What is the best weapon against MRSA? You might be surprised
Newly published research points to 'old standby'
According to a recent study in the Annals of Emergency Medicine, thorough hand washing might be the most cost-effective way to reduce the spread of methicillin-resistant Staphylococcus aureus (MRSA) in the ED.1 Knowing that information is helpful, but experts agree that's only half the battle. ED managers also need to work on boosting compliance rates.
"We found that 20% of infected ED patients did not have typical risk factors that would alert the staff they might be carrying MRSA," notes Elissa Schechter-Perkins, MD, MPH, lead author of the study, assistant professor of emergency medicine at the Boston University School of Medicine, and an attending physician in the Boston University Medical Center ED. "The conclusion we took from that is that it probably does not support testing everyone. It's too costly and time-consuming, and an additional burden on an otherwise overburdened ED staff."
Based on those findings, the researchers concluded that, as opposed to targeted screenings, other infection control measures such as hand hygiene would be the most efficient way of combating the spread of MRSA. In a statement released by the American College of Emergency Medicine, publisher of Annals of Emergency Medicine, Kalpana Gupta, MD, a co-author of the study and chief, Section of Infectious Diseases at the Boston Veterans Affairs Health Care System, said, "MRSA is transmitted by touch, making clean hands essential to stopping the spread of this potentially deadly organism."
The researchers' conclusion is correct, according to Kate Ellingson, PhD, an epidemiologist with the Centers for Disease Control and Prevention (CDC) in Atlanta. "It's very expensive to do active surveillance testing, though active surveillance allows you to cohort patients and institute proper staff precautions like gloves and gowns," Ellingson says. "But in the ED situation, cohorting may be more difficult than in a ward situation."
Key to compliance
While experts agree that hand washing can be an effective and efficient weapon against the spread of MRSA, there is not universal agreement on the best way to boost compliance. Ellingson, however, sees nothing wrong with that lack of agreement.
"The Joint Commission Center for Transforming Healthcare just published the results of a hand hygiene project where they report on eight different locations, and they show a variety of approaches" she notes. (A link to the report, "Hand Hygiene Project: Best Practices from Hospitals Participating in the Joint Commission Center for Transforming Healthcare Project 01/04/2011," is found on the home page of center's web site under "Featured News." Web: http://www.centerfortransforminghealthcare.org.)
However, Ellingson has found some common elements in successful hand washing compliance projects, both in her own experience and in the literature. "One of the common things we emphasize is data feedback; collect data and feed it back to the staff," she says. "You also have to approach it from a cultural point of view and gain buy-in."
For improvement to be sustainable, it has to be taken on by advocates in the unit itself, Ellingson says. "The Joint Commission talks about Six Sigma training, and others talk about training behavior through approaches like Toyota's," she says. "The commonality is that each of them really tries to get down to what root causes are." If you can be specific about the causes, she explains, you can find specific solutions.
Ellingson offers the example of EDs where hand cleaner dispensers are placed in convenient accessible locations, in response to a root cause identified as lack of adequate access to hand cleaning options.
"That's a situation where you can easily implement a solution," she says. "Hidden monitors" are another common solution, involving direct observers out on the floor to observe hand hygiene compliance. "Many times there is an effort to make these people secret, though many healthcare workers will tell you they are not secret," says Ellingson. "But when people know they are being observed, they change their behavior."
Schecter-Perkins disagrees with this approach. "Rather than single out individuals, it might be more effective to adjust the environment to make it easier to be compliant with hand washing guidelines," she says. Schechter-Perkins refers to interventions such as:
- placing signs around the ED encouraging hand washing/sanitizing;
- adding more hand sanitizer dispensers at convenient locations (i.e. just inside or outside patient's rooms) so that it is more convenient to wash hands;
- ensuring that soap dispensers and sanitizers are full and functioning properly.
Ellingson agrees the observer approach has limitations. "One of the big complaints is it gives you a fairly limited view of what's going on," she says. There are automated mechanisms for assessing hand hygeine adherence such as radio frequency identification (RFICD) that could be the "wave of the future" in terms of monitoring, Ellingson says.
