Finally! Gracing the pages of the NYT and appearing at IHI's National Forum on Quality Improvement

There is much catching up to do with you dear readers. Since December 2007, the beta sites have been working hard to continue their work on MRSA prevention and are seeing great, and according to Dr.John Jernigan, the CDC's authority on infectious diseases, have/are achieving statistically significant results!
December 8, 2008, the beta sites were presenting their work and sharing their results with participants from around the country at the 20th Annual National Forum on Quality Improvement in Health Care in Nashville, TN. Proceedings from the conference are available at the IHI website.
December 14th, Positive Deviance and Plexus' PDMRSA Prevention Partnership is one of the NYT Magazine featured ideas of the year. You can access the full article on our website.

We're really excited of the difference we have been making and are continuing to make; preventing infections and saving lives, engaging hospital staff, patients, families and the community in co-creating and co-implementing solutions to sustainably prevent the transmission of MRSA.

A national priority for disease control...

Over the weekend, I read a really interesting article on MRSA in which the authors note "Our findings suggest that S. aureus and MRSA should be considered a national priority for disease control." and mind you, that the sentence in the article is underlined! [No reference citation here- you can click on the link for that.]

Published in the latest issue of Emerging Infectious Diseases, a monthly journal from the Coordinating Center for Infectious Disease- a division of the CDC, it is the latest academic study to shed light on the burgeoning MRSA problem, aside from the [super duper newsmaker] October CDC research article on the extremely high rates of invasive MRSA infections [invasive meaning bloodstream- meaning if you get an infection- you would rather NOT have an invasive one 'cause they're deadly.

Aside from confirming the ridiculous rise of staph infections and the rates of antibiotic resistance, the research indicates that community-associated MRSA is spreading into hospitals- making basic preventative measures in hospitals now more important than ever [ like it wasn't ever important before]

In hospitals, handwashing practices, which have been shown to be the leading intervention for limiting the spread of nosocomial infections, should be improved to meet recommended guidelines (21). Because of the increase in skin and soft tissue infections, standard precautions, including use of gloves, are likely warranted when dealing with all skin and soft tissue infections in outpatient clinics and acute-care facilities. Contact precautions, including use of gowns and gloves, should be implemented for all wound care in acute-care facilities,...

It still blows my mind that we are suggesting to healthcare workers that they should be washing their hands according to recommended guidelines. I think it was about 100 years ago that Semmelweiss discovered that handwashing saves lives- you think the US healthcare workers would accept that fact by now. There's even a treatise on the importance of handwashing on the CDC website. [Anyway...]
But really all of this underscore the fact that infection control programs in the past have missed an essential element, people's behavior. These recommendations, they're really not technical- they're behavioral. And this is what sets our work apart- we focus on the behavioral aspect of MRSA prevention- engaging people to remove the barriers that prevent them from DOING the things they should be doing in order to prevent infections. More about the approach and background can be found in the first post.

Quintessentially PD- A "Central Line" Like Bundle created by the Housekeeping staff

Have just been trying to catch my breath from the past couple of weeks and this Thanksgiving so I am catching up- here is a little story I receive a little back:

Here are the photos [sorry that I had to link to the photos-which by the way will open up to a pdf file- long story- alot of technical details that I couldn't figure it out- but anyhow, sorry.] of what EMS came up with at VAPHS illustrating their check list for terminally cleaning patient rooms. The PD staff (resource group) gathered their peers whose behavior needed to change (learning group).

This is the product of their discussions with minor facilitation and advise from the Laura Morris (ICP) and Candace. At the request of the EMS staff, these illustrations have been laminated, placed on rings and placed on each supply cart and in supply closets on each floor for ready reference. The process and the sense of ownership that it instilled have influenced some "housekeepers" to view room cleaning as an infection prevention process. One of the PD EMS staff actually views their new check list as comparable to the "bundles" used by RN's and MD's to prevent central line sepsis and ventilator pneumonia.

This captures much of PD: staff viewed as the experts by leadership, staff exercising their freedom and opportunity to co create a "penny solution" which is elegant in its simplicity and likely to endure because EMS staff created it and who ever turned their back on something they created? The other noteworthy dimension of this is the peer-to-peer sharing which quickly amplified the solution in both the acute and LTC facilities.

