Lessons from a Pandemic: Part 2

Photo by Volodymyr Hryshchenko on Unsplash

Three weeks ago, I wrote a piece on the lessons I learned from the beginning weeks of the COVID-19 pandemic in Iowa. You can see that here. If any of you feel like I do, three weeks in COVID time seems like a year. It has the feeling of a chapter from Einstein's Dreams. In ordinary time my week has a rhythm to it, with different meetings and activities on different days. Certain nights we go out for dinner. Now, every day is nearly the same at work and after work. It's all COVID, all the time. I sometimes wonder what normal life will be like but it seems so distant that I find it hard to imagine. I know that at some point this will end but it doesn't seem near enough to be real. It's like being in a surreal time warp that could have been an episode from the Twilight Zone. OK, enough weirdness. Here are my latest lessons:

1. Working at home truly increases efficiency. For the first time ever, I worked at home for an entire week. Previously, I had never worked at home for more than a day, and only if I had a project that required intense focus or a need to get it completed quickly. I had multiple Zoom meetings every day and gave four lectures by Zoom. What I now realize is that the many interruptions in my work day, with all the starting and stopping and the re-start after every interruption really reduce efficiency. At the hospital most of my meetings involve a 5-10 minute walk each way and when you have numerous meetings that adds up. And along the way you stop for unplanned chats that increase walking time. I also feel the need to check in with people that I work with and discuss current work issues. That's a good thing, but I now have a better view of how all of this impacts my workflow. 
   
   
2. Medical care doesn't necessarily need to be face-to-face. Last week I had my first telemedicine clinic. I had done telemedicine inpatient infectious diseases consults for small community hospitals in the past but never outpatient clinic. It worked very smoothly. For most patients, particularly those with known problems, auscultation, palpation, and percussion don't add all that much. Once the outbreak is over, it will be interesting to see how many clinic visits return onsite. With advances in technology, patients can have BP cuffs that transmit readings, pulse oximieters, and even wireless stethoscopes at relatively low cost, making good assessment in the patient's home much more achievable.
   
   
3. Determining what is and is not an aerosol-generating procedure (AGP) needs to be thoroughly explored in future research. See these two excellent posts by Tom Talbot here and here to read more about AGPs. 
   
   
4. In times of crisis, healthcare workers' risk tolerance is greatly reduced and risk perception is not always rational. This is natural given all of the information on the outbreak, much of it scary, that comes at us 24/7. There is a cry for zero risk, even though that is likely not achievable. In an effort to advocate for their constituencies, professional societies have added to the anxiety and created more demand for resources that are already scarce, such as testing supplies and personal protective equipment.  
   
   
5. Once and for all, we need to determine the utility of every item of personal protective equipment for various types of pathogens. This will require federal funding to do the needed research. New designs should be evaluated and current PPE improved. 
   
   
6. The focus of infection control and prevention research has been too focused on bacterial pathogens. Looking at journals from the last decade, one can see that most of the papers are focused on drug-resistant bacterial pathogens. These organisms pose little risk to healthcare workers. As above, federal funding will be needed to accomplish the needed work.
   
   
7. CDC has not been helpful by producing confusing information that is not practical, and SHEA and APIC have offered little to no guidance at a time when it is most needed. In contrast, the World Health Organization has produced guidance that is based on sound logic and written in a very clear manner. 
   
   
8. Anthony Fauci is a hero. Where would we be without him? Don't think about the answer to that question. 
   

More to come. Stay safe, everyone!

Mike

  

A Face Shield Strategy to Reduce COVID-19 Nosocomial Transmission

In previous blog posts, I mentioned the implementation of face shields to prevent nosocomial COVID-19 infection. Over the past few days, I have received many questions from people across the country, so I thought it would be useful to pull everything together in a single post and add some details.

Rationale

As we began to prepare for the pandemic, we assessed our inventory of personal protective equipment (PPE). However, knowing current inventory levels alone is not useful. It's deceiving when you see PPE inventory levels of several hundred thousand items. How could we ever run out, right? This is why your inventory levels must be evaluated in the context of normal demand. Your supply chain folks should be able to tell you how many PPE items are normally used on a daily or weekly basis. Next, you need to determine your expected demand for the outbreak. There is no right answer here as there are too many unknowns. You'll just need to make an educated guess. We determined that our critical level of each PPE item was 12 weeks (84 days) at four times normal demand*, although you could argue that this is an underestimate. Next our supply chain group developed an interactive spreadsheet with each row being a PPE item, and columns showing current inventory; normal demand per day; and days of stock at normal demand, two times normal demand, and four times normal demand. The final column (days of stock at four times normal demand) is color coded as follows: red <84 days, yellow 85-111 days, green >112 days (16 weeks). Once this is done, you will likely be surprised to find that what seemed like an abundance is really not so. When evaluating your levels, you also need to consider that some items are on allocation and you can expect to receive periodic shipments, while others are simply stocked out with no promise of future deliveries.

After reviewing all of the above, the most worrisome thing for us was an inadequate supply of face masks (<84 days at four times normal usage). My biggest fear was that we would overuse them early in the outbreak when few COVID patients are hospitalized, then have none after the surge of COVID inpatients arrived. Many hospitals had extended the use of face masks beyond a single patient encounter, which is a reasonable decision in this time of shortage, but we know that face masks lose their effectiveness when they get wet. Some began to use cloth masks, which is also a problem. So I began to wonder whether face masks could be replaced by face shields.

