Saturday, January 30, 2010
Friday, January 29, 2010
Wednesday, January 27, 2010
An accompanying editorial by Titus Daniels and Tom Talbot, both at Vanderbilt, places the new findings in the context of the recent H1N1 'pandemic' and the N95 respirator debate. Importantly they suggest that the benefits seen in both face mask arms of the study may have been secondary to reduced viral shedding from infected mask wearers. They are correct to point out that the Michigan study supports the benefits of hand hygiene and it was also great to see them re-emphasize the importance of annual vaccination, particularly in health care workers, staying home when sick and compliance with proper respiratory etiquette.
Note: Both the article and editorial full-texts are available for free on the JID website; which is very nice for all who don't have a personal or university-based subscription.
Monday, January 25, 2010
The action threshold is the probability of an outcome at which it makes sense to undertake a specific intervention. In this case, how sure do you need to be that white coats or ties are harmful to patients before it's worth banning them? A useful clinical example is the use of the Centor Criteria to diagnosis strep throat (or better to rule it out) based on history and physical and treat with antibiotics without getting a throat culture. Do you really need to be 100% sure they have strep throat before giving antibiotics or is 60% good enough? Of course, before you diagnose someone with HIV or cancer you need to be close to 100% sure you have the right diagnosis because the treatments are so harmful.
In Richard Gross’s book he derived a formula: Action Threshold = Harm/Improvement, where harm is the adverse events associated with the intervention and improvement is how much better the patients are with the intervention compared to without the intervention. If expected improvements outweigh potential harms then the intervention should be considered; the action threshold is the tipping point in modern parlance. All of this flows from the the expected utility model developed by John von Neumann and Oskar Morgenstern, but I digress.
So, how certain do we need to be that removing white coats (or ties or long sleaves) will benefit patients before pulling the trigger on an all out ban? What harm could possibly occur from such a ban? How would this hurt patients - I would say not at all and physicians could certainly find another way to uphold their professional standing. The white coat ceremony didn't even exist prior to 1993 at Columbia University, so how sacred could these stained, unwashed garments really be?
Semmelweis suggested that hand washing could prevent infections and save lives years before Louis Pasteur confirmed the germ theory. How many lives could have been saved if physicians listened to him in the interim? In fact, not enough people even listen now! How bad will we feel if future investigators prove by cluster-randomized trial that white coats harm patients? White coats need to go and when white-coat backers complete the trial showing they are safe and can actually stay clean between patient visits, we can let them back in our hospitals. Until then the burden of proof should be on those that want to keep white coats; use the action threshold and do the right thing.
Sunday, January 24, 2010
An editorial by Andrew Pavia provides a nice balanced summary of healthcare worker vaccination policies and successes. Mandatory vaccination policies have been implemented by several organizations including Virginia Mason Medical Center (Seattle, WA), Hospital Corporation of America, Johns Hopkins Health System, University of Iowa Hospitals, Hospital of the University of Pennsylvania, Children’s Hospital of Philadelphia, and the Department of Defense. Dr. Pavia is right to suggest that influenza vaccination targets should be set at 90% or higher; however, it's unlikely these targets can be widely achieved without mandates similar to what BJC has just described.
Friday, January 22, 2010
Not only is this welcome news for those suffering from C. difficile disease, but it has infection prevention implications—fewer episodes of disease and fewer hospital admissions mean less transmission……
P.S. I also love any treatment that doesn't involve the prolonged use of antibiotics, or the collection and infusion of donor feces....
Wednesday, January 20, 2010
Take note of this quote from Dr. John Jernigan at CDC:
"There are some studies that suggest that programs that have employed active screening have been very effective at reducing MRSA infection rates. On the other hand there are those that have used the strategy and not been so effective. Also there are studies that suggest that MRSA infection rates can be reduced effectively without the use of active screening. It may have to be tailored to local situations and circumstances."I’m scheduled to present a “pro-con” debate with John next month….since I agree entirely with this quote, I’m worried that our “debate” will be very boring.
Addendum: I found the legislation on the interwebs. This is what was submitted, and this is what passed (can you detect the subtle changes?). So the details above must be what the Maine Quality Forum cooked up.
Tuesday, January 19, 2010
I don’t like the “pro-con” format for this issue, because it tends to oversimplify the role of multidrug resistant organism (MDRO) screening in MDRO prevention. If the question is whether screening for asymptomatic MDRO carriage can be a valuable tool in certain situations, the answer is “yes”. If the question is whether every hospital should be forced, by directive or legislative mandate, to screen everyone for a specific MDRO….then, well, my answer is “no”. SHEA and APIC feel the same way, apparently.
