Thursday, October 1, 2015

Stewardship, Stewardship, Stewardship

There has been a plethora of antimicrobial stewardship scholarship published these past few weeks. I'm currently on the inpatient medicine service and have even been harassed by the antimicrobial stewardship team (humor), so I only have a moment to briefly highlight three can't miss articles:

(1) Manisha Juthani-Mehta and co-authors just published an excellent JAMA Viewpoint discussing Antimicrobials at the End of Life.  It is open-access (free), so I hope you have a chance to read it thoroughly, but the main points include:
  1. "Evidence-based and goal-directed counseling about infection management at the end of life must be a routine part of advance care planning and treatment discussions between clinicians and patients with advanced illness."
  2. "Clinical algorithms aimed at improving antimicrobial stewardship from an infectious disease standpoint must also integrate treatment preferences when applied to patients near the end of life." 
  3. "To the extent that inadequate outcome data hinder decision making, researchers should consider whether there is adequate clinical equipoise and need to justify a carefully designed randomized trial comparing symptom control and survival among patients with advanced illness who receive antimicrobials vs high-quality palliative care for suspected infections."

(2) Dan Livorsi and colleagues at the Sidney and Lois Eskenazi Hospital and the Richard Roudebush Veterans Affairs Medical Center in Indianapolis just published an important qualitative study in September's ICHE of factors that influence antibiotic prescribing among inpatient physicians (10 resident and 20 staff physicians). I'm happy to add that Dan Livorsi has just joined our group in Iowa City, where he is helping to jump-start our stewardship programs. Key findings of his study include:
  1. "Antibiotic overuse is recognized but generally accepted; 
  2. the potential adverse effects of antibiotics have a limited influence on physician decision making;
  3. physicians-in-training are strongly influenced by the antibiotic prescribing behavior of their supervising staff physicians; and
  4. other physicians’ prescribing decisions are sometimes questioned, but there is limited peer-to-peer feedback or critique."

(3) Nick Daneman and colleagues in Ontario examined antibiotic use and secondary harms in 607 nursing homes housing 110,656 residents in a recent JAMA Internal Medicine. Their findings are quite striking (if not surprising) in that antibiotic use varied from a low of 20.4 antibiotic days to a high of 192.9 antibiotic days per 1000 resident days. Antibiotic-related adverse events were higher in "high-use" nursing homes even among patients who did not receive antibiotics. An interesting finding (for someone in Iowa) was that rural facilities were overrepresented in the highest tertile of antibiotic use (see figure below), but after accounting for other nursing home– and patient-level characteristics, rurality was found to be protective against antibiotic-related harms." Would be interesting to figure out why rurality is associated with higher antibiotic use but fewer harms but my guess is that rural folks are just awesome. Of note, Lona Mody and Chris Crnich published an accompanying editorial that is worth reading.

Thursday, September 24, 2015

Lovin' Contact Precautions (this time in nursing homes)

Contact precautions get very little love on our humble blog. So little in fact, that I've taken it upon myself to be the resident contact precautions fanboy. Just today on rounds, I was waxing sentimental about the poor yellow gowns that protect us from horrible pathogens and how we unceremoniously toss them into the trash after wearing them - we never even say goodbye...but I digress

There is a new study in the September ICHE by Mary-Claire Roghmann and colleagues from the University of Maryland and University of Michigan that sought to estimate the transmission of MRSA from nursing home residents to healthcare workers' gowns and gloves based on clinical activity and resident characteristics (i.e. skin integrity or stool incontinence).  They aimed to determine if there were certain situations where wearing gowns/gloves would be most protective of HCW contamination (and thus reduce MRSA transmission).  The logic - if gowns and gloves are contaminated, the underlying hands would be contaminated if gloves/gowns weren't worn and since no one has ever gotten hand hygiene compliance near 90-100% anywhere, including nursing homes, then gowns/gloves result in cleaner hands and less MRSA transmission. I know, much more complicated than a cluster-RCT, but important data...but I digress again...

