Background: The literature is replete with attempts to design and promote customized guidelines to reduce infections during the care continuum. Paradoxically, these efforts sometimes result in gray areas where many staff members are unaware of what is required of them, which then leads to confusion, frustration, and uncertainty. We coined the phrase “gray areas” in this context to encompass the variety of situations on the care continuum that are not addressed in the accepted guidelines, and where staff members are unsure of how to proceed.


The purpose of the present study was to characterize the gray areas that were reported by staff and to identify the practices of Positive Deviance (PD) individuals. We define to PD individuals as people who independently develop creative solutions to solve problems not identified by the majority in their community.

Methods: A qualitative constructivist research methodology was used that included personal interviews, observations and video recordings of identified PD practices to enhance infection control. The study was conducted January through March 2018, in two Intensive Care Units (ICU) units at Hadassah Hospital, Jerusalem, Israel. Personal interviews were conducted with 82 staff members from the General ICU (GICU) and Medical ICU (MICU).

Results: The study confirmed that guidelines cannot cover all the different situations that arise during the care continuum and can paradoxically result in the increased spread of hospital infections. Our study found there are numerous individuals who independently develop and implement solutions for gray areas. The creative and practical solutions of PD individuals can address the barriers and difficulties on the care continuum that were encountered by the staff in their communities. For example, inserting a central venous line is a complex practice in the general guidelines, while the PDs provided clear situation-specific solutions not covered in the guidelines.

Volledig artikel gepubliceerd in Antimicrobial Resistance and Infection Control(2018) 7:124

auteurs: Anat Gesser-Edelsburg(1,2*) , Ricky Cohen(1), Adva Mir Halavi(1), Mina Zemach(3), Peter Vernon van Heerden(4), Sigal Sviri(4), Shmuel Benenson(4), Uriel Trahtemberg(4), Efrat Orenbuch-Harroch(4), Lior Lowenstein(5), Dan Shteinberg(6), Asher Salmon4 and Allon Moses(4)

1. School of Public Health, University of Haifa, 199 Aba Khoushy Ave., Mount Carmel, 3498838 Haifa, Israel. 
2. The Health and Risk Communication Research Center, University of Haifa, 199 Aba Khoushy Ave., Mount Carmel, 3498838 Haifa, Israel. 
3. Midgam Consulting & Research Ltd., 7 Metsada St, 5126112 Bnei Brak, Israel. 
4. Hadassah University Medical Center. Ein Kerem, P.O. Box 12000, 9112001 Jerusalem, Israel. 
5. Rambam Health Care Campus, P.O. Box 9602, 3109601 Haifa, Israel. 
6. Bnai Zion Medical Center, 47 Golomb St, P.O.B. 4940, 3104802 Haifa, Israel.

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