Tuesday, March 30, 2010

VAP: Do you know it when you see it? (Again!)

There's a new paper on the utility (or lack thereof) of CDC's definition of ventilator-associated pneumonia. In this study 4 persons reviewed 50 cases of ventilated patients with respiratory deterioration >48 hours after intubation. Two reviewers were experienced infection preventionists who applied the CDC definition. A third IP used a modification of the CDC definition that was more quantitative, and the fourth reviewer was a physician board-certified in infectious diseases and critical care who used clinical judgment to define VAP. Using the standard definition, one IP assigned the VAP diagnosis to 11 patients and the other, 20 patients. The IP using the modified definition assigned 15 cases as VAP. The physician diagnosed VAP in 7 patients. The IPs agreed on 62% of cases (kappa=0.40). All 4 reviewers agreed on the VAP diagnosis in only 4 cases. This is not the first study to show how complex assigning the diagnosis of VAP can be.

Given that public reporting has raised the stakes to high levels, the CDC can no longer ignore this issue. Consumers cannot make choices on where to receive care if inter-hospital comparisons of infection rates are not valid. There needs to be a convening of IPs and hospital epidemiologists who use the definitions on a daily basis to thoroughly assess each of the HAI case definitions and begin to work on the development of new ones that will be fair to hospitals and helpful to consumers. Otherwise, it's garbage in, garbage out, and the entire concept of public reporting is undermined.

Monday, March 29, 2010

"Lessons of a $618,616 death"

I arrived at the gym tonight with nothing to read. Given that 30 minutes on the bike can seem like eternity, I went to check out whatever was left behind by those smart enough to bring along some reading material. I found only two recent but ragged magazines--BusinessWeek and Entertainment Weekly. My heart sunk--I was facing eternity on the bike. Then the BusinessWeek cover caught my eye: Lessons of a $618,616 death. The cover story was written by Amanda Bennett about her husband, who died after a 6-year struggle with kidney cancer. After his death, she read all 5,000 pages of his medical records, analyzed every medical bill, and tells the story of his illness in an incredibly honest way. She describes some of the fundamental flaws of the US healthcare system, the bizarre workings of the insurance industry, the moral hazard of having good insurance, and the desperation of the terminally ill that leads to a spare-no-expense mentality even when the odds of success are very, very small. In the end, she feels guilty about the fact that the resources spent on trying to save her husband could have vaccinated a quarter million children, yet she admits she would do it all over again. The entire article can be read online here. It's a must-read.   

Another tremendous hand hygiene video

Here is the video that Andreas Voss showed at the Decennial. This fun and informative piece, produced by the group in Geneva, may appeal to the more artistically inclined healthcare worker.

Sunday, March 28, 2010

Cover that stethoscope!

We have placed a great deal of emphasis on hand hygiene in the healthcare setting over the past few years, but unfortunately little is said about the stethoscope. Found hanging from almost every doctor's neck, the device is used many times in the course of a day, but most physicians seldom wipe it down. Studies have shown it to be contaminated with common pathogens. So I was excited to see an article in the Boston Globe about Dr. Richard's Ma invention, a disposable plastic cover (shown in the photo). Do you think physicians are any more likely to use the cover than wiping the stethoscope down?

Photo: David Ryan, Boston Globe

Saturday, March 27, 2010

Bundle up!

The New York Times is confirming that Don Berwick, president of IHI, is going to be named the new director of the Centers for Medicare and Medicaid Services. I recommend this thoughtful post by Dr. Bob Wachter on the appointment. As Bob points out, Don is very much on the "just do it" side of the equation regarding infection prevention and other patient safety issues, and his fame has arisen in large part from his amazing charismatic appeal. How this will translate into infection prevention policies at CMS is anyone's guess.

Religion vs. infection control: an update

We've blogged before about Muslim women who are healthcare workers in the UK facing disciplinary action for refusing to follow "bare below the elbows" on religious grounds. Now the National Health Service has made a concession: these women can now wear disposable sleeves with elastic cuffs when they have contact with patients.

