High stakes metrics and human nature

Eli didn't want to wade into the VA waiting-time crisis, so I'll just do it instead.  Because we’ve covered this ground before. Whenever a metric is tied to a high-stakes incentive or disincentive (monetary bonus or penalty, job security, etc.), gaming of that metric is inevitable. College test scores, crime rates, HAI rates, the dynamic is the same. 

So forgive me if I’m not shocked, shocked, that VA administrators used various ways to game their waiting-time metrics in response to what this NY Times report describes as “pressures to excel in the annual performance reviews used to determine raises, bonuses, promotions and other benefits.” Fudging dates, creating “ghost clinics”, keeping two sets of appointment books—all are being reported to have occurred in some facilities. If you think this is the scandal, you are missing the point. The scandal is that the VA has too few physicians to see an expanding number of veterans needing care (see Eli’s post for more on the trends contributing to primary care shortages).

So I hope lawmakers begin working to fix that problem, once they finish expressing their outrage for the cameras. The VA is an excellent healthcare system, one that matches or outperforms the private/non-VA sector in many measures of care quality and safety. I’m sad that this is getting lost in the current media frenzy—read this piece for a nice counterpoint.

The Primary Care Crisis in Three Wee Little Pictures

I don't intend to cover the current primary care, wait time crisis that's in the news. The topic, of course, is way beyond my area of expertise as a hospital epidemiologist.  However, as I've been reading the news reports, these three "trends" seem to be behind the crisis. There is nothing much we can do about trend #1. However, when you combine an aging population with huge pay discrepancies between primary care (Psychiatry, Internal Medicine, Family Medicine and Pediatrics) and other specialities (trend #2), you have a recipe for a crisis. Trend #3, requires more discussion, but paying more for healthcare over the past few decades doesn't seem to be gaining us more clinicians (the dark red area on the third image - use a magnifying glass if you can't see it).

The Year in Infection Control - 2014 (Part 2)

A couple weeks ago, I posted an excellent summary of the year in infection control given at ECCMID 2014 by Christina M.J.E Vandenbroucke-Grauls. That talk was Part 2 of the session. Below I've posted Part 1 as delivered by Professor Barry Cookson. It was also excellent. Thanks to both for sharing their slides. Enjoy!

Hand hygiene: It's ginormous

An important new paper in the American Journal of Infection Control helps to put hand hygiene compliance efforts into perspective. The authors performed the study in 12 patient rooms in an adult medical ward in a 746-bed teaching hospital. Using video surveillance, they analyzed the number of hand hygiene opportunities using the World Health Organization My 5 Moments framework. The key finding was that there are approximately 72 hand hygiene opportunities per patient-day. Nurses account for 75% of the opportunities, while physicians account for 5%. Care of patients >65 years presented more opportunities than younger patients (80/day vs. 67 for those 50-64 years vs. 64 for those under 50 years). The proportion of opportunities for each WHO Moment is shown in the figure below:

Most hospitals that measure compliance using direct observation are primarily measuring Moments 1 and 5, about 65% of the opportunities. One might argue that these are the two most important moments in terms of overall magnitude of risk, but Moment 2 is also very important from the standpoint of transmission risk per opportunity.

If we assume that 72 opportunities per patient day is roughly the average (ICUs likely more, lower acuity wards likely less), and apply that to my hospital, which had 207,000 patient days last year, I can estimate that we have about 15 million hand hygiene opportunities yearly. This does not include procedural areas or the Emergency Department. Fifteen million is a lot better than my old nebulous estimate of infinitely many. Lord Kelvin would be proud. But it also means that we are directly observing <0.5% of all the opportunities. It's daunting to think that our goal is near perfect compliance with 15 million acts of human behavior, but like any other health-related behavior, change is incremental and reaching the goal typically requires decades of work. Infection prevention is not a pursuit for the faint of heart!

The Year in Infection Control - 2014

Earlier this week, I was lucky enough to attend ECCMID in Barcelona. What a wonderful meeting and amazing city. One of the highlights for me was attending the Update in Infection Control session chaired by Professors Barry Cookson and Christina M.J.E Vandenbroucke-Grauls. Christina has shared excerpts from her talk, which I've posted below. Her talk was great - hope you enjoy. Thanks Christina!

Food for thought...

A few months ago I blogged about a study that explored the biologic plausibility for replacing the handshake with the fist bump from an infection prevention standpoint. Now there's a new opinion piece in JAMA (free full text here) by pediatricians at UCLA, which raises the issue of whether hospitals should become handshake-free zones. The authors propose alternatives to the handshake, such as the hand wave, the hand over the heart, the bow, and the namaste gesture. I suspect that many will scoff at this recommendation, but I think we need to be open-minded and critically look at all potential mechanisms of transmission in the healthcare setting. I find it very interesting how high tech solutions to infection transmission seem to be all the rage, even when they're ridiculously expensive and marginally effective, while very simple potential strategies are quickly dismissed.

