Could being “deviant” help to eliminate the leading cause of hospital deaths in the United States?

Every year, nearly 200,000 people die during hospitalization, not from the disease or injury that put them in the hospital in the first place, but from VTE — a venous thromboembolism event. This is what happens when a blood clot forms in the deep veins of the legs or pelvis (deep vein thrombosis, or DVT), and then breaks free and travels to the lungs, causing a pulmonary embolism.

To put that figure into perspective, four times as many Americans die each year of VTE than from car crashes. Food-borne illnesses, often much more widely publicized, account for about 5,000 deaths in the United States each year, as opposed to 200,000 for VTE, a largely preventable condition.

Just about anyone who is hospitalized and confined to bed for a period of time after illness or injury is vulnerable, although added risk factors include longer surgeries, age over 40, bed confinement for more than 72 hours, a family history of clotting disorders, and recent pregnancy and delivery. (VTEs are also the leading cause of childbirth-associated maternal deaths in the United States.)

In April, the Wall Street Journal reported that VTEs are fatal about one-third of the time and that the rate of these incidents is on the rise due to an aging and more obese population and an increase in complicated surgeries — yet screening for VTE risk is not common. Only about one-third of patients receive the recommended preventive therapies for VTE, such as blood-thinning medications and special compression stockings after surgery.

To tackle the problem, Medicare began withholding payments from hospitals for certain preventable occurrences of blood clots, refusing to reimburse for DVT and pulmonary embolisms after knee or hip surgery, for instance.

But instead of starting educational campaigns and sending compliance officers around to hold meetings, hospitals looking for ways to improve their VTE screening and preventive measures might look to a “bottom-up” form of quality improvement that, at several hospitals, has all but eliminated another unnecessary cause of death: hospital-acquired infections with MRSA (methicillin-resistant Staphylococcus aureus).

MRSA infected nearly 95,000 people in U.S. hospitals in 2005 and killed more than 18,000 of them. Strategies for prevention of MRSA transmission, such as barrier precautions and strict hand hygiene, are straightforward and well known — but U.S. hospitals have had enormous difficulty in getting them universally adopted. Educational campaigns and quality improvement initiatives have largely failed. Fixing the MRSA problem isn’t about buying a new, expensive piece of equipment — it’s much cheaper and more complicated than that, because it’s about fundamentally changing behavior.

But at six hospitals that recently piloted an innovative approach to intractable institutional problems — known as positive deviance — MRSA rates have dropped to virtually zero. For example, Albert Einstein Medical Center in Philadelphia saw its MRSA infection rate drop by 70 percent between 2006 and 2008. During the same time, the intensive care unit at Franklin Square Hospital Center in Baltimore, Md., experienced a 100 percent drop in MRSA infections, with 0 infections throughout 2008.

What exactly is positive deviance (PD), and how does it work?

PD is based on the idea that, in most communities, there are certain individuals or groups (positive deviants) whose unique approaches to common problems help them find solutions that elude their colleagues. PD uses a process of interviews to identify these people and their successful strategies, and helps them to spread virally through the community — from the bottom up, rather than the top down. Solutions are generated from within, and thus less likely to be rejected like so much foreign DNA.

And they come not just from the ranks of doctors and hospital executives, but from transport workers, cafeteria staff, orderlies, social workers, nurse’s aides and room cleaners. At Albert Einstein, for example, a transport worker named Jasper Palmer became concerned that hospital gowns were overwhelming trashcans and spilling out of disposal bins, ending up on the floor and increasing contamination. So Palmer thought of a new method for disposing the gown, rolling it into the size of a baseball, and pulling his gloves over the gown to contain it. A nurse noticed his approach and spread it around as part of the PD project. In most hospitals, surgical procedures are named after the surgeons who create them; this de-gowning approach was dubbed the “Palmer Method.”

The problem of unacceptably high VTE rates at many U.S. hospitals seems to beg for positive deviance. Much like MRSA, it’s a cause of illness and death that is eminently preventable — and the strategies for prevention are well known. Yet they aren’t being put into practice at most institutions, in part because it all comes down to the people at those institutions to do so.

But with a national push for VTE prevention compliance coming from the Surgeon General’s office, Medicare and the Joint Commission (a national hospital accrediting body), it would seem that the time for a new strategy is here. And to eliminate problems that seem built into their very culture, perhaps every hospital could use a few good deviants.

About the Author

Gina Shaw is the medical writer for The Washington Diplomat.