Sunday, November 29, 2009

Positive deviance and common sense

When I first heard about “positive deviance” (and learned that research funding was being distributed to study it), I assumed it was a new, high-level approach to quality improvement that I needed to master. But every time I read about it, or asked someone to explain it to me, it seemed very much like common sense…..empower people to change things for the better, then recognize and learn from those who succeed.

So I enjoyed this article about positive deviance from the Boston Globe, loaded with examples (several from healthcare settings). The first sentence of the last paragraph sums it up for me:
“At bottom, positive deviance amounts to simple common sense”

Many of the controversial infection control approaches we discuss in this blog are best understood as the opposites of positive deviance. I’m thinking of legislative mandates and other dogmatic, punitive approaches to infection control (e.g. legislation requiring hospitals to adopt a single approach to MRSA control, mandating an annual vaccine under threat of dismissal, etc.).

Any of you out there who consider yourselves black-belt positive deviants, feel free to enlighten me about its many complexities.

Thursday, November 26, 2009

A low-cost but effective hand hygiene observation program

The December issue of Academic Medicine has a paper that describes UCLA Medical Center's hand hygiene program, which uses pre-health career college students as volunteer observers. The students are trained to use standardized tools and the program yields about 9,000 observations per year. The authors of the paper note that the advantages of the program are that it gives the students experience in the healthcare setting and its low cost ($5,000/year). Disadvantages are the lack of nighttime observations and gaps in observations when the university is not in session. Hand hygiene across the institution has increased from 50% to over 90%. Click here to view the program's website.

At VCU Medical Center we are currently in the third year of our observer program, which also relies on students (undergraduate and graduate). Our observers are paid an hourly wage, which allows us to obtain nighttime observations as well as year-round coverage. Although our program is four times more costly (still a bargain), it yields four times as many observations, and the results in improvement in hand hygiene compliance are very similar to those at UCLA.

Wednesday, November 25, 2009

New Jersey hospital bans neckties

Jersey City Medical Center will now prohibit healthcare providers from wearing neckties. Bowties are still allowed. From the infection control standpoint, I think banning white coats would have a bigger impact, but it's a good start to push healthcare workers to become more cognizant of the role of clothing in infection control.

Tuesday, November 24, 2009

More freaky feedback, please

In a post today on his “Freakonomics” NY Times blog, Stephen Dubner continues the hand hygiene discussion Mike blogged about recently. He highlights a reader comment about “closing the loop” by providing real time reminders to doctors that their hands are contaminated. I agree that providing frequent and timely reminders is a critical part of improving hand hygiene, but I don’t think it is necessary that such reminders focus solely on the presence of microbes….I (unlike some of my colleagues) believe that most physicians have accepted the germ theory of disease, and most also realize that their hands can (and do) carry pathogens that pose risks to patients.

So I think several varieties of feedback will do: adherence rates, infection rates, bedside reminders from patients, families or healthcare workers, the intermittent presence of a discreet observer, any of these will help. It is essential, though, that such feedback be provided as close to the point of care as possible (we all know how effective feedback is when given in a large auditorium or conference room!). And as for the common refrain that we’ll never achieve sustained adherence rates over 60-70%? Wrong. We have plenty of experience now that higher rates can be both achieved and sustained.

Sunday, November 22, 2009

Looking for a flu shot?

If you're wanting to get a flu shot, Google has a great tool--FluShot Finder. Click here, enter your zip code, and you'll get a listing of where the seasonal and H1N1 vaccines are available near you, along with a map. Pretty cool!

Impact of bare below the elbows on hand hygiene

A new study in the Journal of Hospital Infection evaluated the quality of hand hygiene in physicians and medical students using an alcohol based product that contained a fluorescent marker, which allowed for a highly quantitative measure of surface area that was decontaminated. (I'll post a link to the PubMed citation as soon as it's available). Hand hygiene effectiveness was compared between study subjects who were bare below the elbow and those who were not. As might be predicted, there was no difference in decontamination of hands between the two groups; however, decontamination of wrists was significantly better in the bare-below-the-elbows group.