Photo: ChristaInNewYork

Meager and unsatisfactory

It’s nice to see antimicrobial resistance featured in a Sunday NY Times editorial—nothing that we haven’t already covered in Eli’s recent post on the WHO report, but worth reading nonetheless. 

If you believe that “you can’t improve what you can’t measure”*, the most disheartening sentence in this editorial about the WHO report is “…few countries track and monitor antibiotic resistance comprehensively, and there is no standard methodology for doing so."

*This saying is a paraphrase of Lord Kelvin, who also said:

“When you can measure what you are speaking about, and express it in numbers, you know something about it; but when you cannot express it in numbers, your knowledge is of a meagre and unsatisfactory kind.” 

“Meager and unsatisfactory” is a great description of the status of our current response to the antimicrobial resistance threat.

Our long and winding road

We issue frequent reminders on this blog about how little we really know about healthcare-associated infection (HAI) prevention, and have called many times for increased support for HAI research. We also enjoy pointing out well-designed studies that help advance the field. So I’m happy to direct you to SHEA’s just-released update on HAI prevention advances and roadmap for HAI research. From surveillance to prevention, implementation and dissemination, this review summarizes our progress-to-date and provides an exhaustive list of research priorities. So read it and get to work!

How does a study become an internet meme?

According to the internet the steps to starting an internet meme are: (1) have an idea, (2) find a picture that reflects what you want to imply and (3) "now this is where the skill comes in."  The first two steps are pretty easy to understand, but I'm currently trying to sort out what step 3 actually means.

For an example of a study becoming a meme witness Maggie Carrel's (geography professor at Iowa) recent ICHE study where she geocoded Iowa Veterans and found that those living near a large pig CAFO where at greater risk for MRSA nasal colonization on admission to an acute care hospital. You can read a bit more about her study in Maryn McKenna's Wired blog post.  I suspect Maryn's writing is where the skill comes in because Maggie's study is now a meme (image below) from PEW's health initiative - Supermoms Against Superbugs. Super.

h/t to co-author Tara Smith for finding the meme.

Gratuitous Hand Hygiene Post: Automated Surveillance Technology

Today, May 5th, is Hand Hygiene Day. If you're looking for links to hand hygiene campaign material, the CDC page is a great place to start. Instead of the usual hand hygiene video or bundle of interventions, I wanted to highlight a recent study our group completed that was just published in AJIC.

The study was led by Melissa Ward, one of Loreen Herwaldt's star research coordinators.  Melissa, spent many months scouring the medical literature for evidence that automated hand hygiene surveillance systems are accurate, effective and cost-effective. After an initial 3,463 article abstracts were identified, she painstakingly reviewed each one to find 42 articles that were original science and evaluated at least one aspect of at least one surveillance technology.  Four types of systems were identified: electronically assisted/enhanced direct observation, video-monitored direct observation, electronic dispenser counters, or automated hand hygiene monitoring systems.

To save you some time, here are the main conclusions from the study: Few articles assessed the accuracy of these electronic monitoring systems and those that did reported "little to no hand hygiene compliance rate differences between direct observation and automated or electronically assisted systems, including electronically enhanced direct observation." However, two studies found differences favoring the automated approach, so we concluded that "more research should be done to validate the accuracy of these systems."

Most importantly there was little evidence that "these systems can improve hand hygiene compliance" and there is currently "limited evidence to recommend the adoption of one type of system or approach as no high-quality quasiexperimental studies, cluster-randomized trials or decision-analytic modeling studies have been completed or published that would allow the comparative effectiveness of system types or individual systems to be assessed."

So what is my gratuitous (second definition: "free") advice: "Facilities should pilot test systems compared to gold-standard, directly observed compliance surveillance before they are widely implemented."

WHO: Antimicrobial Resistance

Last week the WHO released a report covering global surveillance for antimicrobial resistant bacterial pathogens. The report starts off by highlighting the major gaps in knowledge about the magnitude of the MDR-bacterial problem and suggests that the post-antibiotic era is a very real threat. While the levels of resistance in the report are very alarming, the authors also note that worldwide surveillance lacks coordination, so it's likely we're only seeing the very tip of the iceberg.  One interesting aspect of Dr. Fukuda's introduction was his acknowledgment that TB, malaria and HIV have much better surveillance systems and should serve as models for MDR-bacterial surveillance.

The report focuses on "nine" bacteria-drug combinations: E coli vs 3rd gen. cephalosporins and fluoroquinolones,  K. pneumoniae vs 3rd gen. cephalosporins and carbapenems, MRSA, S. pneumoniae vs. penicillin, nontyphoidal Salmonella and Shigella vs. fluoroquinolones and N. gonorrhoea vs. 3rd gen. cephalosporins.