A year in the blogosphere

Today the blog celebrates its first birthday! It's been great fun for all of us and we thank our readers. At the Decennial Meeting last week, we were stopped by many who just wanted to let us know they enjoyed following the blog.

The hottest topics of the year were (in order, based on the number of postings):
1.  H1N1 influenza
2.  MRSA
3. Active surveillance
4. Public reporting of healthcare associated infections
5. The role of white coats and clothing in infection prevention

Interestingly, the number one topic, H1N1, wasn't on our radar screen when the blog started a year ago, but it appeared suddenly and held our attention for most of the year.

According to Caslon Analytics, "the average blog has the lifespan of a fruit fly," with 60-80% of blogs not surviving past the first month. Of those blogs that survive past day 1, the average lifespan is 126 days. So, I guess we've beaten the awful odds of blog neonatal mortality.

As always, we invite you to post your comments.

Friday, March 26, 2010

New studies on alcohol-based hand sanitizers

There are two new studies on the use of alcohol for hand hygiene. Antimicrobial Agents and Chemotherapy has a study from the University of Virginia in which volunteers had their hands inoculated with rhinovirus followed by hand hygiene. Water alone removed the virus from 12% of study subjects, soap and water was 31% effective, and alcohol was 81-87% effective.

In the second study, just released by BMC Infectious Disease, researchers found that with the use of alcohol foam, the larger the volume applied, the longer it takes to dry. Makes sense. But the investigators found that the volume of alcohol that would dry by 30 seconds was only slightly better than water alone in removing E. coli that had been inoculated onto the hands. So more is better; a little dab won't do ya.

Thursday, March 25, 2010

Chalk one up for the bed sitters

The BMJ has a great essay on the UK's recent prohibition of sitting on patients' beds. Written by Iona Heath, a general practitioner, this piece takes to task a bizarre series of rules to improve infection control in British hospitals. She writes: 
This ban on sitting on the bed seems to be imposed without exception even for patients who are known to be dying. How and why has this happened? Infection control is clearly a subset of "health and safety" but needs to guard against taking on too much of its rhetoric and public face, which is increasingly characterised by its lack of humanity, common sense, and even humour.

Wednesday, March 24, 2010

Universal MRSA screening in Newborns

We are all just digging out of our email (and other) piles created while spending a week in Atlanta at the Decennial. In doing so, I just came across this abstract (or here) that I must have missed while there. I found the economic evaluation interesting. Researchers at Loyola University completed a study on 2031 newborn-mother pairs during a 21-month study. The study only detected four positive neonates and 3 positive moms. The testing cost their health system $40,000/MRSA detected. Of note, the authors suggested that this level of cost was not cost-effective but it is pretty clear they didn't using the US Panel for Cost-Effectiveness (1996) criteria to make such a claim.

While this does seem like a lot of money to pay to detect an MRSA colonization, what it really points out is that these types of studies shouldn't be used to make any medical decisions. The main reason is that unless the hospital you work at has the same population prevalence of MRSA colonization, the results can't be applied to your hospital. Even the much talked about cluster-randomized trials are basically useless for informing medical decisions around what is the best method to control transmissible infections in a specific setting. That is of course, unless these trials intervene in 30+ hospitals that are similar to yours, which isn't going to happen. There's just too much variability between hospitals in terms of size, length of stay and MRSA prevalence. The only way to properly analyze MRSA transmission and prevention is through the use of mathematical simulation models which allow for variable hospital characteristics and MRSA prevalence. If these models use the best available data, they could greatly inform medical decision makers.

Tuesday, March 23, 2010

Defining our way to zero?