Why face shields?

• They provide greater facial surface area coverage than face masks by protecting all the facial mucosal surfaces from infectious droplets. 
• Given that the eyes are protected, we can eliminate the need for goggles when a face mask is worn. And we know that healthcare workers are really bad at wearing eye protection.
• They prevent you from touching your face. One of the major drawbacks of face masks is that some people will touch their faces even more to adjust the mask and this poses a risk for autoinoculation by contaminated hands.  
• Face shields are durable, can be cleaned after use, and reused repeatedly.
• Many people (myself included) find face shields more comfortable than face masks.
• Communication is better with shields than with face masks as your face is visible to patients and coworkers. 
• If all of your healthcare workers are shielded, social distancing becomes less important.
• And importantly, this is a device that is diversified across other industries. There is greater availability since the medical supply chain is so stressed at this time.  

Are there any disadvantages compared to face masks? The only one I can think of is the possiblity of a droplet coming in an upward trajectory going under the bottom edge of the shield. Although the probability of this is small, this can be minimized by having the shielded healthcare worker flex their neck when standing over the patient (for example, when performing a physical exam), bringing the bottom edge of the shield closer to the HCW's torso. Moreover, when doing a procedure that normally requires a face mask, we recommend that a mask be worn under the shield anyway. 

A few people have asked what is the evidence that face shields can replace face masks, and those particularly inclined toward methodolatry (the profane worship of the randomized clinical trial as the only valid method of investigation) continue to demand that face shields not replace face masks. Do I have evidence? No. To me, this is just plain common sense--we have a product that is reusable, cleanable, covers more of your face, decreases the risk of autoinoculation, and keeps us from burning through our mask supply. We have hospitals in the US where nurses are using bandanas to protect themselves. In this extraordinary time, I can live without a clinical trial.

Implementation

We quickly found that face shields marketed for medical uses were stocked out. One of our pharmacists went to a local hardware store and found shields used for grinding. We then explored vendors that supply hardware and agricultural products (see more here on the purchasing process). In addition, the University of Wisconsin has a great website that includes diagrams for construction of shields, and Johns Hopkins has a "recipe" available that can be used to create 50,000 shields. We placed the Wisconsin diagrams on the hospital website and several manufacturing firms responded that they could fabricate them for us. In addition, we have had some designed and produced by people interested in 3-D printing. One of our physicians, modified the Johns Hopkins' information and has her kids at home making shields. We also placed on our hospital's website a request for donation of face shields that people have at home, and we received many donations. It has really been a community effort. As our supply of shields grows daily, we deploy them throughout the medical center. At this point, the shields are handed off from one worker to the next as their shift ends, but our ultimate goal is for every person to have one for their personal use. 

Here are the instructions we give to our staff on when to use face shields:

• Wear the face shield with every patient encounter (COVID and non-COVID patients) over a medical mask. Think of it as a new component of standard precautions--every patient, every time.
• For COVID patients (confirmed or suspect), if an aerosol generating procedure is being performed, wear the face shield over an N95 respirator.

To help introduce the concept to our workforce, we produced this video:

We still have some details to iron out, such as the best product to clean the shield, since some products damage polycarbonate. We have had some of the shields break, so fabricating replacement shields to repair them is ongoing. 

Lastly, I have had a number of people who want to purchase their own shield ask me which one I recommend. Over the past two weeks, I have tried many models and have become a face shield connaisseur. If you want to buy your own, I think the best is the Uvex Bionic S8510 made by Honeywell (shown in the photo to the right). It is more sturdy than many other models, provides greater facial coverage (extends laterally on the face to your ears), and is comfortable. What really sets it apart is the V-shaped, downward projecting bottom border of the shield. This allows it to sit close to your upper torso, minimizing the risk of upward trajectory droplets. As an added bonus, from a sartorial standpoint, you'll look top-notch in this one! It's the kingdaddy!

This is probably more than you ever wanted to know about face shields. But it's a crazy time and we hospital epidemiologists are doing things I could have never imagined just a month ago. The bottom line is that by employing face shields we are able to protect our workforce while extending the duration of time that we will have face masks available.

Stay safe and be well!

Mike Edmond

*Addendum: A hospital in New York reported 15-30 times normal demand for face masks.

Lessons from a Pandemic

Photo by Martin Sanchez on Unsplash

We are in the early stages of the COVID-19 pandemic, but it's already very clear that the Infection Prevention community in the US has never faced such an enormous challenge. Reflecting back on the past two weeks, we have learned many things that will make us better prepared for the long term. My goal is to keep track of these in this blog. So here we go:

1. We are far too reliant on single-use disposable products. Having a large supply of cloth surgical gowns and isolation gowns that can be laundered is essential. I'll comment on disposable face masks below. Less reliance on disposables will also be better for the environment.
   
   
2. The supply chain for medical products needs geographic diversification. It wasn't all that long ago that we had numerous shortages of medications and IV fluids due to the hurricane in Puerto Rico, and now we have this crisis due to concentration of manufacturing in China.
   
