Is hospital design making us sicker - Wait for the RCT?

• Confirmation bias – looking for evidence to support a pre-conceived opinion, rather than looking for information to prove oneself wrong. 

We've written often about cognitive biases and how they influence medical decision making. How else can we explain one colleague demanding RCT evidence before supporting influenza vaccine mandates for healthcare workers while at the same time ignoring the lack of RCT evidence when pushing bare below the elbows?  And what about another colleague calmly supporting influenza vaccine mandates yet slamming bare below the elbows while wearing his professional white coat and demanding cluster randomized trials? Confirmation bias anyone? (note: both of those colleagues have been me at various points in my blogging "career")

We've also written often about hospital design and how it might be changed to improve infection control. On this subject there was a nice editorial in the NYT a few days ago by Dhruv Khullar that linked poor hospital design to excess healthcare associated infections, falls and noise impairing sleep. I've included his paragraph on HAI below.

"It’s no secret that hospital-acquired infections are an enormous contributor to illness and death, affecting up to 30 percent of intensive care unit patients. But housing patients together very likely exacerbates the problem. Research suggests that private rooms can reduce the risk of both airborne infections and those transmitted by touching contaminated surfaces. One study reported that transitioning from shared to private rooms decreased bacterial infections by half and reduced how long patients were hospitalized by 10 percent. Other work suggests that the increased cost of single-occupancy rooms is more than offset by the money saved because of fewer infections. Installing easier-to-clean surfaces, well-positioned sinks and high-quality air filters can further reduce infection rates."

If you click on the links like I did, you'll notice one links to a 2008 JAMA editorial, another to a single hospital, uncontrolled quasi-experimental (before-after) study, another to a cost-analysis based on data from a single ICU, and the last to a 2008 non-analytic literature review. Given how expensive it is to convert hospital space from double (or more) to single hospital rooms and how scant the evidence appears to be, I suggest we consider the opportunity costs of these recommendations. If we won't spend any money on robust hand hygiene compliance programs, why should we support these huge architectural changes? Shouldn't we have more studies that examine bathroom location, copper surfaces, room proximity to nursing stations, lighting, alert systems, etc etc, before we rebuild hospitals that we'll be stuck with for the next 30 years?

Take the case of the beautiful Rush University Hospital that opened in 2012 (image above). I drove by it 3 weeks ago and to my (not) surprise, it was no longer gleaming white but more of a zebra-striped white/grey/black from air pollution. The hospital, I assume, is now stuck with years of cleaning expenses after a marketing/architectural leader no doubt suggested "white=clean=hospital" and will have less money in their infection control budgets. Did someone study white buildings in industrial cities?

Why do we fight over cheap reversible policy changes and not over expensive irreversible changes to our hospitals? I'd much rather support bare below the elbows or even influenza vaccine mandates - programs that can be reversed if additional trial data becomes available - than these hugely expensive, irreversible architectural changes. I'm holding out for better randomized trial data.

image source: TERRA

Watch this video! It will change your life and the future of the world!

The overselling of science can be pretty hilarious when described by John Oliver, yet it infects not just the media but also scientific journals and professional conferences. One of the aims of this blog has always been to question the latest fad sweeping infection prevention nation; see Dan's recent post on ADI for CDI or my talk on public reporting of HAIs. In addition to highlighting the bit at the end of the video that notes the 70% increase in authority that descends upon those wearing a white coat, I've pulled out these quotes for you to ponder:

"Just because a study is industry funded or its sample size was small or it was done on mice doesn't mean it's automatically flawed, but it is something the media reporting on it should probably tell you about." - John Oliver

"I think the way to live your life is to find the study that sounds best to you and you go with that" - Al Roker

What can infection control learn from aviation safety?

We all like to believe that we work in a safe healthcare environment - one that is safe for our patients and colleagues. But the truth is, we care more about our own feelings and time than we do about patient and healthcare worker safety. 

We've discussed the white coat "debate" and the contact precaution "debate" many times already on this blog and elsewhere. If you want to see a nice overview of the white coat debate, Phil Lederer has a new post up on The Conversation. Thus, I don't want to get into the specifics too much, but as a reminder, clinicians wear white coats to carry things, stay warm and as part of our professional uniform. As far as contact precautions, we wear them to significantly (clinical and statistical significance) reduce MRSA infections with the majority of evidence suggesting contact precautions prevent transmission of clinically significant pathogens in inpatient settings.

The major barrier is that healthcare workers hate contact precuations (time, inconvenience) and cling to their white coats and no matter how much evidence we provide them through RCTs, cluster-RCTs and molecular epi studies, they will selectively interpret the data within their own subjective reality (ie cognitive bias). So when our patient safety leaders/deciders are immune from scientfic data (ie the BUGG study or the hundreds of studies that show white coats are covered in pathogens), what are we to do? How can we possibly overcome their cognitive bias (which they hide behind by demanding more and more cluster-RCTs)?