Here is a quote from an Emerging Infections Network post today, regarding how we define central-line associated bloodstream infections (CLABSI):

Is it really worthwhile to adjudicate blood stream infections in patients with central lines as "primary" or "secondary"? The adjudication according to the "definition" is still subjective. For example, a Klebsiella bacteremia in a pt with a PICC and PEG was ascribed to "gastroenteritis" since the pt had some coincident diarrhea and stool fecal leukocyte+ (hence bacteremia was considered secondary). A candidemia was attributed to pneumonia since the pt was immunocompromised (on steroids for BOOP), had a fluctuating CXR and had Candida in his sputum (hence the candidemia was considered secondary). I was told that these attributions were completely reasonable since they were compatible with the definitions and that the institution regularly passes muster when audited. It is distasteful to argue but anyone looking closely would see a discrepancy between the clinical diagnosis and the adjudicated diagnosis. Since the public is taking these numbers seriously, there is a problem.
This EIN post goes to the heart of a very important issue in healthcare associated infection reporting—the subjective interpretation of National Healthcare Safety Network (NHSN) definitions. Of course we already know that ventilator associated pneumonia (VAP) rates are a load of crap (I’ll leave it to Klompas and Platt to explain why). It is less well recognized how much fiddling is going on with the CLABSI definition. The post above is a great example of what is happening across the country in hospitals that are under increasing pressure to “get to zero”, and as public reporting of infection rates becomes the norm rather than the exception. Hence those hospitals that apply the NHSN CLABSI definition very strictly are punished with higher CLABSI rates. Meanwhile, hospitals celebrating “zero” rates may in fact be no more “safe” than before they began fudging their definitions.

How to fix this? Either via an expensive and cumbersome validation system for public reporting (any ideas for CDC and state public health departments on how to do this?), or via more specific definitions from NHSN.

Monday, March 22, 2010

Aneurin Bevan

"... no society can legitimately call itself civilized if a sick person is denied medical aid because of lack of means."
—Aneurin Bevan, In Place of Fear

I suspect many in the US will have never heard of Aneurin Bevan. I recently came across his name while reading the obituary of Michael Foot. In the wake of England's Labour Party landslide victory in 1945, Bevan was appointed Minister of Health, charged with starting the new National Health Service and asked to solve the nation's housing shortage. He was the youngest member of the cabinet. His "National Health Service Act of 1946" did not come into force until July 1948 after great fights with the conservative party and a showdown with the BMA.

It has been interesting to read the postmortem stories and talks of battles ahead. What I'm struck with are the similarities and differences between Britain's fight in 1945 and ours. Tough economic times, major housing issues (bombs vs foreclosures), landslide victory for one party and the long duration of the battle for universal coverage. At the same time, England's left nationalized healthcare and ours maintained a free-market system which will now be challenged by the "free-market" right. Oh, well. It hasn't even been a year...or has it been 65?

Wednesday, March 17, 2010

More on contaminated neckties

A new study from Ireland of 95 doctor's ties found that 18% had pathogens recovered when cultured. S. aureus was recovered from 10 ties (8 of the isolates were methicillin resistant), gram-negative bacilli were recovered from 10 ties, and 3 ties had both S. aureus and gram-negative bacilli. The doctors also completed a survey, and 81% reported they would be happy not to wear a tie.

So to recap, we have an article of clothing that serves no function, is commonly contaminated with pathogens, and many doctors don't want to wear them. I think it's time to kill the necktie.

New rule: No sitting on the bed

I've blogged several times previously about some of the unusual infection control regulations in the UK. These include the banning of Christmas decorations, aquariums, and fresh flowers. Now the Brits have a new rule: no visitors or healthcare workers can sit on the patient's bed. I think it might be easier to place each patient in a hermetically sealed container.

Tuesday, March 16, 2010

Decontamination: not so selective?

Remember the NEJM study from the Netherlands that compared selective digestive decontamination (SDD) vs. selective oropharyngeal decontamination (SOD) vs. placebo for infection prevention in ICU patients? The upshot, using 28 day mortality as an endpoint, was that both SDD and SOD were beneficial, but there was no evidence that one was better than another.

