Preventing Hospital-Acquired Methicillin-Resistant ...



Preventing Hospital-Acquired Methicillin-Resistant Staphylococcus

Aureus Infections in Acute-Care Hospitals

Clarke Krugman

Old Dominion University

Nursing Leadership

NURS490W

Spring 2013

Preventing Hospital-Acquired Methicillin-Resistant Staphylococcus

Aureus Infections in Acute-Care Hospitals

The purpose of this paper is twofold: (1) to describe a problem in the acute hospital setting that warrants attention in order to meet one of the Joint Commission's (JC) 2013 safety goals, and (2) to develop strategies for change in order to achieve the selected goal. An analysis of the problem through qualitative and quantitative data collection, and identification of the driving and restraining forces contributing to the problem will be evaluated in order to develop a plan of action. The plan of action will include potential solutions, with estimated available and needed resources. The appropriate personnel necessary to support the plan's success will also be addressed, as well as an evaluation process to measure the outcomes of the proposed change. The significance of the proposed changes merits a consideration of appropriate tactics for the change process in order to ensure effective implementation.

Safety Goal and Supporting Data

Reducing the incidence of Methicillin-resistant Staphylococcus aureus (MRSA) in the acute-hospital setting was chosen for this paper. It corresponds to the Joint Commission National Patient Safety Goal (NPSG) number 07.03.01, which encourages, 'use of proven guidelines to prevent infections that are difficult to treat' (Joint Commission, 2013). MRSA infections account for more than half of the drug-resistant infections in acute-care hospitals (Calfee, et.al., 2008), is widely prevalent as a hospital-acquired infection (HAI), and its increase over the past several years is calculated as over 10% per annum from 1999-2006 (Klein, 2009). Also observed are the increased morbidity and mortality of MRSA patients, and significantly longer hospital stays with concomitant costs (Calfee, et.al., 2008).

Potential Solutions: Evidenced-Based

The reservoir for MRSA is contaminated hands, clothing and equipment of patients, visitors, and healthcare workers from MRSA-colonized or infected patients. Community-acquired MRSA, like HAI MRSA, can also be spread in hospitals (Calfee et al., 2008).

There are several solution options to help prevent hospital acquired MRSA infections in acute care hospitals. Multiple articles have been published and research done for purpose of developing strategies to prevent spread of this infection. One solution, according to the Joint Commission, is to put in place a surveillance program that can assess patients when admitted to insure the right action is taken to isolate transmission to other patients (Joint Commission, 2013). Another solution is to have hospital staff members follow policies and procedures to help reduce transmission. These policies include the use of isolation carts with adequate gloves and gowns located outside patient’s rooms, and adhering to contact precaution protocols (Joint Commission, 2013). The Joint Commission suggests the, 'implementing an alert system that identifies readmitted or transferred patients who are known to be positive for MRSA and having this system integrated into the admission system to help reduce MRSA transmissions' (Joint Commission, 2013).

Still another solution to preventing the spread of MRSA is 'ensuring cleaning and disinfection of equipment and the environment are done' (Calfee et al., 2008). Continuing education of staff should be comprehensive, 'including risk factors, routes of transmission, outcomes associated with infection, prevention measures, and local epidemiology' (Calfee et al., 2008).

The best way to reduce transmission of MRSA involves proper hand hygiene performed by all staff member and visitors within the hospital. Implementing a hand-hygiene compliance program is essential in reducing MRSA within an acute care hospital setting. Multiple studies have been done over the years resulting in hand-hygiene being a primary method to prevent the spread of infection. Proper education of healthcare personnel, patients, and patients' families regarding hand-hygiene can sufficiently reduce the spread of MRSA. One study showed that when 'hand hygiene compliance rates increased from a baseline compliance of 49% to 98%, MRSA rates decreased from 0.52 HAIs per 1,000 patient days in 2005 to 0.24 HAIs per 1,000 patient days by year-end 2008' (Lederer, Best, and Hendrix, 2009). This and other corroborative data conclusively supports the implementation of proper hand-hygiene and hand sanitizing measures to reduce MRSA infection in an acute care hospital.

Suggested Solution and Step-by-Step Plan

In order for hand washing compliance to be accepted throughout the hospital it will take several steps to implement a thorough policy. One unit in the hospital would be selected to be the test group. It might be best to pick the unit that has the poorest hand washing compliance. Success in the poorest unit enhances the plan's chances of success throughout the hospital. The trial period should be three months (Al-Hussami, 2011).

The first step of the plan is to emphasize importance of the process to the staff and education of the staff. This would involve classroom or continuing education classes for all personnel. The staff involved includes nurses, doctors, transport personnel, case managers, social workers and any other worker that has direct contact with the patient or goes in and out of the patient’s room. The teaching format could be on-line, lecture, short presentation, or an amalgam of various modalities.