The first thing we can do is point them to the patient safety movement's favorite target: aviation safety. In aviation safety, do they require cluster randomized trials before making us put our tray tables up during takeoff or before banning us from sleeping in the aisles? Is their an RCT that proves that only folks 13yo and older can sit in an exit row? The answer is no. Airline safety is built on logic and scientific evidence but not randomzied trials. For example, you could test to see at what age children can open and lift an exit door safely and use that as a cut-off for setting age restrictions in exit rows. Amazing, huh?  The equivalent in patient safety would be the dozens of studies showing that white coats are coated with pathogens and that long sleeves touch patients. With that level of evidence, an airline safety person would ban white coats in 30 seconds. They wouldn't care if it's inconvenient to carry your iPad without a white coat, just like they don't care that it's inconvenient to put your 5 pound laptop away before landing. Common sense prevails in airline safety! It should also prevail in infection control.

So how do we ultimately create a safe healthcare environment? First, we should continue to demand the highest level of evidence and funding for trials that help develop and test new patient-safety interventions. But in the meantime, we need to put our patients first by using the proven tools (contact precautions) and scientifically sound policies (bare below the elbows) that we already have at our disposal. The highly resistant bacterial pathogens aren't going to sit around waiting for a $20 million dollar cluster randomized trial proving white coats harm patients. And even if they did, there would be folks who would find reasons not to listen anyway - it's cold! Just like aviation safety experts do, we should use the best data available and common sense to make for the safest hospitals today and we should also acknowledge how our cognitive biases cloud our decision making.

To have a truly safe healthcare system, we need to put our patients' safety first and not hide behind a lack of cluster-RCTs that may never be done. If we follow the logic of folks clinging to their white coats or contact precaution deniers, we will soon not even have to wash our hands between patients. Wait, we already don't wash our hands you say? Yes - my point exactly.

When medical-decision making goes awry

There is a very sad case report in today's New York Times that describes a missed case of S. pyogenes sepsis in a 12-year-old boy.  The initial diagnosis of viral gastroenteritis resulted in an ER discharge that delayed therapy.  Our very own Mike Edmond discusses the case in the article.

We've all lost sleep at night since we first started medical school worrying about cases like this.  It's pretty easy to fall into the false belief that we can avoid these misses in the care of our own patients, but sadly we're all susceptible to the frailties of the human mind and cognitive biases.

Some of the biases that I think impacted this sad case were highlighted in a 2010 American Medical News article by Kevin O'Reilly and include:

• Anchoring bias – locking on to a diagnosis too early and failing to adjust to new information. 
• Availability bias – thinking that a similar recent presentation is happening in the present situation. 
• Confirmation bias – looking for evidence to support a pre-conceived opinion, rather than looking for information to prove oneself wrong. 
• Diagnosis momentum – accepting a previous diagnosis without sufficient skepticism. 
• Overconfidence bias – Over-reliance on one’s own ability, intuition, and judgment. 
• Premature closure – similar to “confirmation bias” but more “jumping to a conclusion”

Until diagnostic systems can be designed that can help prevent these biases from intruding on our decision making, sadly these horrible cases might not be 100% preventable.

Batting .400: Baseball Good, Doctors Not So Good

Brian Goldman, an Emergency Medicine physician in Toronto, discusses mistakes in medicine including the causes (e.g. cognitive bias) and the culture of denial that prevents us from openly and honestly discussing and, therefore, reducing the risk of mistakes.  He mentions the VA in the 200+ comments below the talk on the TED website: "The VA has pioneered the widespread use of decision support - including comprehensive use of clinical practice guidelines - to get MDs to consolidate their practice patterns around evidence-based approaches. The result is that VA hospitals are treating patients better and at lower cost."   Link for iDevices: Brian Goldman TED.com

Accentuate the negative

Dan has posted previously on how difficult it is for authors to get negative studies published.  Perhaps this is the real reason why the STAR*ICU study took 4+ years to make it to press.  I suspect that if the study was completed the exact same way that it was but found a benefit for barrier precautions, it would have appeared in press around 2009 or even earlier.  Just a guess.

Mike has posted at least twice on Ben Goldacre and his blog/book called Bad Science (part 1 and part 2).  Ben has a new post in the Guardian that discusses how medicine, academia and popular culture all favor positive, eye-catching and potentially spurious trial results and ignore important negative studies.  His discussion centers around a paper published last year that seemed to provide evidence of precognition - you know it before it actually happens.  That "positive" paper received tons of press, while a new negative study can't see the light of day.  I think this sort of bias plays a large role in infection prevention research - it is so much easier to publish a positive quasi-experimental study showing a benefit than a negative study.  This is why it was so great that after 4+ years of waiting the STAR*ICU study, which was a negative study, was published at the same time as the VA study, which showed a benefit.  This way, we could have a rational discussion with the positive/negative evidence receiving "almost" equal billing.

Ben Goldacre "Backwards step on looking into the future" Guardian 4/23/2011

Happy Weekend: It's difficult to see the whole picture...

...when you are inside the frame.  Framing effect, confirmation bias, anchoring, financial conflicts of interest...you name it. We all live in the same place. The yellow "I" could stand for Iowa, but it doesn't. Who doesn't love Sesame Street?