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POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department [email protected] May 15, 2009
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POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department [email protected] May 15,

Mar 26, 2015

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Page 1: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT

HOSPITAL ACQUIRED INFECTIONS

Epidemiological Monitoring Department

[email protected]

May 15, 2009

Page 2: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

CONTENT

• Introduction

• Objective

• Actions and Activities

• Results

• Analysis

• Conclusions

Page 3: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

11/42

Level III of attention

–235 beds with 17,000 discharges annually

–Specialties

* Surgery * Neurosurgery

* Orthopedics * Nephrology

* Gynecology * Urology

* Pediatrics * GI, etc

Page 4: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

Adult ICUAdult ICU

–19 beds, 750 19 beds, 750 discharges/yeardischarges/year

–Mostly trauma and Mostly trauma and surgery admissionssurgery admissions

Adult ICUAdult ICU

–19 beds, 750 19 beds, 750 discharges/yeardischarges/year

–Mostly trauma and Mostly trauma and surgery admissionssurgery admissions

Page 5: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

Neonatal ICU22 beds750 discharges/year

Page 6: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

Microscan ®

Internal en External quality controls with isolates ATCC.

Page 7: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

Introduction

•Staphylococcus aureus is a microorganism that causes infections in hospitals and in the community

•Between 20% to 35% of the adult population carries it transitorily in the nose and oro-pharynx. 50% carries it permanently

•Currently Methicillin resistant Staphylococcus aureus (MRSA) is considered a public health problem because it is the resistant pathogen extended the most world-wide.

Page 8: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

The Lancet: 2006;368:1866Global prevalence of meticillin-resistant Staphylococcus aureusHeiman FL Wertheim, Henri A Verbrugh

Page 9: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

Introduction

Fuente Boletin GREBO 2006

Antibiotic Resistance of Staphylococcus aureus outside ICU

Page 10: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

Introduction

Fuente Boletin GREBO 2006

Antibiotic Resistance of Staphylococcus aureus in ICU

Page 11: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

Introduction

Microorganismo Total PorcentajeStaphylococcus aureus 145 17,28Acinetobacter baumannii 101 12,04Klebsiella pneumoniae 96 11,44Escherichia coli 77 9,18Enterobacter cloacae 45 5,36Pseudomonas aeruginosa 43 5,13Candida albicans 41 4,89Staphylococcus epidermidis 35 4,17Klebsiella oxytoca 32 3,81Proteus mirabilis 20 2,38Enterobacter aerogenes 17 2,03Otros m.o. con aislamientos < 2% 187 22,29Total 839 100

Isolates of Hospital Acquired Infections in ICU from 2001 to 2006

Page 12: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

Introduction

• Working on infection control since 2000

• Need to renew strategies

Page 13: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

Introduction

• 2006 Invitation from Plexus Institute, Merck and CIDEIM to learn about the PD initiative

• Submitted application to participate

• Hospital El Tunal E.S.E and Hospital Pablo Tobon Uribe were selected

Page 14: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

Objectives

• Reduce MRSA hospital acquired infections (HAI) to ‘0’

• To create an Institutional culture to prevent hospital acquired infections

Page 15: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

Methodology

Discovery and Action Dialogues

Page 16: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

Discovery and Action Dialogues

Page 17: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

Activities

• Awareness of problem

• 2007 PD work initiated

• Formation of multidisciplinary learning group

• Individual and in groups Discovery and Action Dialogues

Page 18: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

Activities

• Initiated as MRSA reduction initiative and was rapidly expanded to prevention of HAI

• In June 2007, shared the experience with the US beta sites

Page 19: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

Activities

• Search for better practices

• Listen and capture butterflies

• Involve EVERYONE

Page 20: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

Activities

• Bring ideas into action

• 2008 initiated analysis of results

• Feedback

• Recognition for improvement

Page 21: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

Actions

• Recognition that hand hygiene and isolation precautions are the best prevention strategies.