These investigators have now published a report on changes in antimicrobial resistance after the prophylactic use of antibiotics in this study (tobramycin, polymyxin E and amphotericin for oropharyngeal (SOD) or nasogastric (SDD) administration, and 4 days of IV cefotaxime (SDD)).

Surveillance of rectal and respiratory tract samples from patients in the 13 participating ICUs demonstrated that resistance to ceftazidime, tobramycin, and ciprofloxacin increased in GI tract flora after the SDD intervention and increased in respiratory flora after both SDD and SOD interventions.

I have to read the fine print more closely, but this confirms my view that we should stick with chlorhexidine oral care to suppress oropharyngeal flora, rather than SDD or SOD approaches that use therapeutic antibiotics.

The well-dressed surgeon

AORN, the Association of periOperative Registered Nurses, has developed new draft guidelines on surgical attire available for public comment. The document can be viewed here.

Some highlights:
  • Fresh scrubs are to be donned on entry or re-entry to the OR
  • Hands should be washed prior to donning scrubs
  • Surgical scrubs should not be laundered at home (believe it or not, some hospitals do not currently provide laundered scrubs to OR personnel as a cost-savings measure)
  • All undergarments must be covered by the scrubs (e.g., no crew neck t-shirt or turtleneck with v-neck scrubs)
  • Shoes with holes on the tops or sides (i.e., traditional Crocs) are not permitted

Monday, March 15, 2010

Safe Patients, Smart Hospitals

I had some beach time last week so I read Peter Pronovost's new book, Safe Patient, Smart Hospitals. It's the story of his journey in patient safety, which starts with his father's death, likely hastened by a medical error. Parts of the story are probably familiar to those who work in infection prevention, but I think it's worth reading.

One of the major points he makes is that the checklist, while important, can really only work when the hospital unit embraces a culture of safety. An aspect of the book that I particularly liked is his criticism of some of the work in quality improvement because measurements lack validity. Like Pronovost, I've been accused of trying to do research by QI folks, when all I was asking was to measure a process or outcome accurately and precisely. He also points out how often ego gets in the way of doing the right thing. Over and over, I kept wondering why change is so difficult in  hospitals even when the data for a new intervention are compelling. And he reinforced my belief that infection prevention, like many other aspects of patient safety, is all about high levels of compliance with simple practices.

Unfortunately, I suspect that Dr. Pronovost is preaching to the choir. Those who might benefit most from his words are least likely to turn the pages of this book.

Saturday, March 13, 2010

Patient safety education: Let's get it started!

I just reviewed the new white paper, Unmet Needs: Teaching Physicians to Provide Safe Patient Care, which outlines recommendations on incorporating patient safety concepts into medical education beginning at the start of medical school. Moreover, it even calls for incorporating questions on patient safety into the MCAT, and assessing medical school applicants for interpersonal skills that promote patient safety. We know that it's too late to begin teaching patient safety after medical school graduation, and it's too important for an incremental approach.

Thursday, March 11, 2010

Herd Immunity in Influenza

Mark Loeb and colleagues have produced another fine study. They report in JAMA the results of a cluster-randomized trial where they vaccinated children aged 3-15 in 49 small communities in rural Canada. Children were vaccinated with either inactivated trivalent influenza vaccine or hepatitis A vaccine as a control. Confirmed influenza (RT-PCR) was 61% lower in non-recipients in the communities where children were vaccinated (3.1%) compared to non-recipients in unvaccinated communities (7.6%). Their main conclusion was that "a significant herd immunity effect can be achieved when the uptake of vaccine is approximately 80% in clusters in which children and adolescents aged 3 to 15 years are immunized." One note: this study was completed during the 2008-2009 season.

