Trish Brown, RN, CCRN, is a staff nurse in the surgical intensive care unit (SICU) at Albert Einstein Medical Center, Philadelphia. When she is assigned to a patient who tests positive for a resistant organism, she knows what to do. Before entering the patient’s private room, Brown performs hand hygiene at a nearby sink, then dons gloves and a disposable gown taken from a wall unit at the patient’s doorway. After caring for the patient, she removes the gown and gloves, disposes of them, then washes her hands and exits the room.
The diligence of Brown and her coworkers has resulted in a 30 percent decrease in the incidence of methicillin-resistant staphylococcus aureus (MRSA) infections and earned Albert Einstein Healthcare Network two awards from the Hospitals and Healthsystem Association of Pennsylvania (HAP) in April.
The problem of MRSA
The ability of bacteria to develop resistance to antibiotics appeared just a few years after penicillin became widely available in the 1940s. When newer antibiotics were developed, bacteria mutated to overcome them as well. Then came MRSA.
A study published in the Journal of the American Medical Association indicates that since 1960, about 20 percent of bloodstream infections acquired by hospital patients were caused by S. aureus bacteria. “The proportion of hospital-onset S. aureus infections that were methicillin-resistant reached 64.4 percent in U.S. intensive care units in 2003,” according to the study.
The study authors attributed longer lengths of stay, higher death rates, and increased costs of care to MRSA infections. As a result, the infection control community changed its focus from developing new antibiotics to preventing the spread of the organisms themselves.
To address this need, Albert Einstein Healthcare Network developed its SMASH program — Stop MRSA Acquisition and Spread in our Hospitals. The award-winning program focuses on prevention of MRSA through positive deviance (PD).
“In every community there are certain individuals [the positive deviants] whose special practices/strategies/behaviors enable them to find better solutions to prevalent community problems than their neighbors who have access to the same resources,” explains the Positive Deviance Initiative website (www.positivedeviance.org), created by Tufts University’s Friedman School of Nutrition Science and Policy in Boston. PD is a culturally appropriate approach tailored to a specific community to address problems as diverse as malnutrition, lack of education, and even human rights issues, such as female genital mutilation.
For Einstein, PD translates into encouraging staff initiative to find solutions to MRSA infections. The SMASH program was designed to empower all employees.
Staff-driven solutionsDottie Borton, RN, BSN, CIC
Dottie Borton, RN, BSN, CIC, infection control practitioner for Einstein, is a member of the team that introduced the SMASH program. Her team holds “discover and action dialogues” (DADs) with frontline staff — from nurses to housekeepers to patient transporters. During the DADs, the staff contributes suggestions to combat MRSA, such as surveillance, signage, storing supplies, and computer alerts. The team works with leadership to expedite the staff proposals, rather than imposing top-down initiatives.
“Our job is to find the person in the group that gets it done,” Borton says.
Four nursing units piloted SMASH before it was rolled out throughout the hospital. “The culture has changed,” says Borton. “Everyone is more comfortable about reminding others to do things right.”
The DADs continue. A recent proposal came from Brown’s colleague, Maryanne Donnelly, RN, BSN, CCRN, a staff nurse in the SICU. She suggested using a waterless hand antiseptic foam instead of gel for hand hygiene to make it easier to put on gloves after sanitizing. A pilot using the foam is starting on the SICU.
“The whole SMASH initiative has been very empowering,” says Brown.
The effort has not been inexpensive, however, as more supplies are being used. But Borton says she is pleased because this means increased compliance. “If we have prevented an infection from occurring or a patient being colonized with MRSA or prevented a death, then it is worth it,” she says.
“I’ve been in infection control for over 30 years,” adds Borton, “but [the SMASH initiative] is different because the staff owns it and talks about it and has pride in it.”