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Childhood Game of 'Tag' In Boston ED Changes to 'Assassin'

Cheryl Clark, for HealthLeaders Media, June 4, 2009

On May 1, the emergency room team at Beth Israel Deaconess Medical Center in Boston agreed to a game of "Tag, You're It," primarily to improve hand washing and avoid transmitting infections, but also to add fun to a rote task.

They did so in part because federal investigators were about to launch a 7-day review of the campus after of a cluster of methicillin-resistant Staphylococcus aureus infected 19 newborns and 18 mothers in another part of the hospital. Though the infections were not found in the ED, there was a concerted effort among the staff to avoid any citations stemming from heightened scrutiny, explains ED chief Richard Wolfe, MD.

Wolfe says state officials had done a preliminary review on the other campus and could not identify a cause for the MRSA cluster. "But they did find some errors in practice including hand hygiene that triggered some serious citations." As a result, he says, "we were all targeted for this very intense review." He adds, "We had not had a survey as intense as this one."

Complete hand-washing compliance is tough for even the most dedicated providers, Wolfe says. During a normal shift, one might wash hands 100 times, or six times for each of the 150 patients a day treated in the ED. "When we did internal observations, we could usually spot a miss within the first 10-15 minutes," Wolfe says.

With "Tag," any time any of the 120-member staff noticed a provider not washing one's hands before or after patient contact, the negligent staffer's name would be posted on all dashboards of all computer monitors throughout the hospital system. They read: "Tag! So-and-so is it."

The employee tagged would have to live with that rap until he or she tagged another staff member or until the end of the shift, whichever came first.

Wolfe says he thinks the game worked because "the ED did not generate a single citation."

However, three weeks after the game began, a few members of the staff, including nurses, physicians, and technicians, became "nervous" and asked to stop the game, Wolfe says. Some felt their jobs might be vulnerable in a time of layoffs, "although we had made it clear that this would not happen and there were no consequences," to getting tagged.

"But they felt that anything might come back and haunt them."

So just before Memorial Day, staff agreed to pause the game for a few weeks to regroup. Now, he says, they're going to try another approach that will not shine such a spotlight on those who lapse.

The answer, he says, appears to be a variant of the game "Assassin." Employees who are tagged will just be marked out of the game, not listed on computer monitors or anywhere else.

"To win the game, you'll have to not be caught yourself, but you still have to catch others. They'll win by staying 'alive,'" Wolfe says. The last person still playing would be the winner. There also will be a prize, such as cash or movie tickets.

Wolfe is approaching the effort with a scientist's eye as well. "We're going to let things settle down for a while to go back to baseline compliance, and evaluate how hand hygiene practices changes during a game period. Then we'll stop the game, to see if there is resilience to compliance, or whether habits will shift back to baseline."

As for the MRSA cluster, where it originated remains a mystery, Wolfe says. He hypothesizes that it was recognized and reported by the hospital after Beth Israel Deaconess started routinely looking for it. In any case, he says, no additional clusters have reappeared.


Cheryl Clark is senior quality editor and California correspondent for HealthLeaders Media. She is a member of the Association of Health Care Journalists.
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