   
3. Just-in-time inventory management is not a great idea in healthcare, particularly when the supply chain is rooted in a single geographic area. Most hospitals, especially larger ones, have some strategic stockpile of products, but it's unlikely that any have inventory levels to manage an outbreak that lasts for many months. Hospitals and government (both at the state and federal levels) have a lot of work to do in this area.
   
   
4. We have a new standard for evaluating personal protective equipment (PPE). In the old days (like last year), the standard for evaluating a new PPE product was: is the new product better than currently available products? Today's standard is: is the new product (let's say a bandana to cover your nose and mouth) better than nothing? I'll push that a little further and argue that the new standard should be: is the bandana no worse than nothing? Healthcare workers are very afraid, and I'll freely admit that I'm one of them. We all want to proactively protect ourselves. Even if the bandana is minimally protective, if it provides some level of psychological safety, we need to respect that and allow our workers to wear "homemade" PPE.
   
   
5. Going forward, the new attire standard for healthcare workers should be hospital-laundered scrubs. These should be donned after hospital entry and doffed prior to leaving. This will require that hospitals construct adequate changing and shower facilities. And scrubs should be coupled with a bare-below-the-elbows approach to patient care.
   
   
6. To the greatest extent possible, no-touch technology should be built into hospital design. Sensors that detect a hand wave for door opening are a great advance.
   
   
7. Face shields should and will replace face masks. They provide greater facial coverage and make it physicially impossible to touch your face. And I find them more comfortable than face masks. Sturdier models can be wiped down and reused. I suspect that every healthcare worker will purchase one, just like they purchase a stethoscope. For this outbreak, I am advocating that face shields be worn for every patient encounter since many patients with COVID-19 are minimally symptomatic. It should become a new component of standard precautions.
   
   
8. The community really wants to help us. I have recieved numerous forwarded emails from colleauges who have friends and relatives who want to sew masks or isolation gowns, donate their face shields and N95s, or whatever they can do to play a part in making things better. This is beautiful.
   
   
9. Infection Preventionists are true heroes. They are working around the clock to keep hospitals functioning. These people are the salt of the earth. They work in the background with little recognition and are some of the most committed people I have ever met. Thank you, thank you, thank you!

These are my initial thoughts. More to come. Get some rest and stay well!

Mike Edmond

Practical Strategies for Physicians to Avoid COVID-19 Infection at Work

The physician workforce is one of the most valuable resources of any hospital, and in the midst of the COVID-19 outbreak we need to do everything possible to ensure that physicians stay healthy. Like other hospital epidemiologists, I spend a lot of time thinking about practical ways to reduce the risk of infection. So to that end, I want to offer some suggestions for reducing your risk of acquiring COVID-19 at work.

• Personal infection prevention: I strongly recommend that everyone in clinical areas follow bare below the elbows. This means that there should be nothing on your forearms, including wrist jewelry and wrist watches. This prevents contamination of sleeves and allows you to perform good hand hygiene. Hospital-laundered scrubs, doffed before going home, is optimal. We want to minimize clothing contamination, so I recommend not wearing white coats, cover jackets, or fleece jackets. Neckties are problematic because they frequently touch the patient/patient surroundings and are rarely cleaned. If you feel the need to wear a necktie, tuck it into your shirt. If you wear a long sleeve shirt, roll up the sleeves. Perform hand hygiene like never before (at least before and after every patient contact), and remember to wipe down your stethoscope after each use. Lastly, avoid touching your face.

• Work rooms: Physician work rooms are often small, so we need to think about how to achieve social distancing in these small spaces. One way to do this is to bring your laptop to work and do your documentation in another site to reduce the number of people in the work room. Also, it’s important to declutter these rooms so that housekeeping can come in to clean all the surfaces. It’s very difficult for them to do this when there is clutter everywhere. You should also wipe down your workspace before you use it. Avoid shared foods in work spaces.


• Conservation of personal protective equipment: Supplies of PPE are tight because many of these products are manufactured in China and factories are closed. This means we really need to conserve these items so that we can safely care for COVID patients for what may be an extended duration. At my hospital, we have modified contact precautions for non-COVID patients to not include gowns, since gowns are particularly in short supply. We continue to wear gloves for patients in contact precautions. If you anticipate a splash or spray, wear a gown for any patient. One way to think about this is to ask yourself: would I rather have this gown to care for a C diff patient today, or this gown to care for a COVID patient 6 weeks from now? I think this question puts the issue into perspective. Face masks and face shields marketed for medical use are in short supply, so consider purchasing a face shield from a hardware store. Here is an example of one. This particular model completely covers your face even laterally, and I think provides good protection and is comfortable. If you are a physician in an area such as urgent care or the emergency department, where there are many patients with respiratory symptoms, I would consider wearing the shield the entire shift. Avoid touching the shield, and wipe it down after use. To reduce supplies used, reduce the number of persons entering the patient room to the minimum necessary.


• Workflow: Again, we need to think about social distancing. In teaching hospitals, we tend to travel in packs, and this needs to stop. Consider asynchronous rounding (attending rounds with each intern separately) to avoid congregating in the hallways on rounds. You might also consider batching your duties to the degree that you can and doing more of your documentation at home. Avoid elevators.