Monday, January 18, 2010
Hajo Grundmann and others in Europe have just published a very interesting paper in PLoS Medicine with an accompanying editorial by Frank Lowy. The authors collected MSSA and MRSA samples from 450 hospitals in 26 countries during 2006–2007 and completed spa typing on all of the isolates to determine genetic relatedness. They then geographically mapped the spa types. What they found was the unlike the widely distributed MSSA, dominant MRSA spa types formed distinctive geographical clusters within regions. Check out their interactive map (here). I think this shows that regional efforts will be required to control the spread of MRSA since it appears that it's mainly spread by patients who are re-admitted to different hospitals.
I won't begin to suggest what those efforts should be, but we certainly have multiple potential interventions and a single approach won't work in all places all of the time. However, since JJ Furuno's Archives of Internal Medicine paper a few years ago found that patient self-report of a hospital admission in the previous year detected 76% of MRSA carriers on admission, we have been using this regional spread hypothesis to control MRSA at University of Maryland Medical Center. Instead of obtaining nares swabs on 100% of admissions, we've swabbed only the highest-risk patients (admissions in the past year to any hospital and/or active skin infection) and detected and isolated almost all patients who subsequently developed MRSA infections - saving lives and saving millions of dollars too. Dollars we can spend to reduce CLABSIs or SSIs or another MDRO.
Thursday, January 14, 2010
Wednesday, January 13, 2010
The simplest way to help is to give money to support the earthquake response, to outfits like the Red Cross, Partners in Health, and Doctors Without Borders.
Tuesday, January 12, 2010
Read it for yourself, but the Council of Europe just passed a resolution calling for an investigation into the role of big pharma in the WHO decision to declare a pandemic. An emergency debate is scheduled for later this month…..pass the popcorn, this should be interesting.
Monday, January 11, 2010
In the latest example of this phenomenon, Dr. Bill Jarvis* ignores evidence that MRSA infections can be prevented without active detection and isolation (ADI). For example, he attributes the impressive MRSA reductions in the UK to ADI. Unfortunately for Dr. Jarvis, ADI for elective admissions wasn’t mandated in the UK until March 2009, and still hasn’t been mandated for urgent admissions. But MRSA bloodstream infection (BSI) rates began falling in the UK in 2005, and had fallen 56% by the end of 2008. An NHS website and a recent parliamentary report attribute these reductions to improvements in horizontal infection control practices (primarily hand hygiene and environmental disinfection), not to ADI.
Similarly, Jarvis doesn’t mention the over 50% reduction in MRSA BSI achieved in U.S. hospital ICUs (again, without widespread ADI). Mike will soon report (at the Decennial Meeting) the elimination of MRSA infections from ICUs without ADI. At Dan’s hospital, where only the burn unit performs ADI, the MRSA infection rate (nosocomial MRSA BSI/10K patient days) is lower than the lowest rate achieved by universal ADI in this much-heralded study.*
Jarvis belittles those who believe MRSA infections can be prevented without resorting to ADI as “active resisters and organizational constipators” who have only “emotional” arguments. In doing so he alienates those who share his goal (the prevention of all healthcare associated infections, including those due to MRSA) and who have taken concrete strides to achieve it (he also appears to have forgotten that the largest controlled trial of ADI demonstrated no benefit).
Dan and Mike (joint posting)
*COI alerts: Dr. Jarvis, and five of the eight authors of the Robiscek study, all have documented conflicts-of-interest with makers of rapid MRSA detection tests.
What do you think—“OK” if Pfizer really has no say in the content, or “not OK” because the conflict of interest is inherent in the Pfunding mechanism? (take our blog survey!)
Since this is an infection prevention blog, I’ll pose a parallel example specific to our field: what if Cepheid approached your infection prevention program and agreed to give you a million dollars to put together a year-long series of CME programs on MRSA control…..no strings attached, and you get to choose the speakers and content. Would you take it?
Sunday, January 10, 2010
Results showed that blood culture had a sensitivity of 25% vs. 20% for PCR, a similar negative predictive value (18% vs. 17%), and an area under the curve of 0.63 vs 0.60. Using blood culture as the gold standard, PCR had a sensitivity of 61%. Both PCR and culture detected organisms in 40 patients (38 were the same organism). As far as individual methods, there were 24 organisms only detected by PCR (largely E. coli and Klebsiella) and 52 only detected by blood culture (E. coli, S. pneumo, S. aureus and a large number of CoNS considered contaminants). Six species detected by culture were not in the PCR menu (e.g Listeria, Salmonella).
