Friday, December 31, 2010
Wednesday, December 29, 2010
The physician in me agrees that if the physical exam is of any value, we ought to be better trained to perform it on all patients, obese or not. But the hospital epidemiologist in me asks: how useful is the physical examination, and how often should it be performed in the acute care setting?
Consider what we know about the utility of the physical exam, the efficiency of pathogen transmission by direct contact, and the difficulty of achieving sustained excellence in hand hygiene (not to mention the disinfection of stethoscopes, coats, etc.). Is it wise to encourage multiple potential examiners (medical students, interns, residents, attendings, consulting physician teams, nurses, respiratory therapists) to have such frequent direct contact with acutely ill hospitalized patients?
I have alluded to this issue before, but in the spirit of this blog’s title (controversies), I’ll state the question more directly. Is it time to re-evaluate our physical examination practices in the acute care setting?
Monday, December 27, 2010
Today’s holiday advice: avoid houses constructed of cake and frosting. Assuming you manage to avoid being eaten by a witch, you face the threat of staphylococcal food poisoning. The Illinois Department of Public Health reports that several outbreaks of food-borne illness have been linked to an Illinois bakery with the unfortunate name Rolf’s.
Saturday, December 25, 2010
Dr. Scott Augustine emailed me about this posting and included a video which allows you to visualize the air currents when a forced air warming device is used. It's worth viewing and I think demonstrates plausibility for increased infection risk.
Wednesday, December 22, 2010
The U.S. Department of Health and Human Services just sent me an e-mail announcing two new national awards to recognize success in “reducing and eliminating central-line associated bloodstream infection and ventilator-associated pneumonia.” The awards are co-sponsored by the Critical Care Societies Collaborative.
The announcement states that the awards are intended to motivate. There should already be several potent motivators at work here (e.g. saving lives, reducing lengths of hospital stay and costs, CMS public disclosure requirements, etc.). But if the prospect of getting a plaque and a free trip to Chicago is what your organization needs to get over the hump, then by all means get to work. I’m also in favor of anything that raises the profile of HAI prevention, so it is good to see on that level.
Speaking of raising profiles, there was a very similar award presented at the Fifth Decennial, to recognize excellent team performance in infection prevention. It would have been nice to see SHEA, APIC and IDSA co-sponsoring this, too.
Tuesday, December 21, 2010
The major findings were:
- The hands of the anesthesia provider were contaminated with one or more major pathogens 66% of the time
- Bacterial transmission to the IV stopcock set occurred in 11.5% of the cases, with 47% of the isolates matching those on the anesthesia provider's hands
- Bacterial transmission to the anesthesia machine occurred in 89% of the cases, with 12% of the isolates matching those on the anesthesia provider's hands
Monday, December 20, 2010
So I decided to give it a try. Here I typed in the word "MRSA" and this is what I found:
And here, I added "malaria" (shown in green) to the mix:
So looking at the big picture (at least as far back as 1800), gives us some perspective--perhaps more of a public health view.
Can't you tell that I'm now on vacation and have too much time on my hands?
Sunday, December 19, 2010
Wednesday, December 15, 2010
I hope the timing of the article doesn't impact the bill modernizing the FDA that recently passed in the Senate but has yet to make it to President Obama. 48 million and 3000 are too many, especially in 2010.
Well, there is some good news. We now have more accurate estimates of infections due to foodborne pathogens in the US. When you have better data, you can have a a more modern, risk-based food safety system. This is why Dan and I argued in our recent JAMA editorial that we need a continued expansion of the existing but somewhat limited hospital-infection and MDRO surveillance system in the US.
see also: William Neuman NY Times article
|I wish I could swim like a dolphin|
The comment made in the NY Times article about being higher up on the evolutionary scale is a risk factor for S. aureus attraction to hemoglobin seems a bit dubious. For example, most of us think dolphins are at the highest level of evolutionary ladder and they weren't studied from what I can tell. ;)
NY Times article
Pishchany G et al. Cell Host & Microbe, December 16, 2010
Tuesday, December 14, 2010
Thus, when small 'underpowered' studies actually find an effect, it has to be a very large effect to reach statistical significance. So, small studies report overestimates of the effect.
One thing we know about before-after, quasi-experimental studies, which are commonly used in assessing infection prevention interventions, is that they are underpowered and over-estimate the effect compared to randomized trials. Power is derived from sample size, effect size AND study design, among other things.
QE studies in our field also suffer from publication bias since many have been completed by clinicians who won't go through the trouble of reporting negative studies. How many papers have you read in ICHE/AJIC/CID that mentioned ADI for MRSA not working? Even if ADI for MRSA is the greatest control measure ever, which it might be, given a normal distribution of benefit, you would expect some studies to be negative, would you not? Where are they?
Even, when negative studies do appear (e.g. Harbarth JAMA 2008 or Charlie Huskins hopefully soon to be published STAR-ICU trial) they are often not believed or even thought to be flawed! Why? Nothing works 100% of the time and a negative study is NOT an erroneous result. A negative study is certainly not prima facie evidence of a flawed study. You must use all of the data, assess it based on quality and power and look for publication bias. (this is my advice to epidemiologists of all ages)
So, are we over-estimating the benefits of ADI and other interventions used in infection prevention?
