Week 5 Main Post – Positive Deviance

Use of Positive Deviance

More times than not, and especially within high reliability systems, the focus in healthcare is on errors, harm to patients, and near misses (Lawton, Taylor, Clay-Williams & Braithewaite, 2014). This has been sending negative messages for a long time (Lawton & et al., 2014). While no one would argue against the need to identify the negative and the near misses, there is also a clear obligation to recognize the good examples in healthcare. Now is the time to send more optimistic signals to clinicians, focusing on the behaviors, processes and systems contributing to resilient, safe care. One approach to focusing on success is positive deviance. Positive deviance is the idea that solutions to common problems mostly exist within clinical communities rather than externally with policy makers or managers, and that identifiable members of a community have tacit knowledge and wisdom that can be generalized; moreover, because the solutions have been generated within a community, they tend to be more readily accepted and feasible within existing resources, thus increasing the likelihood of success and, potentially, of adoption elsewhere (Lawton & et al, 2014). While positive deviance can be used to describe the behavior of an exemplary individual, the term can also be extended to describe the behaviors of successful teams and organizations. The purpose of this discussion is to identify a problem in healthcare and how the use of positive deviance can be applied in order to promote patient safety.

Healthcare Problem Identified

Catheter-associated urinary tract infections (CAUTIs) are the most frequent type of healthcare-acquired infection, accounting for up to 80% of hospital-acquired infections (Connor, 2018). The National Hospital Safety Network (NHSN) releases guidelines to define a CAUTI. Part of the definition includes the presence of a urinary catheter for more than 2 consecutive days in an inpatient location as well as the presence of at least one symptom from a specific list of symptoms (Norrick, 2019). Each year the rates continue to rise leading to extended hospital stays, increased health care costs, and patient morbidity and mortality (ANA, n.d.). Nurses play a major role in reducing CAUTI rates to save lives and prevent harm.

The act of inserting a catheter results in bacterial colonization in the bladder at a rate of 3% per day, with a risk of bacteriuria is 25% after seven days, and after 30 days, 100% of indwelling catheters are colonized with bacteria (Townsend & Anderson, 2018). While not all bacteriuria results in the patient being symptomatic, 10% to 24% of these patients will develop a symptomatic CAUTI (Townsend & Anderson, 2018). Overuse of indwelling urinary catheters (which is 15-20% of hospitalized patients) contributes to the frequency of hospital associated urinary tract infections and the duration of urinary catheterization is the single most important risk factor for developing CAUTI (Taha & et al, 2017). Each day an indwelling urinary catheter remains, the patient has a 5% increased risk of developing a CAUTI (Taha & et al, 2017). Up to 60% of CAUTI are considered preventable and can normally be contributed to lack of the use of one of the recommended evidence-based infection-prevention practices (Taha & et al, 2017).

Applying Positive Deviance

Most CAUTI bundles in place to prevent CAUTI include the use of catheters only for evidenced based reasons. The issue rises when staff insert catheters without a reason. The physician may order the catheter and not notice there is no approved reason. It falls back to the nurse to catch these and not place the catheter until it is confirmed the catheter insertion is meeting the criteria. The next issue is nurses at times will enter a reason in haste, not verifying the reason is correct. Initially, we would ask for a corrective action plan from the nurses that entered reasons that were not otherwise supported in the chart (such as for use on critically ill patient that is not in critical care or retention with no evidence of a bladder scan/retention evidence). Now, we recognize monthly, the nurses who place catheters with the correct documentation present. There is also one nurse on each unit that has a “history” of correct documentation that will participate with every mini root cause analysis meeting that is held involving their unit that can offer tips and support to the nurses found with deficits during the meeting and afterward. Another way we decided to use positive defiance is related to the use of non-catheter devices, such as the daisy catheter and the pure-wick. It is reported monthly which units utilize these products based on their stock replenishment. We also recognize per unit how many catheters were avoided with the use of these devices. We had several units not utilizing these at all that returned to these products once it was “publicly reported internally” the usage for each unit.

Since CAUTI’s are not defined until after day two of a catheter and the risk of a CAUTI increases with each day of its use, our bundle also includes a shift documentation to confirm the continued necessity of a catheter. This does not always work in our advantage to discontinue catheters as nurses frequently respond with previous data and do not “stop and think” to review the continued necessity. Examples of such incidences include a catheter inserted for critical care patient on vasopressors requiring hourly input/output documentation. After a few days, the vasopressors are stopped. The nurses then document the reason to keep the catheter is for “retention” but there is no evidence to support retention or any attempts to remove the catheter. We report at least weekly, the catheter days for all catheters on each unit and now we report the average catheter days per unit with a goal for less than 2.0. Reporting the average per unit has resulted in a decline with the catheter days and foleys being removed sooner.

Conclusion

Originating in international public health projects, positive deviance has been embraced to improve quality and safety in healthcare organizations. Healthcare professionals need more sincere and constructive praise, and a positive message to balance the extensive criticism they receive. Attention being placed on the positive aspects and the good outcomes can put more emphasis on safety than just the recognition of the negative outcomes. People in general like to be “on the good list” and recognized, which positive deviance also supports.

References

American Nurses Association (ANA). (n.d.). ANA CAUTI Prevention Tool. Retrieved from https://www.nursingworld.org/practice-policy/work-environment/health-safety/infection-prevention/ana-cauti-prevention-tool/

Connor, B. T. (2018). Reducing catheter-associated urinary tract infections. Retrieved from https://www.americannursetoday.com/wp-content/uploads/2018/02/ANT_BestPractices_CautiPrevention.pdf

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