Wednesday, March 10, 2010

CLSI steps into the MRSA surveillance arena

The Clinical and Laboratory Standards Institute (CLSI) is “a global, nonprofit, standards-developing organization that promotes the development and use of voluntary consensus standards and guidelines within the health care community.” The guidance produced by CLSI is widely respected and adopted as a standard in clinical laboratories. I was interested to see that CLSI has now completed a document devoted almost solely to MRSA screening! See here for sample pages. The document was developed to “provide infection preventionists...with the latest information regarding the development and implementation of a successful MRSA surveillance program.”

Check out the author list on the third page, filled with experts in various aspects of MRSA detection and control.

Now ask yourself these two questions:

How many on the above list are (or have ever been) actual hospital epidemiologists or infection preventionists who do not have blatant conflicts of interest with the makers of rapid MRSA detection tests (e.g. research funding, honoraria, employee)?

I count two (Dr. Salgado, who trained under Barry Farr and is a longtime proponent of active MRSA screening, and Dr. Weber).

How many are employed by companies that produce rapid MRSA detection tests and therefore stand to reap millions from widespread MRSA screening?

I count four, including the Medical Director of Diagnostics at BD-GeneOhm, the Senior Director for Scientific Affairs at Cepheid, the Director of Government Affairs at Cepheid, and a product manager for BD-GeneOhm.

I look forward to reading the full document—I hope it is more balanced than the abstract, which flatly states that active surveillance + contact isolation reduces MRSA transmission (Really? Does it always? Is it necessary?).

ADDENDUM: I reread this post this morning, and realize it comes across perhaps more harshly than I intended. I believe CLSI is a great organization--I am a proud participant on their antifungal susceptibility testing subcommittee. I also understand the need to involve industry in the development of these standards, for several reasons. I further believe that a guide to implementation of an active surveillance program could be quite valuable. Heck, Mike and I wrote one a couple years ago, but didn't focus on the detailed lab issues the CLSI guidance does.

What I meant to convey in my post was the now-pervasive influence of industry in infection prevention. It is simply a fact that diagnostic companies stand to reap great profits from a move to “universal” MRSA screening. This inevitably leads to lobbying for legislative mandates, funding of speakers and “opinion leaders”, and representation on expert panels, etc. This isn’t new, the conflict of interest issue is pervasive in medicine.

Monday, March 8, 2010

You're Fired!

Those are the two words that hospital epidemiologists everywhere wish they could say to non-compliant healthcare workers. At least it's one of my dreams. According to a story in the Philadelphia Inquirer, if you're the lucky infection preventionist at Abingdon Memorial Hospital in Pennsylvania you can actually say that to clinicians that don't wash their hands on room entry and exit. After several years of trying to improve compliance with education and constantly retelling a tragic story of a patient's death from MRSA (the mother of one of the hospital's primary care physicians), they were able to improve hand hygiene compliance from 31% to a plateau of around 80%. With this improvement they report reductions in CLABSI, VAP and SSI but not UTIs.

However, they weren't satisfied. Their new plan is to give index cards to compliant staff that make them eligible for a raffle (carrot). What do non-compliant individuals get? The same cards but with a message that they have one strike against them (stick). If they get three strikes, they will receive a letter that their reappointment is conditional and they might lose their job. It will be interesting to see if compliance improves and if anyone is fired. I suspect the observers may be hesitant to give out that third strike, but I hope not. I also hope my title doesn't infringe a Donald Trump trademark.

Sunday, March 7, 2010

Transplantation associated rabies

There's an interesting and disturbing report in Clinical Infectious Diseases that describes the transplantation of organs to six recipients from a donor with undiagnosed rabies. The donor was a 26-year old woman who presented with an encephalitis-like picture and negative testing for the usual causes of encephalitis. Approximately six weeks post-transplant, it was noted that three of the recipients began to exhibit symptoms similar to the donor. Review of archived brain samples from the donor revealed characteristic histopathologic and electron microscopy findings of rabies. Further investigation about the donor revealed that she had traveled to India where she sustained a dog bite. All of the recipients were treated with rabies immune globulin and vaccine. The two cornea recipients underwent explantation of the corneas, did not become ill, never exhibited any virologic evidence of infection, and survived. The liver recipient also remained healthy and had no virologic evidence of infection; however, it is important to note that he had received rabies vaccine 20 years earlier. The other three recipients (lung, kidney, kidney/pancreas) all died of rabies despite aggressive treatment with the Milwaukee protocol.

