1. POSITIVE DEVIANCE: USEFUL METHODOLOGY TO PREVENT HOSPITAL ACQUIRED INFECTIONS Epidemiological Monitoring Department vigepi@hospitaleltunal.gov.co May 15, 2009

2. CONTENT Introduction Objective Actions and Activities Results Analysis Conclusions

3. Level III of attention –235 beds with 17,000 discharges annually –Specialties * Surgery* Neurosurgery * Orthopedics* Nephrology * Gynecology* Urology * Pediatrics * GI, etc

4. Adult ICU –19 beds, 750 discharges/year –Mostly trauma and surgery admissions Adult ICU –19 beds, 750 discharges/year –Mostly trauma and surgery admissions

5. Neonatal ICU 22 beds 750 discharges/year

6. Microscan ® Internal en External quality controls with isolates ATCC.

7. 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.

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

9. Introduction Fuente Boletin GREBO 2006 Antibiotic Resistance of Staphylococcus aureus outside ICU

10. Introduction Fuente Boletin GREBO 2006 Antibiotic Resistance of Staphylococcus aureus in ICU

11. Introduction Isolates of Hospital Acquired Infections in ICU from 2001 to 2006

12. Introduction Working on infection control since 2000 Need to renew strategies

13. 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

14. Objectives Reduce MRSA hospital acquired infections (HAI) to 0 To create an Institutional culture to prevent hospital acquired infections

15. Methodology Discovery and Action Dialogues

16. Discovery and Action Dialogues

17. Activities Awareness of problem 2007 PD work initiated Formation of multidisciplinary learning group Individual and in groups Discovery and Action Dialogues

18. 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

19. Activities Search for better practices Listen and capture butterflies Involve EVERYONE

20. Activities Bring ideas into action 2008 initiated analysis of results Feedback Recognition for improvement

21. Actions Recognition that hand hygiene and isolation precautions are the best prevention strategies. Emphasizing hand hygiene with alcohol gel Emphasizing isolation precautions practices Education

22. Education and Feedback

23. MRSA Screening

24. Results Qualitative changes CULTURE Various groups being involved: environmental services, security, the community. Administrative support MORE FRIENDS FOR PREVENTION

25. 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

26. MRSA Results SCREENING (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

27. MRSA Results Downward trend of MRSA colonization (p:0.0046). p: 0.054 MRSA colonization rate in the ICU

28. 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

29. MRSA Results p:0.73 MRSA infection rate in the ICU

30. MRSA Results p:0.032 Overall MRSA infection rate in the hospital

31. MRSA Results p: 0.0001 MRSA infection rate in the hospital

32. HAI Results All Hospital Acquired Infections

33. HAI Results Endemic corridor for Hospital Acquired Infections per 1000 patient days

34. HAI Results Corredor de la tasa por mil días estancia de IAH

35. 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

36. 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.

37. 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

38. 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

39. 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.

40. 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

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

42. 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.

43. 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.

44. ¡PREVENTION IS FIRST!

45. Historia beta