Link: Gelman's post
Gelman and Weakliem American Scientist, 2009 (PDF)
Sunday, December 12, 2010
The validity parameters were as follows:
- Sensitivity 48%
- Specificity 99%
- Positive predictive value 85%
- Negative predictive value 94%
Saturday, December 11, 2010
- Carl Elliott has written a piece on ghostwriting in medical journals (free full text here). He notes that one large pharmaceutical company labelled it's ghostwriting campaign "Case Study Publication for Peer Review." Sounds like a boring campaign name until you look at the acronym (CASPPER). Not so friendly, this ghost, however.
- Megan Mcardle writes about information technology in medicine (or the lack thereof) in "Paging Dr. Luddite" (free full text here).
- An eye-opener by Robin Fields, "God Help You. You're on Dialysis," uncovers problems with quality and safety in outpatient dialysis centers and how little is being done about it (free full text here).
Friday, December 10, 2010
Thursday, December 9, 2010
The NPR article states that the processor costs $64,000 in US but could be $17,000 for developing countries. Tests will cost $17. If you need to do three tests in smear-negative patients to rule out TB with a sensitivity of 90%, it would cost $51. I wonder if developing country budgets can absorb that cost?
Wednesday, December 8, 2010
There is a recent post that covers the topic well in Decision Science News, edited by Dan Goldstein from Yahoo! Research and the London Business School. Try to answer the question below. The answer is available if you expand the post (and if you read the DSN post)
Tuesday, December 7, 2010
There are many potential reasons for this 'decline effect' including publication bias - only publishing positive findings, especially in major or high-impact journals. Dan had a nice post discussing positive outcome bias a couple weeks ago. Another issue might be selective reporting of results by investigators desperate to find strong associations so that they can get published and then get re-funded. Certainly regression to the mean is important - ye olde bell-shaped curve. One thing they don't mention is confirmation bias, which I think drives both NIH funding and publication decisions and could be responsible for some of the reduced effect sizes seen in later vs. earlier publications.
This 'decline effect' is troubling given what it says about the scientific process. One wonders if changes in how science is funded and reported could impact this?
|Iowa is below Minnesota, to the left of Illinois with a large nose|
and small mouth; most consider it the most handsome state.
I also thought that moving to Iowa would limit my exposure to these sorts of transmissible pathogens. It's not like I see people most days; ain't nobody here but us chickens. I even thought Dan was joking about measles and mumps. We have vaccines, we can't possibly have measles and mumps around here! Apart from what people say, I really do think wishful thinking can prevent influenza if we wish REALLY really hard. If even one of us gives up hope - bam, pandemic.
Chicago Tribune article
h/t Mark Vander Weg
Monday, December 6, 2010
Friday, December 3, 2010
Thursday, December 2, 2010
I’m not sure this is big news, as I am not aware of how many states have decided to step into this issue—I had assumed that most would leave it up to each hospital. Maybe someone can enlighten.
I am blogging about this for two reasons. First, and most importantly, because West Virginia is Mike Edmond’s home state (or at least he went to college and med school in West Virginia). Here is a photo of Mike as a child, before he decided to pursue a career in medicine and was more interested in the banjo. Second, I wanted to report that our hospital is now at a 93% influenza vaccination rate without a mandate. If you recall, last year our shiny new mandate went down in flames after SEIU filed an injunction. So I’m especially proud of the fact that our healthcare workers are stepping up to be vaccinated without being forced to do so by threat of termination.
|University of Iowa, Class of 2013|
Example for VAP, NPSG.07.06.01 in Hospitals requires 7 steps:
1) A plan
2) Hand hygiene before/after caring for ventilated patients
3) Semirecumbent position of patient
4) Regular antiseptic oral care
5) Daily weaning assessment
6) Daily sedation interruption
7) Measure VAP process measures and outcomes
Hospital Program draft versions of NPSG.07.06.01 (VAP) and NPSG.07.07.01 (CAUTI) (PDF)
LTC Program versions (PDF)
JC page that provides links for submitting comments.
h/t Marc Wright
- Omission of mechanical bowel preparation
- Preoperative and intraoperative patient warming
- Increased concentration of inspired oxygen during and immediately after the surgical procedure
- Limiting intraoperative intravenous fluid volumes
- Use of wound barriers to protect the surgical wound from contamination during the procedure
The overall rate of infection was 35%. In the control group, 24% of patients developed an SSI vs. 45% in the intervention group (p .003). In multivariate analysis, the bundle was shown to an independent predictor for SSI (RR 2.49, CI95 1.36-4.56).
I was struck by the very high rate of infection in this study, so I looked at CDC's most recent surveillance report, which shows that the mean pooled infection rates for colon surgery depending on risk category ranges from 3.99% to 9.47%. The authors postulate that their case ascertainment may be greater since the study was performed at a VA hospital where outpatient follow-up of patients is much easier to track. However, even in light of that, the rate still seems quite high. But on the other hand, unless there is something very unique about these patients or the care provided at this hospital, you might think that an effective prevention bundle would have even more impact in a setting with exceedingly high infection rates. This raises more concern that the bundle was not just ineffective but actually increased the risk of post-operative infection.
This paper is another example of how immature implementation science remains. I think the authors of this paper are correct to conclude that bundles of evidence-based interventions need to be formally tested before there is wide spread implementation.