Acting against MRSA

Jon Lloyd begins the series of guest blogs from the front line. Jon is a retired surgeon and is currently the Coordinator for the Southwest Pennsylvania MRSA Prevention Collaborative for the federal Centers for Disease Control and Prevention and the Veterans Administration Pittsburgh Healthcare System. In this entry, he recounts the experience of using improvisation [inspiration from Keith McCandless and the Billings Clinic team] as a tool for opening dialogue between staff on a unit and orthopedic residents on infection control practices:

Improv with 4West staff and Ortho Residents


Like most hospitals, we have struggled with infection control. Like everyone else, we have tried evidence-based, knowledge-based, technically oriented approaches. We’ve had educational sessions, campaigns on hand hygiene and power-point presentations. We’ve made supplies readily available and put soap dispensers everywhere. We’ve used active surveillance with high tech molecular testing. But all these efforts haven’t made much change in physician behavior. So we decided to approach infection control as a cultural problem, and try to create a fun and safe way to mirror physician behavior back to them, to enable staff to discover their current practices and create their own innovative ways of improving those behaviors. Using improv followed by discussion and refreshments, staff identified problems and came up with four specific solutions, all in less than 40 minutes. Briefly and bulleted, here’s what happened in our 8-9-07 exercise:

• Setting and participants: 4West (a mixed surgical Unit), mock isolation room with debrief room directly across the hall. Isolation room "bugged" with GermGlo everywhere. In addition to 4W staff, the Chief of Orthopedic Surgery and his 5 house staff ("Super Chief," senior and junior residents and intern) were present along with staff from the Ortho Clinic.

• Scene 1: Dressing change on patient in contact isolation precautions for MRSA SSI following ORIF. The patient is played by a male aide. Role switches, by the way, are instructive and invigorating. In an earlier improve, residents and housekeepers and escorts played RNs. Orthopedic residents, their Chairman, Peter Cohen, M.D. and several 4West staff observed. Patient Escort served as director and Charge Nurse facilitated. Director explained that what they were about to see is a condensed, only slightly exaggerated version of what goes on every day. The intent of the improv is to foster safe and fun group learning by doing.

• Action: Entourage of house staff players entered isolation room provoking the RN rounding with them to insist that they come back out and perform HH and don gowns and gloves. Super Chief (SC) says: "We'll only be a minute, just have to change a dressing, gotta get down to the O.R." Without washing his hands, SC put arms in to a gown and gloves and the entourage followed without taking any precautions. SC greeted patient, took scissors out of lab coat pocket and cut through MRSA soaked dressing then put scissors back in pocket. SC’s gown was dangling off his wrists and his tie was flopping around in the wound. When his cell phone rang (the call was staged) SC grabbed the phone from his lab coat, talked, then put it back in his coat. After completing the dressing change, SC threw pus-soaked dressing and contaminated gloves in regular garbage can and placed the soiled gown on hook on back of the door. RN encouraged SC to discard gown. SC replied: "I may return or some one else can use it...just tryin' to save the hospital a little money."

• Debrief: Across the hall in a room with coffee and cookies the facilitator asked, "Based on what we all know about infection prevention precautions, do any of you have concerns about what you just saw?” The junior resident immediately commented on SC’s failure to perform hand hygiene and other house staff entering room with no precautions. The senior resident burst in with commentary on the scissors and cell phone circus. SC, not to be out done, recited the remaining litany of precaution violations: sloppy gowning, improper disposal of contaminated dressing, and hanging used gown on door so that it could be re-used. He also noticed the food tray on the over bed table next to a urinal and used Kleenex. We then turned the lights off and illuminated GermGlow on the hands, face, clothing, cell phone and scissors used by play acting SC. This elicited the usual shock of recognition from the observers.

• Scene 2: Facilitator asked the two residents who are notoriously least compliant with transmission-based precautions to go and change the dressing the right way. They both did everything perfectly; HH, gown/glove, sterile scissors to remove bandage, cell phone unanswered, proper disposal of dressing in the red can, proper removal and disposal of gowns/glove, HH, etc. We returned to the debrief room for more cookies and coffee. This provided an opportunity for the house staff to reflect on what they had seen and done, which led to a rich sharing of their ideas. These included:
(1) Scissors the house staff carry in their lab coats are the ones they use in the O.R., but they are not available on the nursing units. The residents carry them because they are sharper, one blade is blunt and slides under bandage without cutting skin, and they can be autoclaved and re-used. So why can't the nursing units provide them with these scissors?
(2) The gowns suck; it's a nuisance to have to tie them around your neck, so they end up dangling off our wrists. Aren't there gowns with neck loops you can just put your head through?
(3) Put a handle to hang the urinal on the side of the over bed table. That way the urinal isn't vulnerable to tipping over and spilling on the food and other items on the table.
4) Put a coat hanger outside isolation rooms next to the hand hygiene dispenser so we can hang our lab coats up, perform hand hygiene and put on a gown which is kept on a door hanger in an easy, efficient sequence.
Following this flow of terrific ideas, we turned the lights off and shined the UV lamp on the hands, clothing, and personal items of everyone who entered the mock isolation room during the improve. Again, horrors… GermGlow every where. The improv started at 3:30 pm and ended at 4:10 pm. 4W staff and ortho residents lingered for another 15 minutes for more cookies and chatter. Most of the talk was about how fast their ideas would be implemented.
Residents and staff filled out an “Improv Critique Sheet” (see below).

• Outcomes:
(1) A supply of scissors preferred by ortho residents was ordered from central supply. They were available the next morning and the residents used them.
(2) Requisitions for coat hooks on the wall next to the hand hygiene dispensers and handles on the sides of all over the bed tables to hang urinals were filled out, signed by Dr. Jain, Chief of Staff and submitted as urgent requests. These will be available next week.
(3) RNs on 4W found a small supply of gowns with neck loops that fit over the head and don’t need to be tied. They also have thumb holes to facilitate gloving without contamination. Unfortunately they’re plastic and too hot if worn for more than a few minutes. The ideal would be gowns with neck loops and fabric that breathes. The director of supplies has been asked if such a gown is available and if not to ask suppliers to make them. They would sell like hot cakes.
(4) Improvs are planned for the nursing staff on each of the units, medical house staff and attendings and will undoubtedly spread to out patient clinics and support services. As improve actors, we all leave the stage to act our ways into new ways of thinking.
• Learnings:
(1) The apparent amnesia that physicians manifest during patient rounds regarding 158 year old evidence-based infection prevention precautions can be overcome by the dynamic of safe, fun group learning using improvisation.
(2) Knowledge alone does not change behavior.
(3) Bringing knowledge to the surface and learning by doing as a group evokes a desire to change things and simple innovative ideas most of which can be acted upon quickly by expanding the use of existing resources

Jon C. Lloyd, MD, on behalf of front line workers on 4W and the Dept. of Orthopedic Surgery, VAPHS who did all the “work” (fun) on this improv and do the work on a daily basis and who came up with all the great ideas and started acting on them immediately.

“I love acting. It’s so much more real than life.” Oscar Wilde