Johns Hopkins cuts MRSA rates with PD approach
Program expands to 37 sites in Maryland
One of the leading hospitals in the country has slashed infection rates with an approach called "positive deviance" (PD) that encourages frontline workers to share novel solutions to day-to-day problems.
Johns Hopkins hospital in Baltimore targeted a neurocritical care unit (NCCU) in 2006, when methicillin-resistant Staphylococcus aureus (MRSA) was causing between three to 10 infections annually. That rate has been cut to two infections per 100 at-risk patients per month, according to data presented recently in Denver at the APIC conference by Donna Fellerman, RN, BA, CIC an infection preventionist at Hopkins.1
A new approach was appealing because Hopkins is located in the Mid-Atlantic region, which has the highest measured burden of MRSA in the country. More than 70% of MRSA infections in the region are health care-associated. The costs of MRSA infection include an estimated increased cost of $27,000 per patient, 19 additional days of hospitalization, and increased mortality. PD employs a methodology of behavioral and social change that is based on the observation that in most communities certain individuals or groups develop unique strategies to solve apparently insurmountable problems, Fellerman reported. These individuals, the "positive deviants (PDs)," exist in the same environment as their less successful peers. The process of PD does not rely on technology or administrative initiatives; rather, frontline caregivers identify and implement latent solutions.
Interventions are adopted by the group without the usual resistance to a "top-down" approach. The PD initiative was implemented in several units, including the NCCU. Several personnel were trained as facilitators, and they conduct "Discovery and Action Dialogues." This informal approach gathers personnel who are on the unit at the time and stimulates conversations about issues and possible solutions. The role of the facilitator is to enable all participants to brainstorm ideas, the identify peers on responsibility for determining what is necessary to implement outside the nurses' station on a weekly basis, Fellerman reported.
Actions that have been implemented at the hospital as a result of the campaign include:
- Monthly MRSA transmission data are displayed on a large graph in the break room.
- Hand hygiene compliance data are provided to the unit.
- A unit-based infection control committee was established; meetings are held monthly.
- Hand hygiene reminder signs were developed and posted inside the rooms.
- Housekeepers changed cleaning routines, including discarding supplies and changing curtains in isolation rooms.
- The technique of donning isolation gowns was changed based on the observation of one nurse who always had her gown tied correctly.
- Visitors wash hands prior to entering and leaving the unit.
- Visitor's belongings are bagged to avoid contamination.
The application of PD to MRSA prevention started at the Veterans Affairs Hospital in Pittsburgh with a grant from the Robert Wood Johnson foundation, says Jon Lloyd, MD, senior clinical advisor for the Plexus Institute in Bordentown, NJ. The program was expanded to Hopkins and four other beta sites: Albert Einstein Medical Center (Philadelphia); Billings (MT) Clinic; Franklin Square Hospital Center (Baltimore); and University of Louisville (KY) Hospital.
"Then the state of Maryland decided that they would offer training in PD to any hospital that was willing tot try this based on the success [at Johns Hopkins]," Lloyd says. As a result, 37 health care facilities in Maryland — including acute care, long-term care and dialysis settings — are using the PD approach to prevent MRSA infections. Results are not yet available on the expanded study, but the Pittsburgh VA has cut MRSA rates by 50% since 2005 and the five beta sites are averaging about a 36% reduction after one year, he says.
Reference
- Fellerman DP. Positive deviance in action: A behavioral approach to combating MRSA in a neurocritical care unit. Abstract 11-116. Presented at the APIC conference. Denver; June 2008.
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