Friday, November 20, 2009

Tamiflu-resistant H1N1

Two clusters of patients with tamiflu-resistant H1N1 infections have been reported today. One cluster is in Wales, and the other is a cluster of 4 immunocompomised patients at Duke University. The Duke cases were nosocomial in origin. Very worrisome....

Move over, MRSA and VRE....

As we’ve discussed here previously, multidrug-resistant Gram negative rods (MDR-GNRs) are emerging in many hospitals as the major MDRO problem. This month’s ICHE has several interesting articles on MDR-GNRs, including another study by Erika D’Agata’s group in Boston on the high rate of MDR-GNR carriage among long term care facility residents (I previously highlighted this study by the same group). The rate of MDR-GNR carriage among residents of this LTCF was twice as high as that of MRSA (23%, vs. 11%), and VRE were virtually absent. There are other studies in this issue on KPC-producers and carbapenem-resistant Acinetobacter (both from Penn), and on Stenotrophomonas maltophilia pneumonia.

I expect (and hope) that the inane MRSA active surveillance debate will become increasingly irrelevant as more hospitals learn they can reduce MRSA without active surveillance, and as they begin facing the MDR-GNR problem….unless, of course, we all assume that the universal active surveillance paradigm is essential to controlling all of our MDR-GNRs as well! Let’s see, now all we need are simple, rapid, sensitive tests that can detect carriage of all known MDR-GNR phenotypes.

Good luck with that!

Thursday, November 19, 2009

Doctors and neckties

Today's Wall Street Journal has an article on the infection control risks posed by doctor's neckties. There's not much new to be learned from this piece, except that there is another hospital in the US in addition to mine that has recommended no ties and bare below the elbows. A CDC spokesman recommends that neckties be thoroughly cleaned often. Hmm...his ties must be made of vinyl.

Wednesday, November 18, 2009

Occupational hazard

The Associated Press reports today that the professional association representing Santa Clauses is requesting high priority status for H1N1 vaccine for its members.

Tuesday, November 17, 2009

I guess we left compassion off the checklist

Dr. Dena Rifkin, a nephrologist at UC--San Diego, has a piece in this morning's New York Times that reminds us that there's more to good hospital care than appropriate documentation and following the myriad rules promulgated by regulatory agencies. She describes the hospitalization of a relative whose care met all the standards but was characterized by inattentive doctors and nurses. As she puts it, we've gone from treating patients to satisfying the system.

She writes:  "As we bustle from one well-documented chart to the next, no one is counting whether we are still paying attention to the human beings. No one is counting whether we admit that the best source of information, the best protection from medical error, the best opportunity to make a difference — that all of these things have been here all along. The answers are with the patients, and we must remember the unquantifiable value of asking the right questions."

This essay is important for those of us who work to improve the quality of health care. As a hospital epidemiologist who has spent an entire career trying to prevent healthcare associated infections, I think it is important to acknowledge that an infection-free hospital stay is not necessarily the be-all, end-all. Infection control is only one component of a successful patient care encounter, and yes, sometimes infection control is trumped by something more important to the patient.

Thanks to Dr. Rifkin for reminding us that even when every box on the checklist is ticked, it's not enough. In 1925, long before The Joint Commission came along, Francis Peabody taught that "the secret of the care of the patient is in caring for the patient." And so it was. And so it is.