• Emphasizing hand hygiene with alcohol gel

• Emphasizing isolation precautions practices

• Education

Page 22: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

Education and Feedback

Page 23: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

MRSA Screening

Page 24: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

Results

• Qualitative changes

• CULTURE

• Various groups being involved: environmental services, security, the community.

• Administrative support

• MORE FRIENDS FOR PREVENTION

Page 25: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

MRSA Results

SCREENING(April 2007- march 2008)

• Screening compliance at admission was 79% and follow up 81%

• MRSA colonized patients at admission 53/694 (7.79%). Percentage remained stable during follow up ( p:0,57)

• Hospital acquired MRSA 6/53 (11.32%)

• Most sources were blood

Page 26: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

MRSA ResultsSCREENING

(April 2007- March 2008)

Patients who became colonized with MRSA

• Became colonized between day 3 -35, median 11 days

• Rate 11/1000 patient days

• Acquired infection 6/59 (10.17%)

• Most sources were blood

Page 27: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

MRSA Results

TENDENCIA DE LA TASA DE COLONIZACION DE PACIENTES POR SAMR, DURANTE LA ESTANCIA EN UCI, EN UN AÑO DE SEGUIMIENTO

02468

10

1214161820

Abr-07 May-07 Jun-07 Jul-07 Ago-07 Sep-07 Oct-07 Nov-07 Dic-07 Ene-08 Feb-08 Mar-08

Tas

a p

or

mil

día

s es

tan

cia

Downward trend of MRSA colonization (p:0.0046).

p: 0.054

MRSA colonization rate in the ICU

Page 28: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

MRSA Results

MRSA infection rate in the ICU 2,34/1000 patient days. It remained stable

MRSA infection rate in HET was 0.65/1000 patient days with a downward trend

Page 29: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

MRSA Results

Tendencia de la tasa de infección por SAMR en la UCI, en un año de seguimiento.

0

2

4

6

8

Abr-07 May-07 Jun-07 Jul-07 Ago-07 Sep-07 Oct-07 Nov-07 Dic-07 Ene-08 Feb-08 Mar-08

mes

Tasa

por

mil

días

es

tanc

ia

p:0.73

MRSA infection rate in the ICU

Page 30: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

MRSA ResultsTendencia de la tasa global de infección samr, en el

hospital,en un año de seguimiento.

0,00

0,20

0,40

0,60

0,80

1,00

1,20

1,40

Abr-07 May-07 Jun-07 Jul-07 Ago-07 Sep-07 Oct-07 Nov-07 Dic-07 Ene-08 Feb-08 Mar-08

Mes

Ta

sa

po

r m

il d

ias

e

sta

nd

ia

p:0.032

Overall MRSA infection rate in the hospital

Page 31: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

MRSA Results

Tendencia de la tasa global de infección por samr,seguimiento de 24 meses

0,00

0,20

0,40

0,60

0,80

1,00

1,20

1,40

Abr-07

May-07

Jun-07

Jul-07

Ago-07

Sep-07

Oct-07

Nov-07

Dic-07

Ene-08

Feb-08

Mar-08

Abr-08

May-08

Jun-08

Jul-08

Ago-08

Sep-08

Oct-08

Nov-08

Dic-08

Ene-09

Feb-09

Mar-09

Tasa

de i

nfec

ción

por S

AMR

por m

il dí

as

esta

ncia

p: 0.0001

MRSA infection rate in the hospital

Page 32: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

HAI Results

HOSPITAL EL TUNAL, INDICE GENERAL DE INFECCIÓN ADQUIRIDA EN EL HOSPITAL, DURANTE EL ULTIMO AÑO.