I think these results speak for themselves. Neither method is perfectly sensitive at this point suggesting that both methods should be used if possible to improve diagnosis. PCR can be quicker and detect additional organisms, but still missed a significant number. Interestingly, blood culture was more sensitive in detecting organisms from patients who had previously received antibiotics (P = 0.06). This is counter to what I would've suspected.
What I really liked about this paper is that it was completed in a way that was clinically useful since they enrolled patients as they presented to the ED and asked the question in the way a clinician would. This was not some convenient sample study which we so frequently see in diagnostic test comparisons. I also liked how they presented the information, giving the sensitivity/specificity, predictive values and AUC. It will be interesting to see if future studies can document a clinical benefit in terms of reduced mortality and length of stay when PCR is added to our diagnostic battery. Finally, I was impressed that this study was completed at all. Enrolling so many septic patients with questionnaires over such a long period of time is no small feat. The authors should be congratulated.
Friday, January 8, 2010
Wednesday, January 6, 2010
There are two randomized controlled trials* about surgical site infection (SSI) prevention published in the New England Journal of Medicine this week. In one multicenter study, investigators randomized 849 patients undergoing clean-contaminated surgery to preoperative skin preparation with chlorhexidine (CHG)-alcohol or povodone-iodine (P-I), using a primary outcome of SSI at 30 days postoperatively. By intent-to-treat analysis, CHG-alcohol use resulted in lower overall SSI rates (9.5% vs. 16.1% for P-I; p=0.004), and lower rates of superficial (4.2% vs. 8.6%) and deep (1% vs. 3%) incisional SSI.
So CHG, which is already preferred for skin prep prior to intravascular catheter placement, and which is being used increasingly to bathe ICU patients, in catheter dressings, and in oral care, should probably also be preferred for preoperative skin prep. CHG for everyone, everywhere!
In a second multicenter study, Dutch investigators screened 6771 newly admitted patients for S. aureus nasal carriage, using real-time PCR. Of the 1251 S. aureus carriers, 918 were randomized to receive 5 days of either nasal mupirocin (2% ointment twice daily) and CHG soap (daily), or placebo. The rate of healthcare-associated S. aureus infections was almost 60% lower in the mupirocin-CHG group (3.4%, versus 7.7% for placebo; relative risk 0.42 [0.23-0.75]. Most enrolled patients were surgical (88%), and most S. aureus infections were SSI (82%). Among surgical patients, the rate of deep SSI was lower in the mupirocin-CHG group (0.9 vs. 4.4%; RR 0.2 [0.07-0.62]).
The implications of this study are less clear, since the relative importance of the two topical therapies (nasal mupirocin and CHG soap) is unknown. Many centers now routinely use pre-operative CHG bathing for elective procedures. Until we know whether screening and targeted decolonization is superior to the preoperative bathing of all patients with CHG soap, this approach should be reserved for high risk procedures (e.g. cardiac surgery, orthopedic implants).
Dick Wenzel wrote a nice editorial about both pieces, and uses the opportunity to make a point we’ve made several times before in this blog: interventions that can be applied to all patients and that reduce all infections are preferred to organism-specific approaches that carry the added expense and logistical difficulty associated with identifying all carriers of an organism.*COI alert: Both studies were industry supported—one by Cardinal Health, and one by grants from GlaxoSmithKline, Roche, bioMerieux, and 3M.
So, there must be another way. A recent article in Harvard Business Review suggests that our brains actually respond to carrots and not to sticks. Discussing work done at MIT by Earl Miller, the article tells how our brains re-wire after rewards and actually work more efficiently towards the rewarded activity but nothing happens after failure. They do clarify that learning does occur after punishment that is severe (a shock) but in QI this would likely occur only if the offender was fired or had a paycheck withheld. Perhaps our hand hygiene dispensers should put forth a few bars of Beethoven's Ninth after each successful use?
Tuesday, January 5, 2010
I was unaware of many of the details of Hawaii's health care system--maybe I should travel there soon to learn more....now would be a good time, given the weather around here lately.
Sunday, January 3, 2010
I suspect we've all made resolutions at some point, but studies show most of us fail to accomplish our goals. I mean, is Lindsay Lohan really going to stick to this? I give her until St. Patrick's Day, but I digress.