• What to do if you become ill: The most important thing is to not come to work if you have fever or new onset respiratory symptoms. If you begin to feel sick at work, remove yourself from patient care as soon as possible. If you don’t have a thermometer (I didn’t have one until a few days ago), please get one, so that you can check your temp at home should you feel febrile. You might also consider purchasing a pulse oximeter to keep at home for self-monitoring in case you become ill.

Please take care of yourself during this difficult time. Patients need us, so let’s do everything we can to stay healthy!

Mike Edmond

Who the H is a Healthcare Epidemiologist?

We are happy to feature this guest post from Dr. Pranavi Sreeramoju, Associate Professor and Chief of Infection Prevention at UT-Southwestern!

A few years ago, I overheard my husband tell his friend, “yeah, my wife is a teacher at the local medical school”. “Why didn’t you tell him I am a healthcare epidemiologist?” “It’s a mouthful”, he replied. The rest of the conversation went like this:

“Why not say I am a physician?”

“My friend will think you make a lot of money. You don’t.”

“Why not physician epidemiologist?”

“Again, it’s a mouthful”

“Why not use my real job title, chief of infection prevention?”

“You don’t have a lot of authority on your job”

“Why not associate professor?”

“Aren’t you constantly stressing out that your boss thinks you are a publications and grants underachiever?”

“Why not just epidemiologist?”

“Didn’t some of your team members say they are epidemiologists? I thought some of them were nurses and some of them were not. You went to medical school for fourteen years.”

I was clearly losing at this point. “Well, majority of the effort on my job is to oversee the infection prevention program. Not for teaching.”

“Don’t you teach your colleagues when and how to clean their hands all the time?”

Hmmm. I usually didn’t lose arguments with him, but I lost this one. During my fellowship (in infectious diseases) days, my mentor Stephen Weber used to introduce himself to medical students as a mid-level hospital bureaucrat. At that time, I chose to pursue hospital epidemiology as a career mainly because I like to work with patient outcomes at a population level and I didn’t want to travel for work as they did in global health. Traveling for work is not the same as traveling for fun and exploration.

In the thirteen years since that decision, I have had a never-ending professional identity crisis of sorts. I changed what I called myself from ‘hospital epidemiologist’ to ‘healthcare epidemiologist’ when a colleague insisted that my scope is limited because hospital epidemiologists didn’t address the healthcare system as a whole. Well, my professional society has healthcare epidemiology in its name although my professional society journal’s name has hospital epidemiology in it. Not too long ago, APIC changed its name, but not the acronym (thankfully; like the change in name from PCP to PJP), from Association for Practitioners in Infection Control to Association for Professionals in Infection Control and Epidemiology. Even the infections we work on changed name from hospital-associated infections to healthcare-associated infections and I have had to explain the difference multiple times to several colleagues.

When I was recruited to my current job over nine years ago, the chief medical officer at that time, Jay Shannon, wanted me to have the job title, chief of infection control (which later became chief of infection prevention), on par with other physician chiefs of clinical services, because the ‘transformation work’, a.k.a., reduction of HAI rates needs to be done with them. Subsequently, the department I am responsible for changed name from infection control to infection prevention, to keep up with national trends in nomenclature fashion. I had some angst over it because we didn’t know how to prevent every infection, and because I had more influence over the committee I chair rather than the department, the committee is called infection prevention and control committee (“We control what we can’t prevent”; my committee members bought that argument!). Regardless of the four job titles I have ever had in my career, medical director of infection control, hospital epidemiologist, chief of infection control, and chief of infection prevention, I have introduced myself as a healthcare epidemiologist to my fellow ID colleagues, although not so much outside ID.

Not that it’s a mouthful as my late husband complained, but more because it’s hard to explain in functional terms to those outside ID. Is a healthcare epidemiologist a glorified infection preventionist with an MD degree? Is a healthcare epidemiologist truly a mid-level bureaucrat in a health system? Is the healthcare epidemiologist someone who helps his or her team stamp out regulatory fires or prepare them to prevent those fires perpetually, like I have had to do? Does the person reduce HAI using public health tools that were taught in the school of public health, and/ or the ‘quality and performance improvement’ tools including bundles that the folks in quality departments worship? Aren’t those tools very similar anyway? Is this person on par with a quality officer or a safety officer in a health system? Does this person present fancy looking ‘key driver’ maps to hospital boards which look a lot more fashionable than the substance in them? Does this person do nerdy and geeky things like mathematical modeling and does this person do clinical research that rigorously studies transmission of pathogens in healthcare settings? Does a healthcare epidemiologist do antimicrobial stewardship? Or diagnostic stewardship? Does a healthcare epidemiologist evaluate clinical outcomes of patients with infectious diseases? Does this person help achieve the triple aim articulated by the Institute of Medicine in their report on quality chasm in hospitals? Does this person work on ‘culture of safety’ in healthcare systems because if you didn’t have a strong culture of safety, then someone will be seen not washing hands right when the regulatory surveyors are walking down the hospital corridors, and the healthcare epidemiologist has accountability for the ‘findings’? Is the healthcare epidemiologist an ‘infection control officer’ for the health system? Some colleagues have also called me chief of infectious diseases because they didn’t know the difference between infectious diseases and infection prevention, a difference, which I have had to explain. Can someone without fellowship training in infectious diseases have healthcare epidemiologist as a job title? Is a healthcare epidemiologist a ‘suit’?