Monday, November 16, 2009

More on doctors' attire



Over the past few years, I've become interested in the role of clothing in infection control and how clothing affects patients' perceptions of doctors. Two new studies in the Journal of Hospital Infection examine these topics. In the first study by C.L. Shelton et al, 100 inpatients in the UK were asked to rate the appropriateness of physician attire by examining photographs of mannequins dressed in various ways (e.g., suit and tie, dress clothes with tie but no white coat, dress clothes and tie with white coat, scrubs, jeans). No significant differences were noted except that patients did not believe that jeans were appropriate. The participants were then read the following:  "Scientific studies have shown that disease-causing bacteria can survive on items of clothing. Those items which are particularly prone to carrying bacteria include ties and long-sleeved clothes, as they frequently come into contact with patients." The patients were then asked to repeat their evaluation of attire. Scrubs were then significantly preferred over all types of formal attire.

In the second study by S. Palazzo and D.B. Hocken, 75 inpatients in the UK were surveyed regarding their preferences for physician attire. In this study, there was no educational intervention about clothing and infection control. However, 73% of patients preferred that doctors not wear a necktie and 59% preferred that doctors not wear a white coat. Scrubs were deemed appropriate attire by 83% of respondents. Interestingly, in both studies patients stated that they wanted to be able to identify doctors by their dress.

So what's the take home message? Patients get it--they want what is safest. As I have argued before, the white coat is much more about the doctor than the patient.

Sunday, November 15, 2009

Tunnel vision

The Telegraph, one of the UK's newspapers, reports that hospitals there have so focused on controlling MRSA and C. difficile that infections due to other organisms are being ignored. The article points out that this has occurred because infections due to these two organisms are required to be publicly reported, whereas infections due to other organisms are not. The problem is that the others account for 80% of infections. In a 2004 paper, Martin Marshall et al describe seven adverse unintended consequences of public reporting of healthcare quality data. One of these is tunnel vision--a concentration on the issue being measured to the detriment of other important problems. This could be avoided by adopting a non-pathogen specific approach to infection control, which will reduce infections due to all pathogens transmitted via contact.

Wednesday, November 11, 2009

Genetically engineered viruses, distributed from the air by government officials!

Don’t be alarmed, it’s just the Department of Agriculture’s multi-state oral rabies vaccine program. Targeted to raccoons, foxes and coyotes, it involves spreading bait (fishmeal or dog food) containing hidden vaccine packets. The vaccine is a live recombinant vaccinia virus with a gene encoding rabies glycoprotein.

This MMWR report details the second human case of vaccinia infection from contact with vaccine bait. In both human cases, contact occurred after a dog got into the bait and punctured the vaccine packet. This particular case was pretty scary, given that the infected person was immunocompromised from treatment of inflammatory bowel disease.

A photo of the rash, from the MMWR report:

Swine flu mortality estimate

The New York Times reports this morning that CDC has revised its estimate of deaths due to swine flu in the US at 4,000. The revision now will make the swine flu mortality estimate more comparable to the mortality estimate for seasonal flu, which on average is about 36,000 persons yearly in the US.

Tuesday, November 10, 2009

Swine flu and the blood supply

The Wall Street Journal reports today that blood banks are facing shortages of blood products because blood drives have had fewer donors due to illness from swine flu. On top of that, donors are instructed to call the blood donation center if they develop illness in the few day period following donation and the blood is destroyed.

Monday, November 9, 2009

Puscast

For those of you who have long commutes or other stretches of time in which you need a mental diversion (e.g., aerobic exercise), I recommend Puscast, a bimonthly podcast which reviews the infectious diseases literature in roughly 30-minute segments. You can subscribe for free at iTunes or by going to this website. Puscast is brought to you by Dr. Mark Crislip, an infectious diseases physician in Portland, Oregon. He also writes a blog, Rubor, Dolor, Calor, Tumor, which can be viewed here.

I'll beat a dead horse...

See here for CNN's coverage of the swine flu mask debacle, which is well written and a primer for anyone who hasn't been following the debate.

Friday, November 6, 2009

More on the vaccine maldistribution problem

The Chicago Tribune reports that Wall Street banks have received H1N1 vaccine for their high-risk employees. Now we can all breathe a sigh of relief!

