Methicillin-resistant Staphylococcus aureus (MRSA) infections are the most common healthcare–associated infections (HAI) seen within the acute care setting. The major mode of transmission from patient to patient is through the bedside care providers via contaminated hands. Published studies have associated improvements in hand hygiene compliance with decreases in HAI. This article describes a program that was implemented in a large healthcare organisation in the southeastern United States comprising 10 integrated healthcare facilities, to address unsatisfactory hand hygiene compliance rates. The key elements of the program were the use of alcohol-based hand sanitizer and the dedication of resources to collect and report compliance data. In addition, MRSA HAI rates were followed for all the acute care facilities. It was found that the improvements in hand hygiene compliance translated into a real and significant decrease in the number of hospital-acquired MRSA infections.
by Dr James W. Lederer
Methicillin-resistant Staphylococcus aureus healthcare–associated infections (MRSA HAIs) are one of the most common types of infection which patients in the healthcare setting are at risk of acquiring. In a recently published study the most severe form of MRSA, invasive MRSA, was documented to have affected 94,000 patients in the United States in 2005. Of these, 86% were healthcare-associated and approximately 20% of all patients infected with invasive MRSA died [1]. Other organisms such as Clostridium difficile and vancomycin-resistant Enterococci are also responsible for causing infections in the healthcare setting. The connection between infectious organisms colonizing one patient and the subsequent colonization in another patient had been well understood even before the Hungarian obstetrirican Ignaz Semmelweis castigated his colleagues for their poor hand hygiene practices more than one hundred and fifty years ago. Hand hygiene has been a major tenet of infection control practice for many years. Even in 1846 it had been recognized by Semmelweis as highly effective in reducing morbidity and mortality in patients [2]. It was recognized then, and more clearly understood now, that cross transmission of pathogenic organisms takes place through a sequential process from one patient via the healthcare worker to the next patient. In this process inadequate hand hygiene agents or protocols result in the continued contamination of the healthcare workers’ hands and thus ongoing transmission. It has been clearly shown that good hand hygiene agents and practices can interrupt transmission and are associated with a decrease in infections [3].
Our organization, Novant Health, realized that it was necessary to develop a comprehensive hand hygiene program to address HAIs in our facilities. The program needed to address the healthcare workers’ role in the transmission of HAIs, the processes of transmission, the interventions needed to prevent transmission and the outcomes which our patients experienced. Equally importantly, we needed a collective leadership voice to speak out as loudly as Semmelweis against poor hand hygiene practices and in support of the program developed to protect our patients against HAIs.
The president of our organization took the lead in pushing the development of our program. He had a passion and unrelenting drive to do this following the death of an infant from a MRSA infection in one of our facilities. He felt that he was just as responsible, if not more so, for the quality of care and safety of our patients, as he was for the operations and financial stability of our organization. He received Board of Trustees approval to make this a priority for our organization in 2003.
The major elements or our program were based on the Centers for Disease Control and Prevention (CDC) recommendations for Hand Hygiene practices. We also follow all CDC guidelines on isolation practices for patients with resistant or pathogenic infections using the recommendations on transmission-based precautions [4]. We educated all employees concerning their role in transmitting infections to our patients and what they could do to prevent such transmission. We evaluated the technologies available and chose an alcohol-based hand sanitizer. We worked with all clinical units to determine the number and placement of the hand sanitizer dispensers in order to ensure ready access for the staff. At the time, none of the newer wireless or radio frequency monitoring technologies were readily available for use. Therefore, we chose to use clinically experienced hand hygiene monitors to observe hand hygiene behavior throughout the acute care facilities, and to give immediate feedback to the noncompliant staff and their managers. The monitors also collected and reported the compliance data to the organization’s leadership. We had known that our healthcare associated MRSA infection rates were above the national benchmark rate and thus were able to set a lower outcome target MRSA infection rate for our organization. Lastly, we chose an aggressive, hard hitting, internal communications plan to push and challenge our staff towards best practices, full compliance and an in depth appreciation of the healthcare workers’ role in their patients’ infections.