To protect my sanity, I came up with four categories for my job activities. Protecting the floor (e.g., avoiding a regulatory survey failure, controlling an outbreak), Doing the required (implementing programs that are required by stakeholder agencies including regulatory agencies), Aiming high (working on studying or improving outcomes that are not necessarily required by external stakeholders), and Reaching for the stars (e.g., doing innovative research, implementing novel teaching techniques). I began to articulate to everyone that I work on the HAI component of Safety, the ‘S’ in STEEEP, an acronym to describe attributes of Quality of health care provided to patients. However, the different dimensions of HAI extend into timeliness, equitability, efficiency, effectiveness and patient-centeredness, not to mention cost outcomes and satisfaction for patients and healthcare professionals. That’s when I came up with the frame of ‘quality of care related to microbes’. See a previous blogpost I wrote on this topic. However, that doesn’t extend to HIV and other microbes. I have badly wanted to come up with a unifying phrase or a term. I tried to make an acronym out of Infection, Control, Prevention, Epidemiology, Quality, Safety, Teaching, Research, Public Health, and Healthcare Delivery Improvement, and didn’t get anywhere close to a cute acronym that I was after.

These days, I introduce myself as a physician epidemiologist, physician leader for infection prevention, or someone who works on quality of care related to infections, when I talk to those outside infectious diseases. Maybe I should call myself an Infection Quality Officer, or IQ officer for short. May be a LEAP officer, an idea that occurred to me as I helped my mentee apply for the leadership in epidemiology, antimicrobial stewardship and public health fellowship.

I see that other academic departments and divisions that establish programs to address quality of care in the patient population they serve, call the person in this role, a ‘xxxx (department or division name) quality officer/director/chief’ who is either a system-wide quality officer (who works with other divisions and departments in the entire healthcare system) or a divisional quality officer (who works geographically within the division or department. Why doesn’t everyone in infectious diseases who works on quality of care (regardless of whether it is healthcare epidemiology, infection prevention, antimicrobial stewardship, quality of care for specific diseases like HIV or specific populations like transplant patients) band together and create one position- chief/director/office of quality in infectious diseases, like other academic departments or division? Is that giving in to too much peer pressure?

Construct Validity and Infection Control Nihilism

As describe by Cook and Campbell (1979) there are four components of validity: internal validity, external validity, statistical conclusion validity and construct validity. Internal validity relates to whether there is a causal relationship between an exposure (e.g. contact precautions) and an outcome (MRSA infections) that is free of bias. Randomization is thought to improve internal validity through reduction in confounding associated with unmeasured factors. External validity describes the generalizability of the findings to other populations (quasi-experimental studies typically have higher generalizability vs RCTs). Statistical validity is concerned with covariation between exposure and outcome and strength of the association (e.g. Type 1 and Type II error). All types of studies can have high or low statistical validity – it is independent of study design.

Finally, construct validity describes whether a test measures what it claims to be measuring. For example, if you claim a person is ESBL negative, is she actually free of ESBL colonization or infection and will not develop an ESBL infection in the future. As you can see, without high construct validity, all the other components of validity are unimportant. If your study design or microbiological method is unable to detect ESBL properly, it is irrelevant if you’ve completed a cluster-RCT or whether your p-value is significant. Thus, validity theory defines construct validity as the primary concern, subsuming all other types of validity evidence.

Which brings me to studies claiming contact precautions don’t prevent MRSA, ESBL or VRE. Let’s think about MRSA. If an MRSA negative patient is admitted to a hospital with a 4 day length of stay. On average (normal distribution) that patient would be expected to acquire MRSA at the end of day 2. Thus, they would have to go from acquisition to infection over the next two days prior to discharge for most studies to prove she didn’t acquire MRSA. Would two days even be long enough for her to have a positive nasal swab? So, how sensitive are surveillance cultures or clinical cultures at detecting this event. I’d suggest not sensitive at all. Thus, to have strong construct validity in any study looking at the benefits of eliminating contact precautions, the study would have to track patients for a prolonged period of time (months) and in particular look at infections that manifest during subsequent admissions including those to long term care facilities.

So, before we can make claims about the benefits or lack of benefits of infection control interventions we need to design studies with high construct validity. I would suggest that our ability to respond to current MDR-bacterial pandemics will foremost depend on us designing studies with strong construct validity. Pathogens will continue to harm our patients until we identify methods to halt their spread. The current trend towards infection control nihilism that is manifesting with those eliminating contact precautions based on studies with poor construct validity and typically very poor statistical validity (underpowered) is harming our patients – often after they are discharged from our facilities.

Recognizing the Value of Infection Control in Addressing the AMR Crisis

One of the challenges that all infection control and QI programs face is obtaining the necessary funding to complete all their required activities such as surveillance, reporting and prevention. Anthony Harris from the University of Maryland spent a great deal of time (e.g. SHEA White Paper on Necessary Infrastructure) as SHEA President pushing for increased resources for hospital epi activities. In a recent BMJ Quality and Safety editorial, Anthony offered suggestions for advancing the recognition and resources for infection control and QI activities, including societies (i.e. SHEA, APIC, ESCMID) partnering with governments to create comprehensive recommendations for infection control programs and funding.