0

1

2

3

4

5

6

7

Abr-08 May-08 Jun-08 Jul-08 Ago-08 Sep-08 Oct-08 Nov-08 Dic-08 Ene-09 Feb-09 Mar-09

MES

IND

ICE

DE

IA

H

All Hospital Acquired Infections

Page 33: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

HAI Results

0

1

2

3

4

5

6

7

8

ene feb mar abr may jun jul ago sep oct nov dic

ind

ice

limite inferior medialimite superior año 2009año 2008

Endemic corridor for Hospital Acquired Infections per 1000 patient days

Page 34: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

HAI ResultsCorredor de la tasa por mil días estancia de IAH

0

5

10

15

ene feb mar abr may jun jul ago sep oct nov dic

Tas

a p

or

mil

día

s es

tan

cia

limite inferior medialimite superior año 2009año 2008

Page 35: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

Lessons Learned

Positive Deviance is effective to prevent and control MRSA and other HAI

The success of the methodology is in the fact that the people recognize the prevention strategies and, by being suggested by themselves- are adhere to with greater responsibility

Everyone has something to offer regardless of academic status or job description

Page 36: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

Lessons Learned

Cultural changes involve those who have not changed and force them to change

Greater compliance to infection control is achieved in settings of limited resources

People required recognition for their achievments.

Page 37: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

Barriers

It is difficult for the facilitator just to listen without orienting the solutions he/she believes in.

Staff turnover can interfere with cultural changes

During DADs, there are people who discourage the group with skeptic positions

Page 38: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

Barriers

It is difficult to recognize that things are not well or that others are doing things better

The groups are not always able to identify a positive deviant

Page 39: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

Conclusions

Positive Deviance is a useful and cost-effective methodology for the prevention and control of HAI. It provides improved quality and safety for patients , reduced number of infections, and greater control to antibiotic resistance specifically for MRSA.

Page 40: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

Conclusions

Positive Deviance motivates learning in the community and allows the transfer of successful elements by following the behavior of someone who has already obtained good results. It generates immediate and gradual changes that improve behaviors

Page 41: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

Conclusions

There are multiple possibilities to apply positive deviance. There is a wide variety of opportunities yet to be explored

Page 42: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

Conclusions

Beyond the numerical and statistical considerations, we won in the intangible. We won in self-care, in the care of our families. It is a victory for our patients because each infection that we prevent avoids human suffering, reduces risk, y provides a better use of economic resources. In other words, every infection that we prevent generates a healthier society with better quality of life.

Page 43: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

There are people who find solutions to problems; there are others who find problems in the solutions; and there are some who prevent problems… these are our positive deviants.

Page 44: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

¡PREVENTION IS FIRST!

Page 45: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,

Historia beta

Meta

Estrategias

Equipos

Personas

Leccione

s

Descubrimos la Desviación

Positiva

Todos tenemos buenas ideas

Selección como sitio BETA

TIEMPO

Existe otra forma de hacer

las cosasSe debe reconocer a quien hace

bien las cosas

Podemos compartir lo que aprendemos

2007 2008…

Apoyo de Plexus Institute

Patrocinio Merck Sharp

And Dome

El equipo directivo, funcionarios asistenciales, administrativos y la comunidad escuchan y participan.

Curt Lindberg, Jerry & Monique Stermin, Henry Lipmanowikz, David Gasser, Jon Lloyd, Keith M

Higiene de manos precauciones de

aislamiento, educaciòn y cultivos de manos,Tamizaje

en UCI A

Agosto 06

Compartir los resultadosDescubrimiento

y Acción

Las ideas requieren acciones

Si podemos hacerlo con

los recursos que tenemos

Debemos aprender a escuhar

Se hizo visible

lo invisible

SAMRIAH

GRUPO DE APRENDIZAJE DESVIANTES POSITIVOSUCIN

VIG EPI

UCIA, PEDIATRIA, SUMINISTROS, ALMACEN, ANESTESIA, ORTOPEDIA SERVICIOS GENERALES, SEGURIDAD LABORATORIO.COMUNIDAD

Page 46: POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15,