*So make sure you follow the link for the photos of the room checklist that they made*

NYT editorial

Yesterday the NYT has an editorial titled "Another Very Scary Germ" calling for "the need for an aggressive, multipronged approach to curb the growing number of antibiotic-resistant bacteria."
We applaud the call for a multi-pronged approach and even though we are working specifically on MRSA, the sites that are using PD for MRSA prevention are seeing declines in other antibiotic-resistant organisms as well, such as VRE and C-Diff.

See our response to the editorial below:

Re "Another Very Scary Germ" (editorial, Nov. 20):"

The New York Times is absolutely right in advocating an aggressive, multipronged approach to curb the growing number of antibiotic-resistant bacteria, especially in our nation's health care institutions.

One proven approach is called Positive Deviance. The core of PD's success is the acknowledgement that responsibility for fighting resistant microbes belongs to individuals at all levels, from the custodial staff to the head of cardiology.

Plexus Institute, with funding from The Robert Wood Johnson Foundation, is working with hospitals across the country to test and document the results of PD. Participating hospitals, such as Billings Clinic in Montana, Baltimore’s Johns Hopkins and Philadelphia's Albert Einstein Medical Center, are already experiencing double-digit declines in infections as a result of using PD and engaging everyone in the healthcare environment.

Only by working together, staying true to proven techniques for controlling infections and embracing new ones, can we win this life and death battle.

PD/MRSA Prevention Initiative in the News!!!

I am soooo excited that we are getting air time at local tv stations all around the country. The stories around MRSA are talking about our initiative- using Positive Deviance for MRSA reduction. Here is a direct link to one of the local tv stations coverage, and be sure to click on the red video camera icon above the picture for the video [and see my boss on tv!]. I am pasting the transcript below:

MRSA Attack Plan MRSA keeps making headlines in schools, but historically, its roots are in our nation's hospitals.

Now there's a program to help hospitals cut the risk and spread of infection from the superbug.
It's an innovative approach, called positive deviance and it seems to be making a difference.

After breast cancer surgery, Donna Shinn had another battle on her hands, the drug-resistant superbug, MRSA.

Donna says, "I just know that I was in a private room and just outside my room they had a special sink and everything, for everyone to wash down before they came in to see me."

The precautions are part of 'positive deviance' - a stepped up attack plan on the superbug.

Curt Lindberg says, "in the hospitals that have had the most experience with positive deviance, we've seen declines on the order of 50%."

PD is based on the principle that solutions to problems already exist. The idea is to engage everyone from housekeepers to lab workers to put that knowledge into practice.

Curt says, "it becomes their job then to look among their colleagues to find out the good practices that are achieving better results. So it's kind of finding what's working and then doing more of it."

Dr. Trish Perl says, "what has changed here really has been the ground swell of involvement and the engagement that we've been able to get in this staff."

At johns Hopkins, the PD campaign is called "stomp" - for stop transmission of MRSA permanently.

Dr. Perl says, "we're pushing hand hygiene. We're getting 'em, you know, alcohol gels all over the place. Wash your hands."

Dr. Wendy Ziai says, "we've also taken a number of steps to try to decrease transmission coming into the hospital. We're requiring all visitors to wash their hands with the chlorhexadine, the Purell wash before entering the unit."

Incoming high-risk patients are swabbed for the MRSA germ. If a test is positive, the lab can immediately page the floor nurse to put the patient in isolation.

Dr. Ziai says, "we are looking into new forms of environmental decontamination to take place, you know, in the unit once the patients that are at high risk or who are infected have left those rooms to try to decontaminate those rooms better."

Posters keep the program's progress front and center while the entire staff bones up on infection control with an in-house version of jeopardy. But is this "all out" effort cutting MRSA infections?

Dr. Ziai says, "we used to have a fairly, one of the highest transmission rates in the hospital of any ICU and we have actually decreased that significantly."

Proving positive deviance gives positive results.

Taking from lessons learned in the healthcare setting, schools can better protect students from infection.

The CDC recommends better hand washing, cover cuts with a clean, dry bandage and avoid sharing personal items.

They also suggest schools establish cleaning procedures on frequently touched surfaces.

The positive deviance initiative is supported by the plexus institute with a grant from the Robert Wood Johnson Foundation.

Other stations around the country that are airing the PDMRSA video clip includes: [And should you see the coverage in your local news- please please send me the link!]