Specifically, he recommends:

(a) guidelines by major organisations outlining the optimal reimbursement and full time employee (FTE) of hospital epidemiologists and infection preventionists for healthcare facilities in various settings. Currently, agencies such as CMS list certain conditions of participation for institutions relative to infection control and soon to be antibiotic stewardship; however, details of these requirements are vague and should be expanded

(b) as reimbursement moves away from fee per service and more towards quality outcomes driving reimbursement and penalties, we need more effective and novel methods of directing resources for day-to-day infection prevention. For example, an infection prevention fee could be imposed on all procedures that require significant infection prevention resources such as surgery or central line insertion and maintenance

(c) funding for state health departments to assist individual hospitals in establishing effective infection prevention programmes

(d) novel reimbursement models such as a fixed fee per surveillance culture reviewed, a fee for each chart reviewed to assess the appropriateness of antibiotic selection or an hourly fee for performing outbreak investigation may be warranted

(e) certification requirements for hospital epidemiology and QI experts that will help recruit and establish more experts to the field.

The full editorial (free full text access) is well worth reading. (COI alert: I'm a co-author)

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.

The white coat debate continues on and on and on and on...

I couldn’t resist blogging in response to Eli’s recent post regarding doctors’ attire. I guess this debate continues on with some new warriors from the University of Michigan. They plan to do a bigger, worldwide study of patient preference for physician attire. We really do need another meaningless study on this topic, don’t you think? While they’re at it, I think they should ask patients their favorite color, favorite flower, and favorite season of the year, because it would have the same impact.

I have blogged on this topic many times (see here, here, here, here, and here) and I won’t rehash all the arguments in this post. But these are the most important ones, I believe:

1. I think we need to act consistently about the role of clothing in infection control. That is, if you believe that contaminated clothing plays no role in transmission of infection, then be consistent and eliminate contact precautions. If you do believe that clothing may transmit pathogens, ditch the white coat and employ bare below the elbows or contact precautions, or some combination of the two. Or if you believe that the white coat magically resists contamination by pathogens, disclose that as well and those of us who believe in the germ theory and other scientific concepts like global warming can move on.
2. If you think that we need more data about patient preference then put the issue of physician attire into context in your survey or test your hypothesis with a clinical trial. Both types of studies have been done. And the results are clear: when placed into context, patients find physician attire to not be very important (not really surprising—most patients would rather have a kind physician who listens well and wears scrubs than a mannequin in a white coat) and when formally tested in clinical trials, attire had no impact on patient satisfaction with their care (see here and here).
3. The white coat is all about the doctor, more specifically the doctor’s ego. It’s truly about professionalism in the most negative sense of that concept (physicians judging other physicians to “protect the profession”).

In my current job as Chief Quality Officer at an academic medical center, I am able to separate my time fairly cleanly into clinical time and administrative time. When I am seeing patients, I wear scrubs, have done so for the past 6 years, and have never had a complaint. Interestingly, when my CEO sees me in scrubs, he always points to the scrubs and comments, “that’s a good look!” I also don’t consistently introduce myself as “Doctor,” particularly in situations where I am likely to follow a patient over a long period of time, and in cases where the patient’s status is tenuous and they need to be able to reach me quickly, I give them my cell phone number. Call my crazy, but this approach to patient care works well for me. When I’m working in my administrative role, I frequently wear a tie, though not always, rarely wear a sports jacket, and almost never a suit. Most physicians have enough common sense to dress appropriately for work, so very few need to be told how to dress. And I respect the fact that each of us has our own style. How you dress is a personal decision, a reflection of who you are. By the same token, there are some patients who prefer their doctor to dress more casually. There is no one size fits all.

So to our colleagues in Michigan, a challenge: in your new survey ask patients the following question: which is more important to you—that your physician be dressed in a white coat or that your physician gives you his/her cell phone number? I can’t wait to see the results.

The limitations of patient-centered infection control

"You can't just ask customers what they want and then try to give that to them. By the time you get it built, they'll want something new." - Steve Jobs

I woke up to Vineet Chopra and Sanjay Saint's editorial advocating for a patient-centered approach to selecting clinician attire. In the editorial they point out that in the 21 of 30 papers they reviewed "patients had strong preferences about what physicians wore. And it looks like patients more often prefer for their doctors to wear formal clothing and white lab coats than not." They also reference the SHEA guidance document on healthcare attire and state there is little evidence "that germs on male doctors’ neckties, long sleeves, or white coats actually spread infections in a nonsurgical setting. So bans on such garments, such as those in place in some countries, may go too far."

So how can we decide what the safest attire is for our patients? I would recommend epidemiological studies that track bacteria spreading in hospitals and attempt to determine if those same strains are contaminating clinician attire using whole genome sequencing.  In fact, CDC released a SHEPheRD Task Order 2015-006 last month that seeks to do just that and more. I very much look forward to the results.