She says that products by Proventix (http://www.proventix.com), Arrowsight (http://www.arrowsight.com/public/as), and HyGreen (http://www.xhale.com/hygreen/?gclid=CLrj16bv4aYCFYrt7QodSlgFzw) are examples of types of technologies designed to automate the monitoring and feedback progress. Also, a cheaper, wireless technological solution is being developed by a group headed by Philip Polgreen, MD, MPH, director of the Infectious Disease Society of America's Emerging Infections Network, a sentinel surveillance group sponsored by the Centers for Disease Control and Prevention, and assistant professor of medicine and epidemiology at the University of Iowa, in Iowa City.
"I think the most effective way would be to have a multi-pronged approach, because there are multiple reasons why it's not being done," Ellingson says. "The ED is such a busy place that most staff members are trying to do two or three things at the same time, so make it easier: Increase supplies and have dispensers available when you walk in or out of a room so they don't have to stop at the nurses' station or sink. They can just wash and go on to the next task." (For details on how one ED's multi-pronged approach significantly improved compliance, see the story below.)
Reference
- Schechter-Perkins EM, Mitchell PM, Murray KA, et al. Prevalence and predictors of nasal and extranasal staphylococcal colonization in patients presenting to the emergency department. Ann Emerg Med Jan 14 2011 [Epub ahead of print]. PMID: 21239081.
Sources
For more information on methicillin-resistant Staphylococcus aureus and hand washing compliance, contact:
- Kate Ellingson, PhD, Epidemiologist, Centers for Disease Control and Prevention, Atlanta. E-mail: [email protected].
- Elissa Schechter-Perkins, MD, MPH, Assistant Professor of Emergency Medicine, Boston University School of Medicine. E-mail: [email protected].
Multiple strategies boost compliance Approach credited with one ED's success The ED at Sutter Delta Medical Center in Antioch, CA, has significantly improved hand washing compliance with a multi-pronged approach that yielded results in just a few months. Before the initiative began, compliance rates were about 40%, according to Shelly Fitzgerald, RN, CEN, charge nurse for emergency services. "Our MD numbers were 61% in August 2009 and up to 80% by mid-November," Fitzgerald reports. "Non-MDs went from 56% to 71%." The program, called "Back to Basics," included not only using regular soap dispensers and water, but also having enough dispensers around the ED, says Adriene Clark, RN, assistant ED manager. Fitzgerald says, "We did not have sinks in all ED care areas, so we made sure we installed hand sanitizers at every point of patient care, including the hallways and outside the doors of utility rooms as well as in triage bays anywhere you might have patient contact." Through interviews with the staff, it was determined that the sanitizers, which are battery powered, were often either empty or had dead batteries that had not been replaced. "We posted the phone number of the single individual who would now be responsible for both," says Fitzgerald. In addition, she notes, there had not been a lot of signage in the department, so she and the infection control director put together posters that rotated on a weekly basis. "They would also show up as screensavers," says Fitzgerald. Mike Whitehair, RN, MSN, CIC, infection preventionist, says, "If anyone Googles 'hand hygiene/hand hygiene posters' you will get a wealth of free resources, which is what we did for our project." The CDC and the VA system (http://www.publichealth.va.gov/infectiondontpassiton) have some easily downloadable posters, Whitehair says. The posters had catchy phrases, notes Clark. "One, which said 'Don't get caught germy-handed,' pictured a hand with a magnifying glass showing the amount of germs that can reside on the skin," she says. Another said "gel in, gel out," referring to staff using hand sanitizers when they went into and out of a patient's room. It was important that the posters be rotated, Clark says. "If you see the same one over and over again, you become oblivious to it," she says. Many of them also pictured staff members on the posters to help "inspire" the staff. Observations were conducted on a weekly basis. Notations were made as to whether the individual observed was a physician, nurse, or tech, but their names were not used. Clark said that one experience she had at the hospital showed her that the messages had clearly taken hold. "I was watching a physician, and he turned to me and said 'Gel in, gel out,'" she recalls. "The more you talk about it, the more aware of it they are." Sources For more information implementing a successful hand washing compliance program, contact:
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