The marketing and communications department’s role was critical. The ability to come up with strong messaging significantly accelerated our overall performance. Some examples of the campaigns included the following:
- Traditional nursing and physician memos and posterboard communications
- Hard-hitting posters (for example, “What You Can’t See Is Killing Them,” “You Could Kill Him with Your Bare Hands”) on the likelihood of staff harming patients because of poor compliance [Figure 1].
- Hand hygiene fairs, where staff could view posters on hand hygiene and infection prevention
- An internal marketing campaign, with life-sized cartoon cut-outs emphasizing hand hygiene at visitor entrances and lobbies.
As stated, the posters used in the internal communication campaigns were often “hard hitting,” which frequently provoked controversy. The intent was both to challenge the employees and to inform them of the importance of hand hygiene in the care of patients and the significant negative outcomes resulting from noncompliance. The marketing challenge was to help create a culture where noncompliance was unacceptable and where patient safety became a responsibility of individual employees. All posters, stickers, ads, banners and other marketing initiatives were posted on to our website (www.washinghandssaveslives.org) and have been made available at no cost to any health care organization requesting them. To date, more than 900 organizations, including 41 from outside the United States, have accessed the materials.
The hand hygiene monitors have been able to conduct 2,000-2,500 individual compliance observations a month across all participating facilities. The hand hygiene compliance data show a marked and sustained improvement in all regions and in our system as a whole from 2006 to the present. The organization has been above 90% compliance since November, 2006. The MRSA HAI rate decreased from 0.52 to 0.16 MRSA HAIs per 1,000 patient days, representing a 69% reduction associated with improved compliance from 2006 to July, 2009 [Figure 2]. At the patient level, this translated into 105 fewer MRSA HAIs for the entire system—from 234 patients in 2005 to 129 patients in 2008.
Such a simple process has such an important outcome. How can other healthcare organizations achieve similar results? Recognition of the problem and a leadership focus on outcomes is paramount. The problem and solution lies with each individual in the organization. In order to drive high compliance, employees must understand the unintended consequences of their poor performance and receive real-time feedback on their individual non-compliance and the organization’s performance as a whole. The unique role the internal communications department played in elevating staff knowledge and awareness helped with employee appreciation of poor hand hygiene compliance as a significant patient safety issue. Reporting actual patient outcomes and organizational MRSA HAI rates helps to impress on staff the link between their behavior and what their patients experience. Through repeated cycles of observation, feedback and reporting and observation, the expectation is that the desired behavior will become more automatic and less dependant on observational pressure. The key challenge is to completely embed hand hygiene as an automatic and unconscious competency in the healthcare culture for all caregivers, much like the campaign to make the fastening of seatbelts an automatic response when driving or riding in a car. The same level of embedded behavior is needed, not only with hand sanitization, but also with all other infection prevention practices, such as isolation precaution barrier compliance.
References
1. Klevens RM, Morrison MA, Nadle J et al. Active Bacterial Core Surveillance MRSA Investigators. Invasive methicillin-resistant Staphylococcus aureus infections in the United States. JAMA 2007;(15):1763-1771.
2. The first (slightly abridged) translation into English of Semmelweis’ treatise, was published in 1941 by F.P. Murphy in ‘Medical Classics’ 5 (1941), 339-478, 481-589, 591-715, 719-773.
3. Pittet, D, Allengranzi B, Sax H et al. Evidence-based model for hand transmission during patient care and the role of improved practices. infection.thelancet.com. 2006; Vol 6: 641-652.
4. Boyce JM, Pittet D. Healthcare Infection Control Practices Advisory Committee; HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force: Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR Recomm Rep 51(RR-16):1-45, Oct. 25, 2002.
The author
James W. Lederer, Jr., M.D.,
Medical Director,
Clinical Improvement,
Novant Health,
Winston Salem, North Carolina, USA
e-mail: jwlederer@novanthealth.org
