Monday, October 26, 2009

Amateur hour

Sometimes the "amateurs" come up with important observations. Samantha Sherman and Patricia Henderson (above) are two of our Sloane Fellows who took on an interesting assignment suggested by MIT's Steven Spear. Thinking through the issue of hospital acquired infections, Steve suggested that a couple people could go to gemba and watch how germs might invade the perimeter around a patient in the hospital. Perhaps this kind of observation could lead to process improvements or other changes that could reduce the rate of infection.

So that's what Sam and Pat did. They are not trained clinicians and have frankly not spent all that much time in clinical settings. But they have good eyes. For many hours, they sat in patient rooms and watched as people entered and left, keeping track of potential sources of infection.

Here's a short excerpt of what they noticed, just the part focusing on hand hygiene. Please remember this was not meant to be a statistically valid sample. Some of the observations have been helpful to our infection control people as they design changes to improve compliance with this important aspect of the hospital.
In other cases, the recommendations might be deferred because different approaches have been found to be more effective. See the post directly above this one for an update on the entire issue.

Sloane Project
Observation Findings


Over the course of 4 weeks, we spent approximately 25 hours observing interactions in inpatient rooms to evaluate what passes the perimeter of the infection zone. We were able to compare notes from our observations and categorize our findings into five categories.

They are:

1. Physical space
2. Equipment
3. Hand hygiene
4. Use of gloves
5. Outside visitors

Hand hygiene

Major inconsistencies with staff using Cal Stat upon entering and exiting patient’s room.
This observation includes: nurses, co workers, food services, physical therapy, family members, couriers and Phlebotomist.

Further training in targeted work groups and visitors (see list above).
All visitors must sign in at front desk before entering patient’s room at that time.
Educate or give visitor a hand hygiene pamphlet that explains the importance of this
Involve the patient; include an antibacterial wipe/napkin on food trays along with an educational reminder to use before eating.

Empty Cal Stat – people were still going through the motions even if nothing was coming out.

1. Monitor Cal Stat usage
2. Install empty warning alerts
3. Flag – visual identifier
4. Blinking red light
5. Beeping sound

No standard protocol for when to wear gloves and when not to (medication delivery, checking wounds, etc.)

Establish best practices; undergo refresher training for all staff.
Use educational humor, display slogans in certain areas of the institution, i.e.
“Spread the word not the Germs”.

During our visits we observed that there is no designated work space for staff within the patient room. Caregivers are often observed using the soiled linen cart as a place to check and/or update the patient chart or they use the space to regroup before coming into the room, or moving on to the next patient room. Also, often times, equipment or charts would move back and forth from the clean bed to the patient bed increasing risk for infection. Floors, chairs, patient bed, and patient tray were used as work spaces to hold phlebotomist cart, charts, medications, and even urinals.

One recommendation is to create a designated space in the room that gets sanitized – perhaps one of those tables that fold down from the wall? If there is no space within the room, it could exist immediately outside the room. In some situations such as the phlebotomist, a rolling work station might be appropriate.

The cleanliness of the rooms also presented some risk. We observed dirty gloves on floor next to trash can; empty drain hanging out of trash can; and dirty paper towels on floor. Additionally, we observed a coworker who cleaned the patient’s belongings while wearing the same gloves used when she cleaned the patient.

Perhaps an easy fix for trash could be to buy taller trash cans. The trash cans are quite short and are often placed in a far corner of the room. If the cans were taller, there might be less likelihood of missing the can. Additionally training is recommended for all staff that is responsible for cleaning and sanitizing the room to educate on the various ways that infection can be transferred.

Some equipment is used on multiple patients – this includes tourniquet, stethoscope, and blood pressure cuff. Not all equipment was wiped properly before being used on the patient.

Some of the items could be assigned to each individual upon arrival – such as a tourniquet or blood pressure cuff. Communication and education around the importance of cleaning stethoscopes may help with consistent cleaning prior to use on patients.


Mark Graban said...

Interesting stuff, thanks for reporting that publicly. What you're reporting here is pretty common stuff, not uniquely BIDMC (lack of standardized processes, workspace not designed to support the work being done).

I think another challenge is how to get "inside eyes" also looking at their workspaces and processes this way. While outside eyes can be very effective in terms of seeing things a new way, I would be a bit concerned about the outside eyes making too many recommendations without getting the inside staff involved. Maybe deeper root cause understanding is needed before leaping to recommendations?

I'd be curious to hear what the follow up is on those observations.

Anonymous said...

How are hand hygiene best practices taught to physicians? I would expect the same high variance in behavior, without the oversight that nurses experience.

Anonymous said...

Anon 10:26;
See the link below for a prominent quality-oriented physician's take on this issue for docs:

If this long link doesn't work, do a blog search for "Wachter's World" and scroll down about 5 posts. He also has a follow up post on this issue about patients speaking up when they don't see their caregivers wash their hands.

nonlocal M.D.

PookieMD said...

Loved this post. I have frequently been frustrated by the lack of work space for professionals in the patient room. When I round, I take charts with me in to the roooms, or park the COW (Computer on wheels) outside of the room. Frequently there is no place for the charts. I don't like to use the bedside tray as it is frequently dirty. Love the idea of the fold down tray! Great post!

emt.dan said...

Again, very interesting stuff. On one level, this stuff is SO simple, on another SO hard to change. One problem with giving the phebotomist a cart, for example, is that it spreads infection room to room, especially if rooms are on precautions (MRSA, VRE, etc).
Consider training tertiary (and contracted) staff, including, for example, EMTs from ambulance companies picking up patients. Think about everything they are involved in while picking up or dropping off a patient.


Being a former Back Office Medical Assistant I know all to well about what should and should not be done. In school we were taught the importance of hygiene. It seems some or most when they left the school did not practice what they learned. I'm not even close to being a Doctor or R.N. but it's not rocket science to have good hygiene in a medical surrounding, professionalism and a sterile environment are key to returning patients. Thanks for this post I hope it makes people in the medical world aware if the importance of flawless hygiene.