The next step would be patient education. Patients would be made aware that it is proper -even encouraged- for them to ask if an attending member of the staff has performed hand-washing prior to any contact activity. It is good practice which encourages compliance, empowers the patient, and serves as a gentle reminder to staff. It could also include signage in the patient room, hallways and any area where they patient and their family could see it (Muhammad, n.d.).

A significant step of the plan would be random audits of hand washing to check for compliance. It would involve actual counts of hand washing. There are several options for obtaining the hand washing counts. One way could be to hire additional staff to count hand washing when they are working. If high technology is available, the hand washing gel or sinks could have sensors in them to count usage. There could be a sensor put on all doors to see if the hand washing numbers correlates to the number of times personnel enters and/or exits the patient’s room. Reviewing the results of the data obtained from the hand counts, washing sensors, patient satisfaction surveys, numbers of hospital acquired infections, and staff feedback, would be of great benefit in figuring out what is working and what needs to change in order to make the plan effective. More in-depth coverage of the data collection and evaluation is found in the 'Evaluation the Change' section of this paper. Further information about the suggested plan and steps are located in the 'Evaluation Process' section of the paper.

Changes in the process can then be used to continue with the trial and a final analysis could be done when the three month period is over. After all of the analysis is done then the information could be shared with other units and used. The information would continue to be gathered. Implementation to the whole hospital should be slow and use the same process of analysis.

Managing the Change

'Could it be that the famous adage that humans are ‘creatures of habit’ in part explains why clear evidence regarding best practices is not enough to elicit a true change in clinical practice' (Rochette, Korner-Bitensky, & Thomas, 2009, p. 1790). The trans-theoretical model of behavior change is a theory used by many health care professionals. Health care professionals use this theory, with their patients, to change habits such as exercise (Rochette, Korner-Bitensky, & Thomas, 2009). This theory can be applied to all aspects of life, including health care practices. Implementing change in health care is ever so important in the face of patient safety.

The trans-theoretical model of behavior change consists of five stages. Those stages are as follows: conviction/precontemplation, contemplation, preparation, confidence/action, and maintenance. The first stage, conviction/precontemplation, occurs when people do not want to change, even though they have all of the resources available. The second stage, contemplation, occurs when people know change has to happen, but they have not made the decision too. The third stage, preparation, occurs when people have decided to make the change and have begun to do so. The fourth stage, confidence/action, occurs when people have made the change. The fifth and final stage, maintenance, occurs when people continue with the change and do not fall back to their old ways (Rochette, Korner-Bitensky, & Thomas, 2009).

Changing the way people practice and their habits can be quite difficult. It can be especially difficult in the acute care hospital setting. The trans-theoretical model of behavior change is definitely applicable to changing practiced habits in the hospital. The five-step approach allows the person to recognize what needs to be changed, and take the appropriate steps for the change to occur. In the case of hand hygiene, health care professionals first need to recognize it as a problem to change. The problem to change is evident due to the rise of resistant infections in acute care hospitals. Next, health care professionals choose to make the change using a step-by-step program. Lastly, the change is made and maintained.

Stabilizing the Change

Once a change has been made, a lot of work goes into maintaining and stabilizing the change. Rochette, Korner-Bitensky, & Thomas (2009) state “maintenance is a dynamic stage, where the person must work to consolidate gains and prevent relapses” (p. 1793). Lewin’s theory of planned change is another theory that proposes a guide for nursing leadership to implement change. Shirey (2013) uses Lewin’s theory and states “stabilize the change so that it becomes embedded into existing systems such as culture, polices, and practices” (p. 70). The key to change is to not give up. Continue to implement the new practice until it becomes second nature.

Evaluating the Change

Qualitative and Quantitative Data

Hospital acquired infections are one of the leading causes of deaths in the United States. The World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) joined to form an accreditation goal for hand hygiene in hospitals in 2009 (Sack, 2009). It is reported that deaths from hospital infections are higher than that of car accidents, AIDS, and breast cancer combined. The rates are around 100,000 deaths a year. With this understanding, many hospitals across the United States put into place studies at their hospitals to determine how they can decrease hospital-acquired infections. Some of the data being collected involves the rates of infections in specific areas of the hospital. Areas such as ICUs have higher infection rates due to the intensity of the workload (Rosenberg, 2011)

Data Collection

Special infection control personnel have been given the task of collecting information in different ways. At some hospitals data is collected by monitors, secret shoppers, and/or hand washing ladies. Their real title is infection prevention observer (Tribble, 2011). Other hospitals calculate how much soap and alcohol sanitizer is being used in each area (Rosenberg, 2011). The information being collected in these different hospitals across the United States show rates of hand washing from 6.5% to 40 % which is considered a very low compliance rate. Because of these low rates, hospitals can spend between $28 billion and $45 billion a year correcting hospital-acquired infection caused by non-compliant hand hygiene. “In 2008, Medicare began to stop reimbursing hospitals (nor are hospitals allowed to bill patients) for the cost of treating some hospital-acquired infections, and the list is expanding every year” (Rosenberg, 2011, p. 3). Medicaid and other insurances will follow suit as the health care reform bill becomes active.

