Yes we can!

In early 2009, I bought three North Face black vests for myself and my colleagues Gonzalo Bearman and Mike Stevens at VCU Medical Center. Our Infection Control Committee had recently recommended that all healthcare workers adopt a bare below the elbows approach when providing care in the inpatient setting. The vests were good at providing some additional warmth on winter days. We avoided fleece and opted for vests that were nylon on the external surface so that they could be easily cleaned with a disinfectant wipe. We started bare below the elbows with just three people in a hospital with a workforce of 10,000.

We didn’t mandate bare below the elbows and we didn’t aggressively push it. We rolled out an educational campaign with a personal infection prevention bundle that had three components: bare below the elbows, hand hygiene before and after patient contact, and stethoscope wipe down after every patient exam. We talked about it in new employee and new housestaff orientation sessions, always noting that this was a recommendation. We had no support from hospital administration, though no one tried to obstruct us. Importantly, we gave doctors permission to not wear white coats and neckties, and continued to role model the approach as we saw patients. Given how attached some physicians are to their white coats, we knew that a mandate would produce a backlash and doom our plans. Still we got some pushback, but our response to the naysayers was consistent, “You’re not required to do this. It’s just a recommendation.” It's hard for anyone to argue with that.

Here we are a decade later, and this week saw the publication of our results with this experiment in the American Journal of Infection Control. Across 40,000 observed encounters in calendar year 2017, overall compliance with bare below the elbows was 84%. Probably not too surprising, physicians were the laggards at 67%, with most other groups in the high 80s or even 90s. But having two-thirds of doctor-patient encounters occur without the 20-square-foot microbiological zoo (AKA white coat), is pretty damn astounding.

What’s also interesting is that in the prior year, overall compliance was only 40%. In hindsight, we can see that 2016 appears to have been the tipping point as compliance doubled in the ensuing year. Now, bare below the elbows is part of the institutional culture. I have given many talks in the past decade on this topic where I’ve been told repeatedly that doctors will never give up their white coats, but Gonzalo tells me that it is now unusual to see a doctor in a white coat on the wards.

There are a couple of lessons here. We’ve again confirmed that changing behavior in health-related interventions is a slow process (probably even slower when the person whose health is impacted isn’t the person whose behavior must be changed). But more importantly, you don’t have to beat people over the head to make it happen. Provide encouraging messaging, role model the behavior, and let uptake diffuse. Patience is key.

Kudos to Gonzalo and Mike for persisting, and to everyone at VCU in the 84% who stepped forward. When I start service tomorrow it will be 10°F here in Iowa, and though this poikilotherm would like to be bundled in 20 layers, you can bet your bottom dollar that I’ll be bare below the elbows.

A Blogger's Return: Relishing the Wave of Infection Prevention Science

Apologies, Faithful Readers (who do I think I am, Stan Lee (R.I.P.)?).  The day-to-day life of a hospital epidemiologist, IDWeek planner, dad and spouse have pulled me away from contributions to the blog.  But, like a bad rash, I'm back!  I was prompted to post not because of a single study or bit of news but because of a thought I had when I received the TOC for the latest issue of Infection Control and Hospital Epidemiology (Disclaimer:  I am a member of the editorial board but did not review any of the articles in this issue including those noted below).  I was struck once again at the diversity of topics and the increasingly strong science that's being performed in our field.   Makes me happy to be a hospital epidemiologist for sure!  A few highlights:

• A systematic review/meta-analysis examining whether evidence supports use of cefazolin for surgical prophylaxis in hysterectomy.  The authors noted a significantly higher SSI risk with cefazolin vs. cefoxitin or cefotetan (risk ratio, 1.7; 95% CI, 1.04–2.77; p = 0.03) and highlighted numerous limitations with the existing clinical studies.
• A human factors analysis of PPE doffing that identified 103 failure modes with PPE removal (including issues related to the person, the place, the equipment, and the training).
• An analysis of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey data to examine if placement in isolation adversely affected the patient experience (while isolation patients noted worse experience in the general ranking of overall care and in aspects of staff responsiveness, experience was similar in all other domains).
• A thoughtful commentary on defining antimicrobial never events that include inappropriate surgical prophylaxis, use of antibiotics for viral URI, and use of antibiotics for asymptomatic bacteriuria (as my hospital uses a Patient Harm Index of raw events for our quality goals, I love this concept, as it gives antibiotic stewardship some clear measures that fall into that framework).
• Another nice analysis illustrating that claims-based billing code data are not useful to assess infection rates (this time: SSI) when compared to NHSN surveillance gold standard.  Use to rank hospital quality is even stickier, as illustrated by the finding that 65% of hospitals in the best quartile by claims data were ranked in worse quartiles by NHSN data.

And there are so many more excellent studies and manuscripts, so check it out (and keep pushing the IP evidence base forward)!