1. Channel 4 News At Five DMA: 2
KNBC-TV CH 4 (NBC) Los Angeles
11/07/2007 05:00 PM - 06:00 PM Est. Audience: 137,945

2. ABC 15 News Daybreak DMA: 12
KNXV-TV CH 15 (ABC) Phoenix
11/15/2007 05:00 AM - 06:00 AM Est. Audience: 11,002

3. WKRG 5 News At 5 DMA: 61
WKRG-TV CH 5 (CBS) Mobile/Pensacola
11/13/2007 05:00 PM - 05:30 PM Est. Audience: 43,970

4. WKRG 5 News At 6 DMA: 61
WKRG-TV CH 5 (CBS) Mobile/Pensacola
11/14/2007 06:00 AM - 07:00 AM Est. Audience: 22,179

5. The Early Show DMA: 70
WFRV-TV CH 5 (CBS) Green Bay/Appleton
11/15/2007 06:00 AM - 07:00 AM Est. Audience: 14,615

6. 5 Eyewitness News: Live At Five DMA: 70
WFRV-TV CH 5 (CBS) Green Bay/Appleton
11/15/2007 05:00 PM - 05:30 PM Est. Audience: 44,486

7. NewsChannel 11 Weekend Edition DMA: 91
WJHL-TV CH 11 (CBS) Tri-Cities
11/11/2007 11:00 PM - 11:35 PM Est. Audience: 28,988

8. News 19 Daybreak DMA: 127
WXOW-TV CH 19 (ABC) La Crosse/Eau Claire
11/12/2007 06:00 AM - 07:00 AM Est. Audience: 6,905

9. News 19 Live At Five DMA: 127
WXOW-TV CH 19 (ABC) La Crosse/Eau Claire
11/12/2007 05:00 PM - 05:30 PM Est. Audience: 14,202

10. News 3 At Noon DMA: 128
WRBL-TV CH 3 (CBS) Columbus, GA
11/12/2007 12:00 PM - 12:30 PM Est. Audience: 14,149

the philosophy behind our MRSA prevention work

Jon Lloyd as you have "met" previously in this posting, has archived some of his correspondence with people not familiar with our PD/MRSA work and is letting us share them with you, the reader. Inspired by Rilke's Letters to a Young Poet, Jon is titling his collection as "Emails to a Young Positive Deviant" and this particular email really captures the philosophy of the work that we are doing:

Emails to a Young Positive Deviant

(2) Front Line Workers…the True Experts

Your staff will be your greatest source of ideas on overcoming barriers to adhering to the basic precautions like active surveillance, hand hygiene and contact isolation. Given the freedom and opportunity, your staff (RN's, housekeepers, respiratory therapists, food service, et al) will go beyond that and come up with all sorts of other infection prevention precautions that the Infection Control team hadn't thought of. At least that has been the experience at the VA Pittsburgh and the other beta sites. Your staff will become the functional IC team and the IC team will gradually ascend from the role enforcers to become the scientific base and filter for the great ideas that the staff will come to them with for validation.

The other thing that comes to mind is the importance of letting the staff who come up with the great ideas actually implement them. They may need support, but it is critical for the creator of a good idea to be able to act on it. You (MCP, ICP) shouldn't have to be the scientist, educator and do all the work in implementing their ideas. True ownership comes not only from creating the solutions but acting on them. Since we tend not to turn our backs on things we create, staff-driven solutions tend to be more durable than those that come from the outside or from the top of the organization. The closer the staff are to the solutions, the more effective, less costly, simpler, more beautiful and longer lasting those solutions tend to be.

Focus on the inherent strengths of your front line staff, especially the unlikely suspects. Draw on this untapped resource continuously. Your staff will come up with increasingly sophisticated ways of preventing MRSA transmissions and associated infections.

What do Opaque cabinets have to do with MRSA prevention

And really I am not oversimplifying things here. MRSA prevention is more than just the CDC, the SHEA, or the APIC infection control guidelines- it is about getting staff to follow these guidelines 100% of the time. That means engaging them in finding solutions to the barriers that prevent THEM from doing 100% of the time.

So really what do cabinets- specifically the ones that hold isolation gowns- have to do MRSA prevention? See below [ courtesy of Delmarva Foundation/Maryland Patient Safety Center] for a clip of Jeff Cohn, Chief Quality Officer at Albert Einstein Medical Center [one of the PD/MRSA sites] in Philadelphia, PA talking about how PD is helping AEMC prevent MRSA and CHANGE MORE than just cabinets.