In a recent article, The Economist suggests that a major reason for our failure to accomplish our goals is that we have a tendency to procrastinate; no surprise there. We tend to put off unpleasant or costly things into the future. That would be OK if we would stick to a single delay, but it turns out that we are time-inconsistent or “present-biased” and will always put off tough or costly things to the next day. Tomorrow really is always a day away. They reference a paper by O’Donoghue and Rabin.
I suspect this tendency is at the heart of the public health problems we have in the US. When you build a road you have immediate gratification, but the gratification of a well-funded state health department is uncertain and certainly in the future. Perhaps a better example is one I suspect many of us in infection control will soon face: should we push our administration to restock our N95 mask cache that we used to meet the OSHA/CDC/IOM requirement to care for suspected H1N1 cases? Avian flu is still out there and is just as likely to become a pandemic as it was last year.
This issue really concerns me. Even in this mild pandemic, we all saw how quickly the supply chains dried up for critical supplies. However, I suspect that hospital administrators will assume that the next pandemic will be this mild or forget the supply chain difficulties we had. Even more of a concern for me is procrastination. Will they assume that they can delay purchasing N95s for a cache because we just had a pandemic so the next one won't happen soon? They can "wait 'til next year" just like our favorite Cubs fan. The problem is that next year they will wait until next year.
Fortunately, the Economist and authors Duflo, Kremer and Robinson offer a potential solution using an example of why so few African farmers use fertilizer and how this can be improved. The quick answer is that the tendency to procrastinate can be overcome by small upfront time-limited subsidies. This small investment ends up being far less costly than doing nothing or offering a larger subsidy later in the year. What this suggests is that public officials should offer a grant to hospitals who invest in their pandemic cache (mask, antivirals etc) in the next year, but remove the subsidy quickly. This could overcome the inertia to do nothing because of pandemic fatigue or procrastination. Of course, how can we overcome our public officials' tendency to procrastinate? They do have bridges to fix. Thoughts?
Saturday, January 2, 2010
Despite the pains taken by the reporter to present both sides of the issue, I don’t see this as a difficult call. I agree completely with Arnold Relman, former editor of the New England Journal of Medicine:
“[it is] a gross conflict for an official of an academic medical center to be on the board of a pharmaceutical company. If it isn’t stopped, I think the academic institutions are going to lose the confidence of the country and the government…..They will be part of industry itself.”
Number who become infected
Soon there'll be a new user fee from the airlines--$100 for lowest risk of H1N1 infection, $75 for moderate risk, and only $25 for highest risk! But wait, for only $150, your flight attendant will sell you a course of tamiflu. Of course, correct change is appreciated. Oh, I kid the airlines....
For public reporting, hand hygiene compliance is a double-edged sword. Given that hand hygiene is probably the most important measure to reduce healthcare associated infections, measuring it and publicly reporting it should be a high priority. On the other hand (no pun intended), it remains largely unmeasurable. I was interested to know how many observations were performed in the hospitals reported in the London newspaper since the denominators (number of opportunities observed) were not reported in the article. So I went to the Ontario Ministry of Health Patient Safety website, which has several publicly reported metrics for their hospitals (including central line associated bloodstream infection, ventilator associated pneumonia, and surgical site infection rates). There I learned that for hospitals with 100 beds, a minimum of 200 observations is required yearly.
So let's play with some numbers. Let's say that a 500-bed hospital performed 1,000 hand hygiene observations over the course of a year. We'll assume that the mean nurse:patient ratio across the hospital is 1:5, and that on average each nurse has 10 opportunities per hour for hand hygiene. If you do the math, you'll find that for nurses only, there are roughly 9 million hand hygiene opportunities per year in this hypothetical hospital. Measuring 1,000 of those opportunities accounts for one-hundredth of one percent. My conclusion: the hand hygiene compliance rates reported are meaningless. And my advice to the savvy Canadian consumer is to focus on the outcomes measures (infection rates) that are reported.
Unfortunately, at the moment, there's no valid way to measure hand hygiene compliance. Elaine Larson wrote a great review of the literature on methodologies for measurement a few years ago in the Journal of Hospital Infection. I still think it's useful to measure hand hygiene compliance, and the more opportunities observed, the better. And feedback of the data over and over in different ways is key to reinforce the importance of hand hygiene to healthcare workers.
Long story short: inside the hospital, hand hygiene compliance rates have utility. Outside, not so much.
Friday, January 1, 2010
Also, Happy New Year!