON

BELIEVE.

SO WHAT ARE WE DOING WRONG IN

TERMS OF EDUCATION?

>> ACTUALLY I SHOULDN'T BE

STANDING UP HERE BECAUSE I HAVE

BEEN DOING HAND HYGIENE RESEARCH

FOR LIKE 40 YEARS AN NOBODY IS

DOING IT YET.

SO SOMETHING WE'RE DOING IS

WRONG.

I ACTUALLY START OUT THINKING

THESE PHASES.

FIRST I THOUGHT IT'S

MICROBIOLOGY, WE FIND THE BEST

PRODUCT AND THEN EVERYBODY WILL

USE IT AND IT WILL BE FINE FON.

SO WE HAVE GREAT PRODUCTS NOW.

AND THEN THOUGHT OKAY, IT'S A

BEHAVIORAL SCIENCES.

SO THEN WE DID ALL THIS OTHER

STUFF THAT, WORKS BUT IT'S LONG.

AND WE HAVE SEEN HOSPITALS HERE

AND THERE CHANGE THE CULTURE.

THEN WE ARE IN TO NOW SYSTEMS

KIND OF WORK.

AND I HAVE A FEELING WE CAN'T

FOR YEARS WE WERE FOCUSING ON

THE WRONG CLIENT.

IT'S NOT THE INDIVIDUAL NURSE OR

DOCTOR.

IT'S THE SYSTEM.

AND WHAT WE HAVE TO DO IS FIND

WAYS TO DO SYSTEMS-BASED

RESEARCH AND BEHAVIORAL RESEARCH

WHERE WE -- RIGHT NOW ALCOHOLS

ARE WHAT WE THINK IS THE BEST

BUT MAYBE SOMETHING NEW IN THE

FUTURE.

UNTIL WE CHANGE THE CULTURE SO

EVERYONE OF US OWNS IT, RIGHT

NOW THE INFECTION CONTROL NURSES

OWN IT.

BUT WE HAVE TO CHANGE IT SO

EVERYBODY OWNS IT SO WE HAVE TO

MOVE FROM THE INDIVIDUAL TO THE

SYSTEM.

AND THAT'S WHERE THE NEXT

RESEARCH TIME COMES AND THAT'S

THE BEST PROMISE.

I HAVE -- ONE MORE QUESTION,

THEN WE'LL MOVE ON.

(OFF MIC)

THE REGULAR COUNTRIES HAVE A

HIGHER PREVALENCE OF INFECTION

WHILE OUR COUNTRY (INAUDIBLE)

DON'T HAVE SUCH A HIGH LEVEL

UNDERLYING LEVEL OF INFECTION.

(INDISCERNIBLE)

>> SHE'S ASKING BECAUSE WE HAVE

FEWER INFECTIONS MAYBE WE'RE NOT

QUITE AS AWARE.

I THINK IT'S TRUE THAT DURING

THE ANTIBIOTIC ERA IN THE '70s

AND '80s, THERE WERE PAPERS

PUBLISHED THAT SAID WE HAVE

CONQUERED INFECTIOUS DISEASE.

WE'RE DONE.

THEN EVERY TIME A NEW ORGANISM

CAME OUT WE FOUND A NEW

ANTIBIOTIC.

THE PROBLEM NOW IS THAT THERE IS

VERY LITTLE DEVELOPMENT OF NEW

ANTI-MICROBIAL AGENTS AND SO

WE'RE -- WE HAVE GONE FULL CYCLE

AND WE HAVE TO DEPEND MUCH MORE

AGAIN, ON BEHAVIOR.

SO I'LL BE HERE TWO DAYS.

I THINK DR. GRADY WANTS TO CLOSE

THE MEETING NOW.

I'M VERY OBEDIENT, IT'S 11:27.

[APPLAUSE]

>> THANK YOU SO MUCH.

WE REALLY APPRECIATE DR. LARSON

SHARING HER EXPERTISE WITH US

TODAY AND I WOULD LIKE TO

PRESENT HER WITH A MOMENTO OF

THIS EVENT.

I'M ALSO REMINDED IN THE

QUESTION-AND-ANSWER PERIOD THAT

RESEARCH SUCH AS ELAINE'S IS

EXTREMELY IMPORTANT IN HELPING

US IMPROVE OUR KNOWLEDGE BASE

AND IMPROVE PRACTICE.

BUT IT'S ALSO IMPORTANT IN

HELPING TO FUEL OUR RESOLVE TO

DEAL WITH THESE PROBLEMS ACROSS

OUR COUNTRY AND ACROSS THE

GLOBE.

I'M REMINDED OF THOSE OF YOU AT

OUR ANNIVERSARY EARLIER THIS

YEAR OF THE STORY THAT DR. RITA

CALDWELL TOLL ABOUT USING AND

ADOPTING INNOVATIVE APPROACHES.

THAT WAS A STUDY WE FUNDED IN

INDIA WITH THE USE OF SARI CLOTH

TO FILTER DRINKING WATER BECAUSE

IT IS USING MATERIALS THAT ARE

AT HAND IN AN ENVIRONMENT WHICH

-- WHERE THE PROBLEM SO SERIOUS.

IT DID IN THAT INSTANCE REDUCE

THE CHOLERA COUNT BY 50%, EACH

TIME THE CLOTH WAS USED.

SO I THINK THE KIND OF RESEARCH

THAT ELAINE IS DOING IS HELPING

US TO BE ABLE TO ADAPT PRACTICES

WITHIN ENVIRONMENTS THAT THEY

ARE MOST NEEDED.

SO I'M HAVING SAID THAT I WOULD

LIKE TO MAKE THE PRESENTATION TO

DR. LARSON, IN MEMORY OF WHAT

THIS OCCASION TODAY.

SO I PRESENT TO DR. ELAINE

LARSON NIND DIRECTOR 2012,

ELAINE LARSON.

THANK YOU SO MUCH FOR BEING

HERE.

[APPLAUSE]

>> ALSO THOSE THAT ARE HERE AND

ON THE WEB ACROSS THE CAMPUS AN

COUNTRY I BELIEVE AS WELL.

JUST AS YOU LEAVE, I WOULD LIKE

TO REMIND YOU THAT WE DO HAVE

ANOTHER UPCOMING EVENT, THE

WEDNESDAY AFTERNOON DIRECTOR'S

LECTURE SERIES.

SPEAKER THAT -- ANOTHER

INVESTIGATOR OF OURS, DR. MARY

ANN CANICH WHO WILL SPEAK ON

MARCH 7TH, 3 P.M., THE WEDNESDAY

AFTERNOON LECTURE, SHE IS

PROFESSOR OF THE DEPARTMENT OF

DERMATOLOGY AND CUTANEOUS

SURGERY, UNIVERSITY OF MIAMI'S

MILLER SCHOOL OF MEDICINE.

HER LECTURE, SO YOU CAN WRITE

THIS DOWN, IS WIZARDRY OF TISSUE

REPAIR AN GENERATION.

A TALE OF SKIN CELLS WHEN MAGIC

IS ALL BUT GONE.

SO WE'LL SEE YOU BACK 3 P.M.,

MARCH 7TH.

THANK YOU, AGAIN, DR. ELAINE

LARSON FOR BEING OUR 2012

LECTURER.

[APPLAUSE]
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