I think the take home point is summed up in the reports Figure 1, which I've pasted below.  No new antibiotic classes since 1987. We can safely say that the bacteria didn't take a 30-year break while we rested on the laurels of the prior generation(s).

The report is 232 pages long, so you have two options if you want to learn more: (1) Head over to the WHO website and read the whole thing or (2) Listen to my 15-minute interview on Iowa Public Radio from last week. Just click on the audio player below or head over to IPR's page and listen there.



For additional reading on the US burden of antimicrobial resistant bacteria:

1) Sievert DM et al. ICHE January 2013 (2009-2010 NHSN Summary)

2) CDC 2013 Antibiotic Resistance Threats Report

MERS: A Primer

Yesterday the CDC reported the first case of Middle East Respiratory Syndrome (MERS) in the United States. The patient is a healthcare worker who flew from Saudi Arabia to Chicago (via London), and then traveled by bus to Indiana, where he is currently hospitalized.

I suspect this is the first of many posts on this topic. In case you have not been following the MERS story, I put together a summary to get you up to speed.

Epidemiology

• Approximately 400 cases have been reported since the first case was reported in 2012.
• All cases have been acquired in 6 countries in the Arabian peninsula, though some cases became symptomatic after travel to other countries.
• The virus (a novel coronavirus) appears to have originated in bats, but antibodies to the virus have been found in camels.
• Transmission dynamics are not completely understood. Human-to-human transmission does occur, and some cases are associated with contact with camels.
• About 1 in 5 cases have been healthcare workers who cared for patients with MERS.

Clinical (excellent reference by Hui et al here)

• The incubation period is 2-13 days (median, 5 days).
• The illness is characterized by pneumonia, which in most cases is severe (80% require ventilatory support).
• Typical cases begin with fever, cough, chills, sore throat, myalgia and arthralgia, followed by dyspnea and rapid progression to pneumonia.
• Severe cases may be associated with ARDS, septic shock and multiorgan failure.
• Fever is almost always present.
• GI symptoms (nausea, vomiting, or diarrhea) are present in 1/3.
• Chest imaging is always abnormal; findings include bilateral hilar infiltrates, patchy infiltrates, segmental or lobar opacities, ground glass opacities and small pleural effusions.
• Routine laboratory abnormalities are variable.
• Mortality rate is ~30%. In fatal cases, median time from presentation to death is 11.5 days.
• Asymptomatic infection can occur.

Diagnostic Testing (detailed instructions by CDC here)

• In the US, all testing is performed by public health laboratories.
• PCR is available for BAL fluid, tracheal aspirate, pleural fluid, sputum, NP/OP swabs, NP wash/aspirate, and serum.
• Antibody testing: acute (first week of illness), convalescent (>3 weeks after acute sample obtained).

Treatment

• No specific antiviral therapy is currently available.
• Treatment is focused on supportive care.

Infection Control and Prevention (CDC guidance here)

• Contact and airborne precautions are indicated for patients under investigation, and suspected and confirmed cases (see CDC case definitions here).
• Eye protection (goggles or face shield) is specifically recommended.
• At this time, there is no available vaccine or chemoprophylaxis.

Photo: Cynthia Goldsmith/Maureen Metcalfe/Azaibi Tamin, CDC.

Urine Trouble (part 2)

I recently blogged about the teenager who urinated in the Portland water reservoir and the decision made to drain 38 million gallons of water in response. Well, the latest news is that Portland officials kind of changed their minds. Instead of draining the reservoir, they will transfer the water to an empty reservoir to be used as a water feature. I'm not entirely sure I get that logic either.

Dallas Songer, the reservoir urinator, seems to have a better understanding of water contamination and its implications than the Portland water experts. Here's what he said in a recent interview:

"Yeah, it's fucking retarded dude. Like, how they can do that? How can they be like, 'Yeah, we're gonna flush all that water.' Dude, I've seen dead birds in there. During the summer time I've see hella dead animals in there. Like dead squirrels and shit. I mean, really, dude?"

Photo:  The British Gazette

Clean Hands Save Lives - and now there's a book to prove it!

As most of you know, 5 May is the WHO World Hand Hygiene Day. This year's campaign is called "SAVE LIVES: Clean Your Hands campaign - ’No action today; no cure tomorrow – make the WHO 5 Moments for Hand Hygiene part of protecting your patients from resistant germs."

In honor of 5th of May and to further promote hand hygiene and the concept "Economy of Peace," French author Thierry Crouzet has authored a book describing the journey of Didier Pittet and WHO in promoting hand hygiene internationally. The book is available for purchase in print or epub and also for free in 6 languages (no Croatian?!). In addition, this group has created a new website/organization called CleanHandsSaveLives.org.

For hand hygiene fans, after you read the late Sherwin Nuland's story of Ignac Semmelweis, this could be next on your list.