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

Autoři: Ricky Cohen aff001;  Anat Gesser-Edelsburg aff001;  Arvind Singhal aff003;  Shmuel Benenson aff005;  Allon E. Moses aff005
Působiště autorů: School of Public Health, University of Haifa, Haifa, Israel aff001;  The Health and Risk Communication Research Center, University of Haifa, Haifa, Israel aff002;  Department of Communication, The University of Texas at El Paso, El Paso, Texas, United States of America aff003;  School of Business and Social Sciences, Inland University of Applied Sciences, Elverum, Norway aff004;  Department of Clinical Microbiology and Infectious Diseases, Hadassah-Hebrew University Medical Center, Ein-Kerem, Jerusalem, Israel aff005
Vyšlo v časopise: PLoS ONE 14(9)
Kategorie: Research Article
doi: 10.1371/journal.pone.0222608



Despite 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 findings

Our 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.


The 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.

Klíčová slova:

People and places – Population groupings – Professions – Medical personnel – Geographical locations – Asia – Israel – Medicine and health sciences – Health care – Health care providers – Medical doctors – Physicians – Public and occupational health – Hygiene – Biology and life sciences – Bioengineering – Biotechnology – Medical devices and equipment – Catheters – Psychology – Behavior – Neuroscience – Cognitive science – Cognitive psychology – Learning – Human learning – Learning and memory – Engineering and technology – Equipment – Research and analysis methods – Equipment preparation – Equipment sterilization – Social sciences


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