A few months ago we blogged about two cases of Balamuthia encephalitis transmitted by an organ donor in Mississippi. Since then, at least one of the infected recipients has died. The common theme here is that both the rabies and Balamuthia infected donors died with undiagnosed encephalitides. While I agree with Eli that a complete analysis of the problem is warranted, I don't agree that actions should wait for the conclusions of such analysis. Interim actions should be taken. It seems to me that at a minimum there should be an immediate ban on transplanting organs from donors with undiagnosed encephalitides in cases where transplantation is not immediately life-saving (e.g., cornea, kidney, intestine, pancreas, musculoskeletal grafts). And where transplantation is potentially immediately life-saving (e.g., heart, liver), full disclosure of the donor's diagnosis and its implications should be made available as part of the informed consent process. I suspect that donors with undiagnosed encephalitides comprise a small fraction of the donor pool anyway, though I appreciate the scarcity of organs for transplantation.

Primum non nocere!

Coming soon: more superbug stories!

The IDSA has been sending blast e-mails to members, asking us for stories about patients ravaged by antibiotic resistant bacteria. The idea is to generate contacts that allow reporters to personalize their stories about antimicrobial resistance. Here is an example of the kind of story they want to see, from today’s New York Times.

Friday, March 5, 2010

I think I got a touch of the rabies, doc…..

Check out the MMWR for an amazing story of “abortive” rabies—a 17 year old girl survived rabies, apparently intact, without even requiring ICU care. She didn’t return for her follow up clinic appointment. I assume she headed off to Vegas after her physicians explained to her just how lucky she was…..

Thursday, March 4, 2010

MRSA Screening Pro-Con

In January, I promised that I’d post a link to the slides from the “pro-con” session on MRSA screening programs I did with John Jernigan at the Remington Winter Course last week. You can find them here—scroll to Thursday at 5 pm. To view the slides, you have to select “read-only” when the pop-up screen appears. I have another such session at the NARSA meeting in Reston, Virginia on Monday, this time with Lance. A summary of that session can now be found here.

Two things interested me about John’s arguments last week. First, he put a lot of stock in the Staphylococcus aureus antibiogram as one measure of success in MRSA control. I have always felt the “% MRSA” reported in an antibiogram is a very poor measure of disease burden. Which unit would you rather be admitted to: the one with 10 S. aureus infections per month, 3 of which are due to MRSA (“%MRSA” = 30), or the unit with 1 infection per month that happens to be due to MRSA (“%MRSA = 100)? Secondly, he argued that “in-hospital” MRSA infection rates were not a good measure of a hospital’s success in reducing MRSA transmission. So even if a hospital can eradicate MRSA infections from its ICUs, it still might be serving as an “amplifier” of MRSA carriage if it doesn’t implement active screening and isolation. The resulting infections, presumably, have their onset after discharge. The problem with this line of argument is the lack of data suggesting that active MRSA surveillance in the acute care setting prevents “community-onset, healthcare-associated” MRSA disease.

Wednesday, March 3, 2010

And the winner is...

Last night we were in Washington to see Dick Wenzel receive the Maxwell Finland Award for Scientific Achievement from the National Foundation for Infectious Diseases. This award recognizes scientists who have made outstanding contributions to the understanding of infectious diseases or public health. Criteria for selection include excellence in clinical and/or research activities, participation in the training of future leaders in the field, and positive impact on the health of humankind.

Those of you who know me know that it's really rare for me to even wear a tie let alone a tuxedo! But it was a great time and certainly a well deserved honor for Dick.

                                 Mike Edmond, Dick Wenzel, Gonzalo Bearman