Problem-Solving ApplicationHospitals and Nursing Homes Collaborate to Combat Common Foes

C. difficileis an antibiotic-resistant bacterium that primarily infects hospital patients and nursing-home residents across the United States. For hospitals and nursing homes in the Rochester, New York, area however, it has become a particular problem. In fact, one group of hospitals spent up to $5 million a year to deal with this issue. This exercise is important because it shows the positive and negative effects of group and team dynamics on problem solving.

The goal of this exercise is to understand how effective team building and trust building can help combat problems in the workplace.

Read the case about the antibiotic-resistant bacterium sweeping Rochester-area hospitals and nursing homes; then, using the 3-step problem-solving approach, answer the questions that follow.

The Foes

MRSA (methicillin-resistant Staphylococcus aureus) and CRE (carbapenem-resistant Enterobacteriaceae) are two especially resistant and dangerous bacteria, and although you can catch these bugs anywhere, the most common and problematic places are hospitals and nursing homes. When patients are infected in these facilities they are referred to as health care-associated infections (HCAIs). Some patients enter both types of facilities with these infections which need to be treated. But it also is increasingly common for patients to be infection-free when admitted and then catch one of the bugs while a patient. This major problem is made even worse when infected patients are then transferred from one facility to another along with their super bugs. This means health care facilities are not islands with independent challenges contained within, but instead they are interconnected and literally share their problem bugs. And once the bugs are in a facility they spread, often rapidly and mercilessly.¹

Costs and Responsibilities

The Centers for Disease Control estimates approximately 15 percent of hospital patients and 65 percent of nursing home patients carry resistant bacteria (not all will develop infections), which result in more than 23,000 deaths.²Medicare is increasingly rewarding or punishing hospitals based on performance outcomes, like infection rates and readmissions. Hospitals and nursing homes therefore have both moral and financial incentives to act.³

Causes and Solutions

Besides rampant misuse and overuse of antibiotics, which is the fundamental cause for resistance in the first place, the transfer from facility to facility and patient to patient is largely attributed to insufficient hygieneclinician handwashing, patient bathing, and facility cleanliness, all of which can be controlled by health care personnel, but obviously any effort needs coordination, collaboration, and commitment. One nurse may be meticulously clean, but those efforts are undermined by the first/next one that isn't so conscientious.

Many efforts and programs have been initiated to combat the spread of HCAIs, including some in Southern California and Illinois. In fact, fifty facilities (hospitals and nursing homes) are implementing a new protocol funded by the CDC in which patients are bathed with a particular antimicrobial soap, one proven to kill MRSA, CRE, and some of the other most resistant bugs.⁴

Such collaborations are unusual and difficult, as in many cases the facilities in a particular area compete daily for patients and health care dollars.

Put antibiotic prescribing practices aside, assume that you are a chief nursing officer in a metropolitan hospital. Apply the 3-Step Problem-Solving Approach to help mitigate the problem of HCAIs.

questions

What is the main problem in this mini-case?

• Medicare's practice of punishing hospitals based on such performance outcomes as infection rates
• poor hospital and nursing-home performance in terms of patient infections due toC. difficile
• failure of nursing staff and physicians to wash their hands adequately
• competition between Rochester-area hospitals and nursing homes
• prescribing habits of physicians in nursing homes and hospitals in the area

Based on the case and organizing framework, which of the following may not be an outcome of the problem?

• customer satisfaction
• financial performance
• turnover
• group/team dynamics
• group satisfaction

Which of the following would you recommend to hospital and nursing-home leadership to assist in combatingC. difficile?

• having unique checklists of procedures for each location
• promoting silos among hospitals and nursing homes
• having periodic meetings between organizational leadership teams
• using a common computer database for patient records
• increasing insurance billings

Which of the following quotes from the case illustrates the importance of individuals working together to reduce theC. difficileinfection problem?

• "The organizations therefore had both moral and financial incentives to act."
• "Typically, they must also be on antibiotics that wipe out the good bacteria in their gut, allowingC. difficileto thrive there."
• "It is extremely difficult to kill and can live on bed rails, call buttons, and doorknobs for up to five months if they are not cleaned effectively."
• "For instance, a group of hospitals was spending an additional $4 million to $5 million a year to deal withC. difficile-related problems."
• "Another common source of infection is patients who are transferred from one facility to another and bring the bacteria with them, introducing it to a new patient population."