"Not a retraction"....the pushback

Not surprisingly, the lead author of the now-infamous mask study is defending her findings and claiming her data still demonstrate superiority of N95s over surgical masks for protection against influenza. She also claims (as does another IOM member) that this study didn't influence the IOM report.

Really? Dr. McIntyre was a member of the IOM committee, and her recent comments make it quite clear that she long ago decided which mask should be used during influenza epidemics.....to claim that the work her group presented to IOM did not influence the final report is laughable. Us infection control types might not be sharp enough to detect critical flaws in a cluster randomized trial analysis......but we're not stupid.

Mask study FAIL

This is the audio of the IDSA presentation I referred to here.

I'm pretty sure someone has presented data from the same study at ICAAC and IDSA before....but I'm not sure if anyone has ever done so and also changed their conclusion 180 degrees....and in the process influenced a major IOM report that led to a misguided national recommendation for infection prevention that resulted in nationwide shortages of personal protective equipment.
How can a single study do so much damage before undergoing peer review? Yikes.

Thursday, November 5, 2009

Intermountain Healthcare

Here's a preview of this Sunday's NY Times magazine piece on the Intermountain Healthcare approach to improving health care quality, which relies upon standardization and protocol-driven approaches to care.

Posted without comment, both because I haven't finished the article myself, and because I'm on the ID consult service right now--keeping busy seeing patients who for the most part do not fit easily into any diagnostic or treatment protocol.

Wednesday, November 4, 2009

H1N1 infects cat


The American Veterinary Association announced today that a cat in Iowa was diagnosed with H1N1. The virus is believed to have been transmitted from an infected human in the household. The cat has now recovered.

SuperFreakonomics and the hospital epidemiologist

In their new book, SuperFreakonomics, Steven Levitt and Stephen Dubner give us their analysis of why hand hygiene compliance is poor among doctors. They cite the following reasons: the large number of patients that may be seen in a day and how busy doctors are; inaccessibility of sinks, though they note that conveniently placed alcohol-product dispensers are often ignored; perception deficit, that is, doctors believe their compliance is much better than it actually is; and arrogance. Then they put on their economist hats and talk about negative externalities. By this they mean that the doctor bears little risk personally when he or she is noncompliant with hand hygiene and thus the doctor has little incentive to comply. So far, so good. But then they downplay trying to change behavior in favor of solutions that bypass the need for change in behavior (e.g., antimicrobial impregnated products). I think the answer is both behavior change and non-behavioral solutions are required since there aren't enough of the latter to overcome dirty hands. I was particularly happy that they advised doctors to stop wearing neckties to improve infection control (though my happiness is not just infection control related). Also of note, they profile our colleague, Dr. Rekha Murthy, hospital epidemiologist at Cedars-Sinai Medical Center, and her successful program on hand hygiene.

So what's the importance of this? The economists haven't really added any new insights or solutions to the problem of healthcare associated infections. But they clearly will have impact by offering their analysis to the general public. Their previous book, Freakonomics, has sold over 4 million copies, and led to the launching of a blog with a full time editor, and a movie is in the works. How did I learn about their interest in infection control? I saw Stephen Dubner on CNN talking about why doctors shouldn't wear neckties. Interestingly, if you do a Google image search of him, you'll note that he rarely wears a tie.

Monday, November 2, 2009

Never mind!

The same authors who claimed their study results were so convincing that it was no longer ethical to recommend surgical masks for the care of patients with influenza have now admitted that their analysis was flawed, and that their study (when analyzed correctly) shows no difference between N95s and surgical masks for protection of health care workers from influenza transmission (a conclusion now consistent with the JAMA study by Loeb, et. al.).

These data were cited as being of major import in the IOM report, which of course was a major determinant in the CDC decision to stick with N95s for all care of those with ILI during the H1N1 influenza pandemic.

I wasn't at the IDSA presentation where this retraction occurred, but I imagine it involved one of the authors going up to the microphone, meekly stating, "never mind", and rushing off to catch a flight back to Australia.