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What will it take to reduce infections in the hospital?

The outbreak of Ebola, in Africa and in the United States, is a stark reminder of the clear and present danger that infection represents in all our lives, and we need reminding. Despite all of our medical advances, more familiar infections still take tens of thousands of American lives each year – and too often these deaths are avoidable.

Hospital infections kill 75,000 Americans a year — more than twice the number of people who die in car crashes. Most people know that motor vehicle deaths could be drastically reduced. What’s not as widely appreciated is that the far greater number of hospital infections could be reduced by up to 70%.

Changes that would reduce infections are evidence-based and scientific, supported by the Centers for Disease Control and Prevention. For example, the campaign against hospital-acquired urinary tract infection — one of the most common hospital infections in the world — seeks to minimize the use of internal, Foley catheters, a major vector of infection. Nurses who have always relied on Foleys to deal with patients who have urinary incontinence are told to use straight catheters intermittently instead, which increases their workload. Surgeons who are accustomed to placing Foley catheters in their patients for several days after an operation are told to remove the catheter shortly after surgery – or not to use one at all. Similar approaches can be used to reduce other common infections. If we know what needs to be done to lower the rate of hospital infections, why have the many attempts to do so fallen so woefully short?

Our research shows that a major reason is the unwillingness of some nurses and physicians to support the desired new behaviors. We have found that opposition to hospitals’ infection prevention initiatives comes from the three groups we call Active Resisters, Organizational Constipators, and Timeservers. While we know these types of individuals exist in hospitals since we have seen them in action, we suspect they can also be found in all types of organizations.

Active resisters refuse to abide by and sometimes campaign against an initiative’s proposed changes. Some active resisters refuse to change a practice they have used for years because they fear it might have a negative impact on their patients’ health. Others resist because they doubt the scientific validity of a change, or because the change is inconvenient. For others it’s simply a matter of ego, as in, “Don’t tell me what to do.” Some ignore the evidence. Many initiatives to prevent urinary tract infection ask nurses to remind physicians when it’s time to remove an indwelling catheter, but many nurses are unwilling to confront physicians – and many physicians are unwilling to be so confronted.

Organizational constipators present a different set of challenges. Most are mid- to upper-level staff members who have nothing against an infection prevention initiative per se but simply enjoy exercising their power. Sometimes they refuse to permit underlings to help with an initiative. Sometimes they simply do nothing, allowing memos and emails to pile up without taking action. While we have met some physicians in this category, we have seen, unfortunately, a surprising number of nursing leaders employ this approach.

Timeservers do the least possible in any circumstance. That applies to every aspect of their work, including preventing infection. A timeserver surgeon may neglect to wash her hands before examining a patient, not because she opposes that key infection prevention requirement but because it’s just easier that way. A timeserver nurse may “forget” to conduct “sedation vacations” for patients who are on mechanical breathing machines to assess if the patient can be weaned from the ventilator sooner for the simple reason that sedated patients are less work.

Hospital corridor. © Spotmatik via iStock.
Hospital corridor. © Spotmatik via iStock.

We have learned that different overcoming these human-related barriers to improvement requires different styles of engagement.

To win support among the active resisters, we recommend employing data both liberally and strategically. Doctors are trained to respond to facts, and a graph that shows a high rate of infection department can help sway them. Sharing research from respected journals describing proven methods of preventing infection can also help overcome concerns. Nurse resisters are similarly impressed by such data, but we find that they are also likely to be convinced by appeals to their concern for their patients’ welfare – a description, for example, of the discomfort the Foley causes their patients.

Organizational constipators and timeservers are more difficult to win over, largely because their negative behavior is an incidental result of their normal operating style. Managers sometimes try to work around the organizational constipators and assign an authority figure to harass the timeservers, but their success is limited. Efforts to fire them can sometimes be difficult.

Hospitals’ administrative and medical leaders often play an important role in successful infection prevention initiatives by emphasizing their approval in their staff encounters, by occasionally attending an infection prevention planning session, and by making adherence to the goals of the initiative a factor in employee performance reviews. Some innovative leaders also give out physician or nurse champion-of-the-year awards that serve the dual purpose of rewarding the healthcare workers who have been helpful in a successful initiative while encouraging others by showing that they, too, could someday receive similar recognition. It may help to include potential obstructors in planning for an infection prevention campaign; the critics help spot weaknesses and are also inclined to go easy on the campaign once it gets underway.

But the leadership of a successful infection prevention project can also come from lower down in a hospital’s hierarchy, with or without the active support of the senior executives. We found the key to a positive result is a culture of excellence, when the hospital staff is fully devoted to patient-centered, high-quality care. Healthcare workers in such hospitals endeavor to treat each patient as a family member. In such institutions, a dedicated nurse can ignite an infection prevention initiative, and the staff’s all-but-universal commitment to patient safety can win over even the timeservers. The closer the nation’s hospitals approach that state of grace, the greater the success they will have in their efforts to lower infection rates.

Preventing infection is a team sport. Cooperation — among doctors, nurses, microbiologists, public health officials, patients, and families — will be required to control the spread of Ebola. Such cooperation is required to prevent more mundane infections as well.

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