Deconstruction of central line insertion guidelines based on the positive deviance approach—Reducing gaps between guidelines and implementation: A qualitative ethnographic research

Abstract

BackgroundDespite a proven association between the implementation of prevention guidelines for central line associated blood stream infections (CLABSI) and reduction in CLABSI rates, in practice there is poor adherence. Furthermore, current guidelines fail to address the multiple process on the care continuum. This research is based on the bottom-up "Positive Deviance" (PD) approach, through which multiple creative and safer solutions for central line (CL) insertion were identified that were not previously described in the guidelines. The aim of the study was to deconstruct CLABSI prevention guidelines ("during insertion" process only) through the PD approach, working with physicians to identify additional actions that, in practice, help maintain a sterile environment and contribute to patient safety.Methods and findingsOur study included a qualitative ethnographic study involving 76 physicians, working in a division of internal medicine and two intensive care units (ICUs). We triangulated findings from a combination of data-collection methods: semi-structured interviews, focused observations, video documentation, Discovery & Action Dialogue (DAD), and simulations. Deconstruction analysis was performed. A total of 23 creative extensions and variations of CL insertion practices were identified.ConclusionsThe PD approach enables the identification of vital nuggets of hidden wisdom missing from the formal explicit CLABSI guidelines, and therefore helps bridge the gap between theory and praxis. During the guideline's deconstruction process, through collaborative staff learning, the written procedure is transformed into a living, breathing and cooperative one. It can reduce hospital stays and save lives, and therefore needs careful attention of healthcare scholars and practitioners.

A mixed-methods sequential explanatory design comparison between COVID-19 infection control guidelines’ applicability and their protective value as perceived by Israeli healthcare workers, and healthcare executives’ response

“…Recent studies in the field of infection control indicate that the official guidelines focus on the temporal order of actions in their broadest sense and cannot be totally comprehensive as exigency situations arise from the dynamic nature of the work, that exist in the care continuum [28,29].…”

What distinguishes positive deviance (PD) health professionals from their peers and what impact does a PD intervention have on behaviour change: a cross-sectional study of infection control and prevention in three Israeli hospitals

“…An example of this was published by Cohen et al . [18], describing the process by which physicians from ICUs demonstrated PD practices while sequencing operations for central line insertion, which completed the missing parts of the official guidelines. These missing parts, called grey areas, encompass the variety of situations on the care continuum that are not addressed in accepted guidelines, and are where staff members are unsure of how to proceed; they interpreted or understood the guidelines differently [19].…”

“…The quasi-experimental study included three phases: pre-intervention (12 months), PD intervention (6 months) and post-intervention (5 months). Our previous publications [18, 19] focused on the first two phases: The pre-intervention phase included the identification of PDs – that is, health professionals who practised non-normative (positively deviant) practices that delivered better outcomes in maintaining hygiene and (1) were not found on the formal IPC guidelines and (2) were scientifically validated by the infection control units – and mapping of their social networks [20]. The PD intervention phase comprised classification of the PD practices, followed by diffusion and dissemination of the observations.…”

“…To date, studies of the PD approach in the field of infection control have focused on the effectiveness of the approach on HAI and hand hygiene compliance rates [12–17], and reducing gaps between guidelines and implementation [18, 19]. A before-after PD intervention study that was implemented in ICUs and non-ICUs across Veterans Affairs (VA) hospitals in the USA indicated a reduction in HAI of 62% ( P < 0.001) in the rate of methicillin-resistant Staphylococcus aureus (MRSA) in ICUs and a reduction of 45% ( P < 0.001) in non-ICUs [12, 13].…”

New directions for diffusion of innovations research: Dissemination, implementation, and positive deviance

“…Post-Vietnam, the PD approach to identifying, disseminating, and implementing efficacious innovative practices from the inside-out has been employed in over 50 countries to address a wide variety of complex social problems, including decreasing neonatal and maternal mortality (Pascale et al, 2010), reintegrating returned child soldiers (Singhal & Dura, 2009), reducing school dropouts (Singhal, 2013); cutting down the spread of hospital-acquired infections (Cohen, Gesser-Edelsburg, Singhal, Benenson, & Moses, 2019;Singhal et al, 2010Singhal et al, , 2014; enhancing female entrepreneurship in rural areas (Jain, Sachdev, Singhal, Svenkerud, & Agrawal, 2019), decreasing childhood obesity (Foster, Aquino, Mejia, Turner, & Singhal, 2018) and reducing female genital cutting, sex trafficking, and other intractable issues (Pascale et al, 2010).…”