RESULTS! Overall, they enrolled 401 nursing home residents from 13 facilities including 113 (28%) who were MRSA colonized. 62% were nasally colonized, 9% were colonized at the perianal skin and 28% were colonized at both sites. There were 954 HCW interactions (median 7 per patient) with MRSA+ patients with a median duration of 6 minutes. Overall, gowns were contaminated after 14% of the interactions and gloves were contaminated 24% of the time. Gown/Glove isolates were identical (Spa type) to patient isolates 89% of the time. Overall, the contamination rate ranged from zero to 24% for gowns and 8 to 37% for gloves based on activity. So as far as hand contamination goes, there were no safe interactions and thus, we wouldn't expect activity-based precautions to be effective. (See figure below)  Significant predictors of glove/gown contamination included dressing, transferring, patient hygiene, changing linens and changing diapers.

As far as patient characteristics, stool incontinence did not modify gown/glove contamination with MRSA, but skin breakdown was associated with higher contamination when healthcare workers transferred the patient, changed their diapers and helped dress the patient.

My interpretation of the study is that if we want to limit the substantial transmission of MRSA in nursing homes, we better up our game. And that game should probably include gloves and perhaps gowns for most of the analyzed patient care activities. Unless we can get hand hygiene compliance up to 100%, we better just learn to love the glove.

Wednesday, September 23, 2015

Will you trade me a CLABSI for a pneumothorax?

There was an interesting new study published today in the NEJM by Jean-Jacques Parienti and colleagues and funded by the French Ministry of Health. The study aimed to compare the rates of catheter-related bloodstream infection and symptomatic deep-vein thrombosis (DVT) in 2532 adult ICU patients randomized to subclavian (N=843), jugular (N=845) or femoral vein (844) sites for nontunneled central venous catheter insertion. Baseline characteristics were very similar across the three groups.

The results are not very surprising with higher rates of infection and symptomatic DVT when catheters were inserted using the jugular and femoral veins compared to the subclavian veins but these were almost cancelled out by a higher risk of pneumothorax when using the subclavian approach. (see figure below).

Here are my thoughts on the paper:
  1. This is a very nice study that confirms the results of prior smaller studies in the field. 
  2. The overall complication rate is low with approximately 97% of catheters in each group inserted safely without a pneumothorax and without infection or DVT. 
  3. When all complications are included, it doesn’t appear there is a preferred site for catheter insertion. However, since hospitals are penalized for infections and not other complications**, there has been a preference for chosing the subclavian site, since it is associated with fewer infections. Unfortunately, the subclavian site had a much higher rate of pneumothorax. 
  4. One important comment that the authors make is that how long the catheter remains in place can greatly increase the rate of infections and blood clots. So, if the doctor expects the catheter to remain in for a short period of time, she might chose a femoral or jugular vein approach to limit the pneumothorax risk, with very little infection or clotting risk since the catheter will be removed before the complication can occur. However, if the catheter is to remain in place for many days, it is probably worth the higher risk of pneumothorax associated with the subclavian site, which only occurs when the catheter is inserted, in order to reduce the long term infection and DVT risks. 
  5. The study sites did not use daily chlorhexidine bathing and did not place chlorhexidine-impregnated dressings at the catheter insertion site. Both of these interventions have been shown to reduce catheter-related bloodstream infections. Thus, these results might not be generalizable to hospitals that use chlorhexidine bathing and/or chlorhexidine dressings. It's possible that either of these interventions or both could mitigate the infection risk rendering femoral or jugular vein approaches safer than they appear in this study.
  6. Overall, it looks like fears of using the femoral vein are exaggerated, especially when you consider the rates of other complications like pneumothorax. It may be that in our efforts to get to zero CLABSI, we're putting patients at higher risk for other complications. Perhaps a more nuanced target of "any complications per catheter inserted" could replace CLABSI as a quality metric?
**Edit: Mike kindly informed me that hospitals are also penalized for iatrogenic pneumothorax through an AHRQ patient safety indicator, which is included in the CMS Hospital-Acquired Condition Reduction Program. Thus, selecting a subclavian site could lower your CLABSI penalty but raise your pneumothorax penalty. Of course!

