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Atlanticare Regional Medical Center
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Collaborative Interventions Reduce Bloodstream Infections in an Outpatient Hemodialysis Center

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The AtlantiCare Regional Medical Center Bruce A. Eidelson, MD, Dialysis Unit is a 12-station hospital-based outpatient center serving end stage renal disease patients in the Atlantic City, NJ region.


In 2008, US hemodialysis patients had 37,000 bloodstream infections (BSIs). End stage renal patients face a BSI risk 100 times higher than that of the general population. Renal disease sufferers may increase 150% by 2020. The CDC calls BSI prevention a national priority.

The Positive Deviance Approach

The Center joined the CDC Hemodialysis BSI Prevention Collaborative in 2009 and used several strategies, including skin antisepsis and hand hygiene surveillance, but hadn’t reached the goal of fewer than one BSI per 100 patient months. In 2010 AtlantiCare leaders added Positive Deviance (PD) to engage all staff in prevention.

  • Six staff members were trained in PD. They guided discussions and helped colleagues identify barriers to adherence and enact solutions.
  • All employees reported renewed urgency about prevention after hearing a patient infected elsewhere describe her pain and fear and ask, "What did I do to deserve this?”
  • Before introducing PD, prevention adherence fostered by an in-service or skills fair would quickly decline. After PD, infection prevention behaviors were consistently maintained in the upper 90% range, and new improvements, such as involving patients in their own care, continued.


Staff identified shift changes as riskiest times for infection. As individual patients finished treatments, new patients entered, often waiting while disinfection regimens were hurriedly performed. Staff designed a new procedure: all stations were cleaned and disinfected at the end of each treatment, and patients entered stations at 5 AM, 10 AM and 3 PM. Wait times—which annoyed patients—were reduced and cleaning was more thorough.

  • BSIs dropped from 2.04 per 100 patient months pre-intervention to 0.75 after the Collaborative interventions and to 0.24 after the addition of PD.
  • Only one access related BSI occurred during the final 12 months of the intervention.
  • Before PD, front line staff viewed infection prevention personnel as adversaries. After PD, they were viewed as helpful colleagues.
  • Network maps showed growing connectivity and information flow, with more people enacting new prevention ideas.
  • The dialysis unit became the self-described "poster child for hand hygiene.”
  • Employees urged each other and visitors (including regulators from external agencies) to follow prevention practices.

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