Drs. Chopra and Saint recommend a different patient-centered approach as they "plan to survey thousands of patients from the US, Italy, Switzerland and Japan" and "will specifically assess how factors such as age or how often a person interacts with the health system shape patient opinions." Is this a rigorous or unbiased method? Will the surveyed patients know that a quarter of white coats are coated with invisible S. aureus or MRSA and that they are rarely washed? Will they understand that a lack of data supporting transmission from white coat or long sleeve or neck tie is because no one has ever funded such studies? Will they understand that the circumstantial evidence supporting bare below the elbows is as strong as that supporting a clean environment in hospitals? Will their next editorial say that bleach is stinky and irritating to patients, so we shouldn't use it in hospitals unless supported by a patient-centered survey?

Thus, there are several potential limitations to patient-centered infection control and the planned physician attire survey, which I hope they will consider before collecting data and selling the findings. I'm all for patient-centered healthcare where applicable and data are fairly presented to patients and I support evidence-based medicine when we fairly rate the science based on what studies have been funded or will ever be funded. I'm not sure any patients "feelings" about the dirty white coat are worth the increased risk of MRSA or Acinetobacter infection, but we can disagree. All I would ask is that if we do patient-centered research, it's with properly informed patients.

***
Oh, and if we're going to require evidence before making physician attire recommendations, how can the authors write that "scrubs do not belong outside the hospital environment. Especially not in the grocery store." Where is the study that scrubs spread bacteria outside of hospitals and that there is any risk to population health in grocery stores? Clearly the bacteria on cantaloupes are riskier than those on scrubs! And surely the immobile ICU patient with central venous and urinary catheters is at greater infection risk when you wipe your MRSA-contaminated white coat on their catheter than when you brush up against a healthy grocery store patron with your scrubs? Scrubs are at least washed daily - white coat laundering occurs somewhere between every two weeks and... never.

*****
Additional thought, I am not aware that the US, Italy, Switzerland and Japan have mandatory bare-below elbows policies. It might be important to add Scotland or England to the survey since they have had BBE policies for some time and patients may have adjusted their preferences for physician attire.

Infection Prevention Thoughts of the Day

Thoughts of the day. Start reading at the bottom (or not). Be careful out there.

Ebola: Hospital Epidemiologists in the News

It's been amazingly active week for hospital infection control with adult deaths and paralysis in children linked to Enterovirus 68 and there have also been some issues with Ebola. Practically every Hospital Epidemiologist* has been called upon to explain the transmissibility of Ebola and describe how they've been planning to protect healthcare workers and the community. Of course, I can't possibly list all of the mentions in local, national and international media, but if you have a particular clip that you'd like us to post, let us know.

I've been impressed by the clarity and skill that my SHEA colleagues have demonstrated. For example, earlier today Dan was on Public Radio International (PRI) discussing the difference between the virulence and contagiousness of infections and how it's easy to confuse the two. Specifically he said "In the case of Ebola, it is not true that it is airborne, it's not true that you can catch it just by being in the same room as an infected person. It really does require direct contact." Head on over to PRI, to hear the whole interview.

Kent Sepkowitz was on CNN yesterday describing the contagiousness of Ebola with the money quote: "so the super contagious body compartment is blood and it's blood and it's blood." And one of the stalwarts of hospital epidemiology and mentor to many, Leonard Mermel, was on MSNBC's All in With Chris Hayes tonight describing the well-developed screening algorithm that's been implemented at Rhode Island Hospital. I've added the video below. If you want to jump directly to Len Mermel's discussion, it occurs around 12:00. (apologize for the brief ad)

*A hospital epidemiologist is typically an infectious disease physician specialist who develops infection control plans to protect patients and healthcare workers in clinical settings including acute care hospitals and long term care facilities. During outbreaks the hospital epidemiologist helps identify the source of the infection and determines how best to contain its spread. They educate clinicians about the optimal ways to prevent infections (e.g. hand hygiene), while also tracking the use and misuse of antibiotics and the emergence of antibiotic-resistant bacteria. Other goals include preventing post-operative surgical wound infections and infections associated with central venous catheters. They are each hospital's very own disease detective!

Emory's Ebola Unit

This NPR interview gives additional information about the unit.

Ebola protection: How much is enough?

There's an excellent piece in today's New York Times that focuses on the key question hospital epidemiologists across the country are struggling with: what are the appropriate infection control measures to protect healthcare workers caring for patients infected with Ebola virus? We've blogged on this issue to some extent before (here and here). Are contact and droplet precautions enough (as recommended by CDC), or do we need Tychem suits, PAPRs, and fluid resistant booties, or maybe even something beyond that?

What do we know about Ebola viral disease to guide us in this decision?

• The virus is transmitted via multiple routes: direct or indirect (fomite) contact with blood and body fluids (including urine, stool, vomitus, sweat, tears, semen, breast milk, and saliva), droplet, and fecal-oral. Airborne transmission is also possible if aerosolization occurs.
• Healthcare workers are a major risk group for infection.
• The disease manifestations drive transmission (bleeding, vomiting, diarrhea), leading to environmental contamination and contamination of HCW clothing, unprotected skin and mucosal surfaces. Simulated vomiting studies have shown that droplets can travel over 10 feet. The virus can remain infectious 1-2 days outside the human body.
• Healthcare workers have become infected despite use of maximal barrier precautions.
• If transmission occurs, the disease has a high mortality. 
• There is no known effective antiviral therapy. Experience is too limited to understand the impact that state-of-the-art supportive care can have on improving mortality.
• We have no post-exposure prophylaxis.

