POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department [email protected] May 15, 2009
Mar 26, 2015
POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT
HOSPITAL ACQUIRED INFECTIONS
Epidemiological Monitoring Department
May 15, 2009
CONTENT
• Introduction
• Objective
• Actions and Activities
• Results
• Analysis
• Conclusions
11/42
Level III of attention
–235 beds with 17,000 discharges annually
–Specialties
* Surgery * Neurosurgery
* Orthopedics * Nephrology
* Gynecology * Urology
* Pediatrics * GI, etc
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
Neonatal ICU22 beds750 discharges/year
Microscan ®
Internal en External quality controls with isolates ATCC.
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.
The Lancet: 2006;368:1866Global prevalence of meticillin-resistant Staphylococcus aureusHeiman FL Wertheim, Henri A Verbrugh
Introduction
Fuente Boletin GREBO 2006
Antibiotic Resistance of Staphylococcus aureus outside ICU
Introduction
Fuente Boletin GREBO 2006
Antibiotic Resistance of Staphylococcus aureus in ICU
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
Introduction
• Working on infection control since 2000
• Need to renew strategies
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
Objectives
• Reduce MRSA hospital acquired infections (HAI) to ‘0’
• To create an Institutional culture to prevent hospital acquired infections
Methodology
Discovery and Action Dialogues
Discovery and Action Dialogues
Activities
• Awareness of problem
• 2007 PD work initiated
• Formation of multidisciplinary learning group
• Individual and in groups Discovery and Action Dialogues
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
Activities
• Search for better practices
• Listen and capture butterflies
• Involve EVERYONE
Activities
• Bring ideas into action
• 2008 initiated analysis of results
• Feedback
• Recognition for improvement
Actions
• Recognition that hand hygiene and isolation precautions are the best prevention strategies.
• Emphasizing hand hygiene with alcohol gel
• Emphasizing isolation precautions practices
• Education
Education and Feedback
MRSA Screening
Results
• Qualitative changes
• CULTURE
• Various groups being involved: environmental services, security, the community.
• Administrative support
• MORE FRIENDS FOR PREVENTION
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
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
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
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
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
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
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
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
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
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
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
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.
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
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
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.
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
Conclusions
There are multiple possibilities to apply positive deviance. There is a wide variety of opportunities yet to be explored
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.
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.
¡PREVENTION IS FIRST!
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