Entire health system needed to reduce MRSA infections
To reduce the incidence of MRSA and other infections, health care providers and institutions must "engage the hearts and minds of everyone in the hospital," argues Joelle Everett, an organizational change consultant who participated in a pilot project targeting methicilin-resistant Staphylococcus aureas (MRSA).
Special to The Times
I'D like to challenge some of the "conventional wisdom" offered by Drs. Jeffrey Duchin and Neil Barg, based on my experiences as a participant in a pilot project to help hospitals reduce hospital-acquired infections of methicillin-resistant Staphylococcus aureus ("MRSA not hospitals' only infection challenge," guest columnists, Jan. 6). Over a period of about two years, hospitals reduced their rates of MRSA transmission by 73 percent in the participating pilot units, and reduced their housewide incidence rate by 37 percent.
The project, funded by a grant from the Robert Wood Johnson Foundation, brought together Plexus Institute, the Positive Deviance Initiative, the Hospital Association of Pennsylvania, Maryland Patient Safety Center, the Centers for Disease Control (CDC), and six U.S. hospitals and 2 in Colombia. All participating hospitals were required to use active surveillance (test all patients admitted to the pilot units) and isolate patients found to be infected or carriers without an active infection. Each hospital also agreed to follow the standard guidelines about hand hygiene, the use of disposable gowns and gloves with isolation patients, and environmental cleaning.
These precautions are well known, but unfortunately not always followed. The new element in this project was the use of social change and behavioral change principles to encourage adherence to standard protocols. Hospitals had agreed to the "what" — now their challenge was to discover "how" to help staff better protect patients.
Coaches working with the hospitals are experienced in working with change in organizations, and the focus was on a change process called "Positive Deviance." In any situation, there are always a few people who manage to do well, with only the same resources available to everyone. These "positive deviants" are sought out, and their ideas shared with, but not imposed on, others. Each unit has the responsibility to discover where their actions might improve infection control and figure out how to remove obstacles that prevent them from doing so. Volunteers are invited to join the initiative, and encouraged to take many small actions that help to solve the problem. They are highly motivated to implement their own ideas.
In all the pilot hospitals, infection rates began to drop, month by month.
Focus on MRSA Only
I agree with Duchin and Barg that MRSA is not the only infection needing attention. Some hospitals were concerned that focusing on MRSA would detract from infection control in other areas, and CDC representatives watched this very closely. What they found is that the rate of other hospital-acquired infections also dropped. Even though the exact protocols vary a little for different organisms and different medical procedures, better hand hygiene, isolation precautions and cleaning tend to slow the spread of all infections.
Furthermore, when many members of the hospital staff are searching for small actions they can take to personally avoid spreading infection, there is a higher level of collective mindfulness that improves the care of all patients.
The project's coaches, used to addressing organizational change at more general levels, have been very surprised to discover that addressing a very specific problem (MRSA transmission), by engaging everyone in the hospital in conversation and shared problem-solving, is effectively changing the cultures of the participating hospitals.
Mandatory Screening and Isolation
Mandatory screening is somewhat controversial. But it is difficult to make good decisions about patient care without knowing who may be a silent carrier of an antibiotic-resistant infection. As for the problem of false positives, I experienced hospital isolation as a polio patient back in the 1950s. I would surely rather be in isolation, even mistakenly, than to have an undetected and untreated colonization that could endanger my own health, other patients, and health care providers.
The question of isolation patients being neglected comes up often. My late brother-in-law, an anesthesiologist, told me that he supported using gloves and gowns, but that it took him three times as long to make his rounds to patients in contact isolation. At one of our pilot hospitals, a group of doctors decided to do a little research. They asked a number of individuals how long they estimated it took to use proper hand hygiene, gown and glove. Then they timed the individual, and discovered that the actual time was much shorter than estimated, and decreased with practice.
Another hospital gathered data on the amount of staff time isolated patients received, and discovered that the time was about the same as patients in ordinary wards. However, there was a tendency for a nurse to make one visit for several tasks, instead of coming into the room more frequently. Pilot hospitals are quite aware of this issue, and are finding ways to ensure that isolation patients do not suffer a lower quality of care or lack of social contacts.
Family members can be affronted by the suggestion they must put on gowns and gloves to visit with their loved ones, and I can understand their feelings. I also know of a variety of cases where several family members were infected with MRSA and required treatment, which is a high price to pay for not wanting to put on a disposable gown.
Lack of Standardized Tracking Methods
Until recently, it was true there was a lack of standardized methods for tracking MRSA in hospitals. However, as a part of the Positive DevianceMRSA project, infection-control leaders from the pilot hospitals and the CDC worked together to develop and agree on a standard set of measures to be used by all the hospitals in the project. The CDC is now using these well-defined and standardized measures with other hospitals that submit information to the CDC. So the ability to compare and interpret data from various hospitals is now simpler and more meaningful.
I fully agree that mandatory screening and reporting policies alone will not achieve the needed change in multidrug-resistant hospital-associated infections. And we all know that recommended infection control practices do not make a difference unless they are followed. To do that, I believe that we need to engage the hearts and minds of everyone in the hospital — and I know from my own experience that this is possible to begin that process.
Joelle Everett, of Shelton, a consultant on organizational change, is a coach with the project. For further information about the Positive Deviance MRSA initiative, see http://www.plexusinstitute.org/ http://www.positivedeviance.org/
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