“What is the evidence that there is any relationship between hand-washing and infection?” This question served as a wake-up call to critical care nurse Elaine Larson, who in the late 1970s worked in an ICU where many patient-staff interactions were not followed by hand-washing. At the end of a 2-year study, Larson and an epidemiologist colleague observed that providing additional hand-washing facilities “was not associated with reduced nosocomial acquisition of organisms or improved hand hygiene.”
Nosocomial infections, also known as health care-associated infections or HAIs, are a serious public health concern. They are the most common complication of hospital care and are one of the top 10 leading causes of death in the U.S. Yet nearly 150 years after Hungarian physician Ignaz Semmelweis instituted hand-washing to prevent puerperal fever in his obstetrical ward, reducing the mortality rateto less than 1 percent, Larson found that hand-washing as a primary infection prevention strategy was still disregarded by members of the health care community.
NINR director Dr. Patricia Grady (l) presents Dr. Elaine Larson with the 2012 NINR Director’s Lecture Award.
Photo: Bill Branson
At the second annual NINR Director’s Lecture, “Infection Prevention: An Interdisciplinary Team Approach,” Larson, now associate dean for research and professor of pharmaceutical and therapeutic research at Columbia University School of Nursing, professor of epidemiology at Columbia’s Mailman School of Public Health and director of Columbia’s Center for Interdisciplinary Research to Prevent Antimicrobial Resistance (CIRAR), discussed her career-long effort to build an evidence base that would help identify, prevent and control infection. “We knew HAIs were common, but the question was how preventable were they?”
In her early studies, Larson sought to determine what organisms colonized the hands of health care professionals, track caregivers’ hygiene practices and see if there was a correlation between these variables and the rate of HAIs among patients. When she realized the skills needed to answer these questions exceeded her clinical experience, Larson found collaborators, putting together an interdisciplinary team that included a surgeon, an epidemiologist, nursing staff and administration, a microbiologist, a statistician and a dermatologist.
Her team’s findings—that ICU staff persistently carried one or more of 22 species of gram-negative bacteria even after washing; that 21 percent of 541 HAIs contracted over a 7-month period were caused by species found on staff hands; that less than half of the staff routinely washed their hands following contact with infected patients—firmly established a causal link. When they looked at differences in colonization rates by discipline they found that while physicians had higher counts than nurses, nurses had a greater percentage of antimicrobial-resistant flora. This was “very concerning because the colonizing flora remained with staff over time; this wasn’t a transient event,” Larson explained.
These early studies laid the foundation for interventional trials to examine the best methods not only for washing hands, but also for convincing health care staff of the need to do so. She added new collaborators with expertise in psychology, sociology, clinical trials and infectious disease medicine. With the release of the CDC Hand Hygiene Guidelines in 2002, which called for the use of alcohol products rather than soap and water, “a panacea, we thought—no sinks, no drying, cheap and easy,” Larson thought her work was done. But after conducting site visits at 40 U.S. hospitals that participate in the National Nosocomial Infections Surveillance reporting system to assess the impact of the guidelines, she found that hand hygiene rates had not budged since her first study in 1983. Although nearly 90 percent of the 1,359 ICU nurses observed were familiar with the guidelines, the mean rate for hand-washing remained at 56 percent.
Larson realized that she must change her focus from individual to cultural and systemic factors. Her research team diversified again as she added experts in systems theory, organizational change, industrial engineering and economics. She also developed key relationships with other stakeholders in the fight against infectious diseases, including representatives from the New York City health department, CDC, WHO, FDA, EPA, JCAHO, professional organizations, the media and even a soap manufacturer.
In the past decade, Larson’s efforts have targeted practice standards, policy and education. In 2004, she established CIRAR, which teaches interdisciplinary research methods to prevent and control infections and develops behavioral and systems interventions that “make it easier to do the right thing.” She also helped write the 2009 WHO Guidelines for Healthcare Personnel Hand Hygiene, which presents a new approach for teaching hand hygiene.
In closing, Larson shared her motivation to eradicate HAIs, showing the pictures of children she had known who were perfectly healthy, but died from MRSA infections. She noted that in an era in which antibiotic resistance is growing and few new ones are being developed, “we must depend on behavior.”
NINR director Dr. Patricia Grady presented Larson with the Director’s Lecture award, stating, “Dr. Larson’s extremely important research guides practice and fuels the development and dissemination of knowledge across the globe. Her approach for conducting innovative and highly effective team science and for informing her research with practice-based evidence epitomizes what we at NINR, as well as nurse scientists across the globe, do best.”
The NIH videocast of Larson’s presentation is available at http://videocast.nih.gov/summary.asp?Live=10942.