Sunday, September 20, 2015

“The scandal isn't what's illegal, the scandal is what's legal”

This quote, attributed to Michael Kinsley, is applicable to a very disturbing trend that is having an increasing impact on antimicrobial availability: the acquisition of exclusive marketing rights (usually by small private firms) to inexpensive generic drugs in order to jack up their prices astronomically. The antimicrobials pyrimethamine, albendazole, cycloserine, flucytosine, and doxycycline have all experienced price increases of up to 5000%, and there have been several recent posts on the Emerging Infections Network about how this is limiting availability of these agents for those who desperately need them. 

I hope this NY Times story about the pyrimethamine saga draws more attention to this trend, and leads to some regulatory reforms to prevent this obvious price gouging. Because you-guessed-it, there is nothing illegal about this under U.S. law.

Fortunately, because it engenders bad press when people suffer and/or die due to unavailability of an essential drug, some of these “pharmaceutical companies”* will immediately send out the drug at a reduced price (or even without charge) if contacted by the treating physician. Such saints, these folks are….

*I put that term in quotes, because the company that owns marketing rights to pyrimethamine is founded and run by a hedge fund manager

Saturday, September 19, 2015

Is the white coat needed for identification?

If you haven't read Phil Lederer's piece on the white coat at the Conversation, I recommend that you do so. It is very well written and has stimulated a lot of discussion. One of the take-aways for me is that even among many of those who believe we should ditch the white coat, the one argument that gives them pause is the role of the white coat as a means of identification. This is particularly an issue for women and racial minorities, groups that have been historically underrepresented in medicine.

I have two problems with the argument that the white coat is needed for identification. First, unlike the situation in the 1960s, white coats are no longer exclusively worn by physicians. Members of practically every occupational group in the hospital (with the typical exception of students) may wear a long white coat. It's worn by chaplains, administrative assistants, nurse practitioners, physician assistants, you name it. The white coat no longer signifies that the wearer is a doctor. And we have more specific means of identification. Many hospitals now have large occupation-label tags attached to photo IDs (mine is shown), which should be more effective than the type of coat worn.

The second issue I'll articulate is controversial and will probably get me into trouble, but I think it's an important argument to explore. I'm really bothered when a physician says, "If I don't wear a white coat, patients think I'm a nurse." To feel insulted that someone might think you are a nurse implies what you really think about nurses--that they are beneath you. Would an internist (male or female) feel disrespected if someone thought he/she were a neurosurgeon or the chair of the department? I doubt it. And I've mentioned previously that I've been mistaken for a nurse or respiratory therapist many times when I'm wearing scrubs in the hospital, though less so now that I wear my name tag on my scrub shirt (I used to wear my name tag on my waist band but that's not allowed at Iowa). I don't find being misidentified insulting in the least. I just simply answer that I don't have the keys to the medication room or that I'm probably not the best person to change the ventilator settings.

Several years ago (long before I began thinking about killing the white coat) my wife and I and several other people were at a dinner with a visiting professor. My wife made a comment during the conversation about something medical and he said, “Oh, are you a nurse?” She said quite nicely, “no, I’m an oncologist.” He replied, “I’m so sorry that I asked if you were a nurse.” And she said, “Don’t be sorry! I was a nurse. I loved being a nurse. And if tomorrow I were a nurse again, I'd be very happy.” We discussed that interaction last night. As she reflected on the white coat issue, she pointed out that she thinks it's great when a person is proud of their profession, and how the white coat for many people symbolizes that pride and their achievement of completing a very long journey. For some, it also symbolizes the enormous barriers that they have overcome. But she noted that the white coat should not be used as a symbol of who you are not.

I've come to realize that a physician feeling insulted if someone misidentifies them is yet another negative manifestation of professionalism. We as physicians have been socialized to think that we are elite, that we are at the top of the pecking order, that we are better than all the other people who work in health care. That has been given to us unfortunately by our physician colleagues and is part of our culture.

I don’t want to be (or even appear to be) insensitive. I realize that as a white man I’ll never know what it feels like to be an African American woman. But we are trying to eliminate the white coat for patient safety, which should trump all else. Remember that one of the good tenets of medical professionalism, at least historically, is that the patient comes first. Moreover, we are all called, regardless of race or gender or socioeconomic status, to respect all humans (ahh, humanism!). And to verbalize disdain at being identified as a member of another occupation, in my opinion, is classist and incredibly disrespectful.

Ok, I'll get off my soapbox now and let the arrow slinging begin.

