Death by Regulation: Enough is Enough

It gets a little tiring, and certainly frustrating, to be on the receiving end of recurring mandates from “the experts” regarding the care provide by physicians and nurses. It seems that CMS and its watch dog, the Joint Commission (JC), relish adding more and more requirements onto healthcare staff because, obviously, we just don’t seem to understand the importance of initiating these behaviors on our own.

Obsessive hand washing is the newest in a long list of evidence-ignoring guidelines by the Joint Commission

It gets a little tiring, and certainly frustrating, to be on the receiving end of recurring mandates from “the experts” regarding the care provide by physicians and nurses. It seems that CMS and its watch dog, the Joint Commission (JC), relish adding more and more requirements onto healthcare staff because, obviously, we just don’t seem to understand the importance of initiating these behaviors on our own.

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I remember when it was believed that measuring a child’s head circumference was a mandate of the JC. When doctors and nurses pushed back, the JC clarified its requirement and only mandated that hospitals establish criteria when head circumference would be required. Under what circumstances would you expect a child’s head to be enlarging in the ED setting? 

And then there is the requirement that, at least in California, every ED patient be asked if they are the victims of intimate partner violence, independent of why they presented to the ED. To be fair, you have to ask men as well as women. Also in California, if the patient indicates a positive answer, you are required to report it. This feels a bit paternalistic, and there is no evidence that reporting helps and some suggestion that it may worsen the situation. Just another example of strangulation by regulation.

In the ED, our nurses are required to do a nutritional assessment of every patient, but I’ve never heard a nurse tell a patient they were too fat. In addition, an educational preference assessment needs to be done. Are you a visual learner or more of an auditory learner? Don’t forget the latest: the patient’s language preference has to be ascertained and documented so that mandatory translators can be summoned (or called) if needed, even if it is obvious that the patient is fluent in English.

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Now I’m hearing about routine suicide, fall risk and elder abuse screenings as well. Put it all together and it feels as though the belief is that emergency physicians and nurses are obviously not astute enough to do these assessments when they appear clinically indicated, and this being the case, they need to be done on everyone.  One size fits all.

Add to this the the prohibition of the abbreviation MS for morphine sulfate – because, apparently, some idiots thought that MS meant magnesium and that magnesium would be an appropriate treatment for pain.

While we’re on a role, let’s throw in the requirement to time and date all orders. Like this really matters in the ED setting. And don’t forget our “time outs.” We certainly don’t want to suture a laceration on a patient who doesn’t have one or reduce a shoulder on a patient with a normal shoulder.

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The list goes on and on.

One of the latest requirements is that we all develop an obsessive compulsive disorder regarding hand hygiene. Apparently the JC has a 232 page document on monitoring of hand hygiene compliance. Once again, one size fits all. It doesn’t matter whether you are in the ED for an ankle sprain or meningitis. 

It seems we need to learn a thing or two from Ignaz Philipp Semmelweis (July 1, 1818 – August 13, 1865), the Hungarian physician now known as the pioneer of antiseptic procedures. He’s been described as “the savior of mothers” in that he discovered that hand disinfection could drastically decrease the incidence of puerperal sepsis.  Yes, it appears that it’s not a good idea to go from the autopsy room to the delivery room without washing your hands. No argument here. But aren’t we carrying this just a little far? 

We are to the point now that hospitals, in dreaded fear of a citation from the JC, are appointing hand hygiene monitors to at least demonstrate to the JC that they are trying to get these recalcitrant doctors and nurses to get with the program. In the event a JC surveyor sees a violation, the hospital, in an attempt to deal with the violation, can show that their monitoring program has demonstrated 90% compliance. Hospitals are now having all manner of training programs for their oblivious staff and posters all over the place and pizza parties to celebrate the improvements (often marginal) that they are achieving. 

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So here are the rules to the best of my knowledge:

• You have to clean your hands before and after every patient physical contact.
• You have to clean your hands if you contact anything that is in contact with a patient (bed, IVs, monitors, etc).
• Nurses have to clean their hands before preparing or administering medications.
• If you leave a patient and touch anything else (chart, phone, computer keyboard or the like), you have to clean your hands before touching the patient again or touching another patient. (How does this work if you have a computer in the patient’s room and you are doing CPOE or the like? Once you touch the computer is hand hygiene required again?)
• You have to perform hand hygiene before putting on gloves and after removing gloves (Even surgeons don’t clean their hands after taking off gloves – at least they didn’t in the past). And what if you shake hands with family members? Do you have to gel after each handshake if there is more than one family member?)

With regard to using the alcohol gels, you have to:

• Apply one pump of gel to the palm.
• Rub hands together covering all surfaces, including nails, until the alcohol evaporates. 
• After every 10-15 uses of alcohol-based waterless antiseptic, hands should be washed with soap and water, to remove build-up of emollients and thickeners.
• With regard to soap and water hand washing, you have to:
• Wet hands first with warm water.
• Apply 3-5 ml of soap to hands (either non-antimicrobial or antimicrobial).
• Rub hands together vigorously for at least 15 seconds covering all surfaces of the hands and fingers (apparently a frequent source of citations).  Was the 15 seconds determined by randomized trials? 
• Rinse hands with warm water, keeping hands directed down (so that the sewage on your hands doesn’t run down your sleeves).
• Dry thoroughly with disposable towel (are these towels sterile?).
• Use your towel to turn off the faucet (also apparently a frequent source of citations).

So, let’s put this into context. Say an emergency physician sees an average of 2.5 patients per hour (this is misleading, because, at least in our ED, we would average 2.5 but that meant seeing 1.5 at 4am and 3.5 at 4pm). So, assuming a conservative average of two touchings per patient (you are going to be touching the belly pain patient a bunch, same with the chest pain or shortness of breath patient), you would be required to perform hand hygiene about 10 times an hour (about once every 6 minutes) and about 100 times in a 10 hour shift. Does this seem realistic? Hardly. The poor nurses will require even more cleanings.

What percentage of our patients have communicable diseases? Does this matter? Seems like it should. Some conditions are very communicable, such as colds and flu. But even then, how long are we around these patients? We are not living with them. Our actual contact time is likely minutes at best.

Have you seen videos of Obama shaking hands with countless of the unwashed masses? Has he gotten ill? I directed a community ED for 25 years. The number of sick days our doctors had over t
hat period of time could be counted on two hands, truly, and I can assure you hand washing was minimal and predated the use of alcohol gels.

The recent obsession with hand washing in the healthcare setting reminds me somewhat of what happens in the men’s room of airports and restaurants. Everybody feels compelled to do a ritual ablution after urinating. Why? Because others are watching. If you take a shower in the morning, it is likely that your penis is in fact cleaner than your hands which have been touching all manner of dirty objects while the penis is untouched and minding its own business. This being the case, seems you should wash before you urinate. And isn’t urine sterile? And how many of these folks wash at home when no one else is watching?

So, bring on more regulations; we clearly are in need of them. And, with regard to hand hygiene in the ED, I guess there must be a secret agenda. If you require healthcare workers to clean their hands a ridiculous number of times there is the hope that they actually do it a reasonable number of times. 

W. Richard Bukata, MD is the Editor of Emergency Medical Abstracts