Childhood Game Inspires Hospital Emergency Department

Cheryl Clark, for HealthLeaders Media , May 4, 2009

Boston's Beth Israel Deaconess Medical Center is using peer pressure and the threat of humiliation in a playful game of "Tag, You're It!" in hopes of reducing hand-washing lapses among the busy emergency staff.

Last Friday, hospital ED chief Richard Wolfe, MD, persuaded his physicians, nurses, techs, and attendings to bravely accept the challenge. When any team member espies a colleague failing to wash hands between patient encounters, they get tagged. The words, "Tag. So-and-so is it" appear on the dashboard banner of all monitors throughout the hospital.

Wolfe says staff also can be marked for failing to write legibly in patient charts, writing prohibited abbreviations that can be misunderstood, or failing to correctly sign, date, and time all orders.  Having coffee in a clinical area is a big tag-able no-no as well.

But hand-washing is the biggest bête noir at the Harvard teaching hospital. "It is by far the hardest not to trip up on in the ED," he says. "If you have just washed your hands after seeing one patient, you still are expected to wash again before entering the next patient's room, even if you haven't touched anything.  Between the initial evaluation, re-eval, and the discharge, each patient can require six separate episodes of handwashing."

Beth Israel Deaconess sees on average 150 ED patients a day.

Wolfe isn't quite ready to write up the experiment in a medical journal, but that may come.

"We really are into a proof of concept phase for now rather that measuring the outcome of the intervention," Wolfe says. "We want to see if the game will be adopted and run continuously or if it requires regular pushes from leadership to keep it going."

As far as determining whether it works by reducing infections, that's tough in a setting where patient stays are relatively short. "The easiest measure to track compliance will be in the amount of Cal Stat (a brand of hand sanitizer) used," he says.

In his blog "Running A Hospital," Beth Israel Deaconess CEO Paul Levy calls the experiment "A fun game, for serious purposes," and "a good humored use of peer pressure among a group of doctors who tend to be really good at noticing things. Let's see how it works!"

Game rules are simple.

During each shift, a staff member who is caught violating any mandate, has his or her name placed on the banner until that staffer fingers another scofflaw. If at the end of the shift, the "tagee" has been unable to tag another violator, the banner is cleared and the game starts anew the next shift.

There is no punishment for getting tagged, but a monthly award for the one who tag the most frequently.

Wolfe says that at least on the first day, the staff embraced the game even though "a number" of care providers were tagged.

Adding to comments on his CEO's blog, he jokingly wrote, "There is healthy competition developing between the categories of providers: attendings vs. residents vs. nurses vs. techs. So far we have not knocked over any elderly patients, but no promises.

"I agree that proof of the validity of the exercise will depend on this exercise leading to providers adopting compulsive habits once we are beyond the first few days. It will be some time before we can assess this. But, so far, so good."

He also says staff members do not see this as "ratting someone out," but a sense that "we're all in this together."

Wolfe said there was the drive for "a culture of transparency" and "perfection in hand hygiene."

"The drive to eliminate harm, recent DPH citations in other areas, and our culture of transparency was causing us to strive for perfection in hand hygiene. Considerable training, daily e-mail communications, and town hall discussions, along with random audits were performed to try and achieve compliance.

"However, the ED has such a rapid flow of patient-provider contacts (any provider to be in compliance in the ED may need to wash hands up to eight-12 times/hour) that it is much harder than one might think to get there. With all the distractions that trip up providers from being 100% compliant, we were far from eliminating the problem," says Wolfe.

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