Evaluation Process

The types of monitoring hand hygiene have revealed different rates of improvement. At the North Shore University Hospital in Manhasset, NY, they used the monitoring study. They used two L.E.D. displays mounted on the wall of the nursing station in two separate ICUs. On the doors of the patient rooms were monitors that track when someone entered the room and how long it was before leaving the room. Those who pass through the doors had 10 seconds to wash hands. The nurse manager gets an email three hours into the shift telling her the rate of hand washing for the unit. At the nursing unit one of monitors on the wall gives the rate of the week before and the other monitor gives the rate for that day. In this hospital system their rate went from 6.5 % to as high as 91%. The excitement in the nursing staff was noticeable (Rosenberg, 2011).

At MetroHealth Medical Center they had hand washing ladies who observed others to see if they were correctly washing their hands. They had a drop in bloodstream infections by one third of what they were before the study began. This particular hospital was already above average when they began but were able to increase their compliance of hand washing to 98% (Tribble, 2011).

It was felt at all the hospitals that an infection control nurse or employee was needed to help manage and educate the staff on correct hand washing. They also developed interventional strategies that would help nursing and hospital personnel be more compliant by placement of hand washing stations or sinks strategic locations in the hospital and constant evaluation of the processes that were being used in the different facilities. Many of these facilities learned that they had to continue to educate and put reminders in place to keep their compliance percentage high (Smith & Lokhorst, 2009).

Honor Pledge

"I pledge to support the Honor System of Old Dominion University. I will refrain from any form of academic dishonesty or deception, such as cheating or plagiarism. I am aware that as a member of the academic community, it is my responsibility to turn in all suspected violators of the Honor Code. I will report to a hearing if summoned."

Clarke Krugman – 4/9/2013

References

The Joint Commission. (2013). Hospital National Patient Safety Goals. Retrieved from

Klein, E. (2009). Community-associated Methicillin-Resistant Staphylococcus aureus in Outpatients, United States, 1999-2006. Emerging Infectious Diseases, 15(12), 1925. doi:10.3201/eid1512.081341

Calfee, D., Salgado, C., Classen, D., Arias, K., Podgorny, K., Andersen, D., Burstin., H., & Coffin, S., et al. (2008). Strategies to prevent transmission of methicillin-resistant staphylococcus aureus in acute care hospitals. Infection Control and Hospital Epidemiology, 29(S1), S62-S80. doi:10.1086/591061

Lederer, J. R., Best, D., & Hendrix, V. (2009). A comprehensive hand hygiene approach to reducing MRSA health care--associated infections. Joint Commission Journal On Quality & Patient Safety, 35(4), 180-185. Retrieved from

Al-Hussami, M., Darawad, M., & Almhairat, I. (2011). Predictors of Compliance Handwashing Practice among Healthcare Professionals.Healthcare Infection, 16(2), 79.

Muhammad W., D., Mahmoud, A., Iyad I., A., & Manal, A. (n.d). Major article: Investigating Jordanian nurses’ handwashing beliefs, attitudes, and compliance. AJIC: American Journal Of Infection Control, 40643-647. doi:10.1016/j.ajic.2011.08.018

Rochette, A., Korner-Bitensky, N., & Thomas, A. (2009). Changing clinicians' habits: Is this the hidden challenge to increasing best practices?. Disability & Rehabilitation, 31(21), 1790-1794. Retrieved from .

Shirey, M. R. (2013). Strategic Leadership for Organizational Change. Lewin's Theory of Planned Change as a Strategic Resource. Journal Of Nursing Administration, 43(2), 69-72. doi:

Sack, K. (2009, September 10). A hospital hand-washing project to save lives and money. The New York Times

Smith, J., & Lokhorst, D. (2009). Infection control: Can nurses improve hand hygiene practices?. Informally published manuscript, University of Calgary, Faculty of Nursing, Available from Infection Control and Nurses. Retrieved from 2009/infection control.htm

Tribble, S. J. (2011, September 03). Cleveland metrohealth medical center increases hand washing, reduce infections.

Rosenberg, T. (2011, November 24). An electronic eye on hospital hand-washing. The NY Times. Retrieved from

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