Thursday, September 17, 2015

What can infection control learn from aviation safety?

We all like to believe that we work in a safe healthcare environment - one that is safe for our patients and colleagues. But the truth is, we care more about our own feelings and time than we do about patient and healthcare worker safety. 

We've discussed the white coat "debate" and the contact precaution "debate" many times already on this blog and elsewhere. If you want to see a nice overview of the white coat debate, Phil Lederer has a new post up on The Conversation. Thus, I don't want to get into the specifics too much, but as a reminder, clinicians wear white coats to carry things, stay warm and as part of our professional uniform. As far as contact precautions, we wear them to significantly (clinical and statistical significance) reduce MRSA infections with the majority of evidence suggesting contact precautions prevent transmission of clinically significant pathogens in inpatient settings.

The major barrier is that healthcare workers hate contact precuations (time, inconvenience) and cling to their white coats and no matter how much evidence we provide them through RCTs, cluster-RCTs and molecular epi studies, they will selectively interpret the data within their own subjective reality (ie cognitive bias). So when our patient safety leaders/deciders are immune from scientfic data (ie the BUGG study or the hundreds of studies that show white coats are covered in pathogens), what are we to do? How can we possibly overcome their cognitive bias (which they hide behind by demanding more and more cluster-RCTs)?

The first thing we can do is point them to the patient safety movement's favorite target: aviation safety. In aviation safety, do they require cluster randomized trials before making us put our tray tables up during takeoff or before banning us from sleeping in the aisles? Is their an RCT that proves that only folks 13yo and older can sit in an exit row? The answer is no. Airline safety is built on logic and scientific evidence but not randomzied trials. For example, you could test to see at what age children can open and lift an exit door safely and use that as a cut-off for setting age restrictions in exit rows. Amazing, huh?  The equivalent in patient safety would be the dozens of studies showing that white coats are coated with pathogens and that long sleeves touch patients. With that level of evidence, an airline safety person would ban white coats in 30 seconds. They wouldn't care if it's inconvenient to carry your iPad without a white coat, just like they don't care that it's inconvenient to put your 5 pound laptop away before landing. Common sense prevails in airline safety! It should also prevail in infection control.

So how do we ultimately create a safe healthcare environment? First, we should continue to demand the highest level of evidence and funding for trials that help develop and test new patient-safety interventions. But in the meantime, we need to put our patients first by using the proven tools (contact precautions) and scientifically sound policies (bare below the elbows) that we already have at our disposal. The highly resistant bacterial pathogens aren't going to sit around waiting for a $20 million dollar cluster randomized trial proving white coats harm patients. And even if they did, there would be folks who would find reasons not to listen anyway - it's cold! Just like aviation safety experts do, we should use the best data available and common sense to make for the safest hospitals today and we should also acknowledge how our cognitive biases cloud our decision making.

To have a truly safe healthcare system, we need to put our patients' safety first and not hide behind a lack of cluster-RCTs that may never be done. If we follow the logic of folks clinging to their white coats or contact precaution deniers, we will soon not even have to wash our hands between patients. Wait, we already don't wash our hands you say? Yes - my point exactly.

Sunday, September 13, 2015

Let's degown for good

There's a new paper in the American Journal of Infection Control by Keith Kaye's group at Wayne State. The paper is entitled Degowning the controversies of contact precautions for methicillin-resistant Staphylococcus aureus, and it's a systematic review of the literature on the use of contact precautions to prevent transmission of MRSA in the endemic setting. I'll cut to the chase, so spoiler alert for anyone who doesn't want to know what they found until they can read the paper. The authors concluded that contact precautions does not reduce transmission of MRSA.

Every day in the US there are roughly 500,000 people who are hospitalized. If 5% of those inpatients are isolated for MRSA, there are 25,000 persons isolated daily. That's a lot of plastic, paper and tormented patients and healthcare workers. Based on a previous study that determined that on average 48 gowns and pairs of gloves are used per contact precautions patient per day at a cost of $35, that amounts to 1.2 million sets of PPE daily, with a national daily cost of isolation of $875,000. On an annual basis, that's 438 million sets of PPE at a cost of $319 million. And this results in the generation of 49 million pounds of garbage yearly. In lean thinking, that's a lot of muda