23.
PROJECT NAME: Trial of positive deviance in inpatient wards to
reduce hospital infections
Institution: UT Southwestern Medical Center
Primary Author: Pranavi Sreeramoju, MD, MPH
Secondary Author: Lucia Dura, PhD, Maria Eva Fernandez-Rojas, MPH,
Abu Minhajuddin, PhD, Kristina Simacek, MS, Thomas B. Fomby, PhD,
Robert Haley, MD, MPH, Bradley N. Doebbeling, MD
Project Category: Research
Background: Healthcare-associated infections (HAI) are preventable. Positive
deviance (PD) is a yet untested complex adaptive approach that harnesses
diversity and peer role-modeling among members of a group to influence practice
change. This study was done to test the effectiveness of PD in reducing HAI
among hospital inpatients.
Methods: We performed a cluster randomized controlled trial in six medicine
wards at Parkland Memorial Hospital, an 809-bed public academic hospital. The
study period was from April 2011 to March 2013. We enrolled six medical wards
and randomized them into two groups of three wards each. PD intervention was
randomly allocated to one group. The baseline, intervention and follow-up periods
were six, nine and nine months respectively. During the intervention period,
research staff (PS, LD and MEFR) conducted open-ended dialogues with the staff
members of the intervention wards, discovered barriers to use of infection
prevention practices, and sought solutions to prevent HAI. Positively deviant
practices and positively deviant staff members were identified, and potential
solutions were prioritized. The primary outcome was a composite HAI rate of
central line-associated bloodstream infection, catheter-associated urinary tract
infection, hospital-acquired pneumonia and Clostridium difficile infection, per 1000
patient-days. Data were collected through medical record review using standard
national definitions. Modified hospital survey of patient safety climate (HSOPSC),
and social network survey were performed on the staff members at the beginning
and the end of intervention, and the end of follow-up period. The study was
approved by the Institutional Review Board.
Results: During the intervention period, several discovery and action dialogue
and role-playing sessions were conducted. The time effort was 37 hours of ward
manager time and 79.5 hours of staff time. It took several months before the staff
members began to take ownership of the process. Over 180 positive practices and
ideas emerged. During the seventh month of the intervention period, the staff
members of the intervention wards named three key projects for implementation.
They are a) patient education on hand hygiene, b) patient education and
engagement on how they can participate in their care during the hospital stay, and
c) standardization of infection prevention practice skills among staff members. The
primary outcome, the rate of HAI per 1000 patient-days in the intervention group
vs. the control group was 4.14 vs. 4.82 in the pre-intervention period, 3.39 vs. 2.67
in the intervention period, and 2.62 vs. 3.00 in the post-intervention follow up
period. The differences were not statistically significant. The results of modified
HSOPSC showed significant differences in culture of safety between the
intervention and control groups, although there was no time x group difference.
Social network analysis revealed that the average number of relationships per staff
member decreased to a greater extent in the control group compared to the
intervention group. During the intervention and follow-up periods, the six study
wards experienced an average turnover of 53%.
Conclusions: Positive deviance intervention in inpatient medicine wards to
reduce HAI was not effective when implemented for a nine-month period when the
wards were experiencing a high staff turnover.