'Positive Deviance' Model Keeps MRSA at Bay

MRSA (methicillin-resistant staphylococcus aureus) is on the run at Albert Einstein Medical Center in Philadephia and five other health care sites, thanks to an approach called "Positive Deviance." The Albert Einstein Healthcare Network hosted a Jan. 8-9 conference that completed a groundbreaking project to reduce MRSA's spread, with Einstein's SMASH team -- the initials stand for Stop MRSA Acquisition and Spread in our Hospitals -- playing a leading role. Dr. Jeff Cohn, the center's chief quality officer, described the approach in the Winter 2007 issue of the Prescriptions for Excellence in Health Care newsletter.

SMASH has reduced the facility's MRSA infection rate by nearly 30 percent, from 0.55 cases per 1,000 patient days in early 2006 to 0.39 cases per 1,000 patient days from July-December 2007. In real numbers, 19 fewer patients acquired MRSA infections in 2007, according to Cohn. "Positive deviance not only has succeeded in keeping patients safe and reducing MRSA infections; it also reinforces Einstein's continued commitment to innovation and quality improvement," he said.

Positive deviance relies on staffers who already follow protocol to come together and find ways to encourage others to imitate their good behaviors. Steps in the process include: helping people define the problem, helping the community identify the PD staffers, and helping the community design a method for spreading PD practices. Cohn said an example of how the center's practices changed is its approach to storing disposable gowns. People entering the isolation room of a MRSA patient are asked to don them, but lack of available gowns at the point of entry into the rooms was identified as a barrier to consistent behavior. This was solved, he wrote, by moving the gowns to boxes on tables outside the rooms, wrapping them individually and stacking them on the tables, and storing them in clear cabinets outside the rooms so it was easy to check on supply and restock if necessary.

The network's pilot units have begun to do surveillance cultures during patient admission, transfer, and discharge. Patients identified as being colonized with MRSA are flagged in the clinical information system and placed in contact isolation, Cohn wrote. The network learned that more than 20 percent of patients in some units were colonized with MRSA on admission; multiple prior hospitalizations, residence in nursing homes, and being on hemodialysis are significant risk factors for colonization, officials there found. Einstein adopted the PD approach with funding from the Robert Wood Johnson Foundation's positive deviance/MRSA eradication initiative and was facilitated by the Plexus Institute. Five other health care institutions participated in the research project: Johns Hopkins Hospital in Baltimore; the University of Louisville, Kentucky; Billings Clinic of Billings, Mont.; Franklin Square Hospital in Baltimore; and Veterans Affairs Pittsburgh Healthcare System.

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