Now put yourself in the shoes of a 26-year-old ICU nurse with a 1-year-old child at home who has just been assigned to care for an Ebola-infected patient with active vomiting and diarrhea for a 12-hour shift. What level of protection would you want? It's nurses who will likely face the highest risk since they care for patients for long periods of time and have the most contact with blood and body fluids.

It's interesting in the New York Times piece to contrast the perspective of Nancy Foster, a non-HCW executive of the American Hospital Association, who works in an office far removed from the patient care setting, to that of Dr. Michael Callahan, an infectious disease specialist who has direct experience in Africa with Ebola outbreaks. Ms. Foster tells us that gloves, gown, face mask and eye protection are “perfectly fine.” Dr. Callahan notes that the "perfectly fine" strategy “led to the infection of my nurses and physician co-workers who came in contact with body fluids.” The Ebola veteran notes, “I understand the desire to maintain absolute protection in U.S. hospitals.”

How we deal with perceptions of risk is fascinating. The risks we choose to accept and those we don't can't be explained rationally. But that's quintessentially human. As I see it, healthcare workers that accept the challenge of caring for Ebola patients are providing a great service and face a level of risk that is hard to define. These brave souls deserve to have input on the personal protective equipment they wear. And if they want Tychem suits, so be it. Our job is to then ensure that they can safely use them.

Photo: Newsweek.com. Boris Roessler/DPA.

Why are we dialing it up to eleven?

Yesterday, Dan posted an excellent summary of what's happening in US hospitals as they scurry to plan for the public health issue du jour--Ebola. He astutely points out that there seems to be a disconnect between what we know about Ebola transmission and what we're doing (or planning to do) with regard to safely caring for patients infected or suspected to be infected. I thought it would be interesting to examine what's driving the disconnect. As I see it, a number of factors are at play here:

Mixed messages

Michael Ramirez, Investors.com

As noted by Dan, at a press conference prior to the transport of two Americans with Ebola infection to Emory University Hospital, Dr. Bruce Ribner stated: "Emory University Hospital has been asked to accept two patients who are currently in Africa infected with Ebola virus infection. Our facility was chosen for this because we are one of only four institutions in the United States capable of handling patients of this nature." Not stated, but nonetheless presumed by the infection prevention community is that the agency doing the asking was CDC, given CDC's physical proximity and given that quite a number of CDC physician-epidemiologists hold faculty appointments at Emory's schools of medicine and public health. However, just a few days later, CDC's primary message was that any hospital in the US should be able to safely care for Ebola patients.

Photo: Cellou Binani/AFP/Getty Images

It's also difficult to reconcile the CDC recommendation for contact and droplet precautions--highly familiar to all healthcare workers--with the images of healthcare workers on the ground in the outbreak epicenters and in Atlanta dressed in Tyvek spacesuits. And who hasn't seen the video footage of the infected American doctor emerging from the ambulance in Atlanta also dressed in the same manner? However, it's important to keep in mind that the exposure risk for healthcare workers in the outbreak setting, caring for multiple very ill, infected patients with scarce resources, is far different than the controlled setting of the average American ICU.

Fear and managing risk

Our greatest fears often revolve around areas where we lack experience, and very few healthcare workers in the US have ever cared for a patient with viral hemorrhagic fever. Importantly, not only does Ebola Fever have a high mortality rate and no proven effective therapies, there is also no post-exposure prophylaxis. A simple lapse in infection control protocol cannot be undone with a pill or injection. One way we attempt to manage fear is to overprotect: if one barrier works, two must be better. In general, redundancies mitigate risk, but this isn't absolute. As Dan pointed out in his post yesterday, we may inadvertently increase risk by complicating infection control protocols with gear that healthcare workers may find distracting, uncomfortable, and lack training to use. The litigious nature of American society also impacts our decisions regarding infection prevention strategies. And many healthcare workers, while willing to accept much greater health risks in their personal lives, demand zero occupational risk.

Non-epidemiologic decision making

In many hospitals today, healthcare epidemiology staff have become advisors to hospital administrators who ultimately make decisions regarding the logistics of infection prevention. And their decisions may not be purely based on science. They often have aversion to approaches that would appear to be out of the mainstream of what other hospitals are doing, even if that's suboptimal. In addition, infection prevention seems to be increasingly used as a public relations tool. If you don't believe that, do a simple Google search and you will find scores of press releases published in local newspapers from hospitals who have purchased germ-zapping robots. By the way, I believe that one of the best uses for a hydrogen peroxide vapor robot would be terminal disinfection of the Ebola patient room. Perhaps those hospitals who have invested in this technology should be the first to receive Ebola patients.

Paramilitarization of public health

In the run-up to the Iraq War, the Bush administration sought to engage the public health and medical communities in the war on terror. Much effort was devoted to preparations for bioterrorism. Who can forget the smallpox vaccine debacle? Preparedness was all the rage, and the Joint Commission couldn't resist jumping on that bandwagon.  Admittedly, some of the impacts of this were positive. For example, hospitals became more tightly linked to public health agencies and those agencies became much more engaged and proactive. But a new group of professionals emerged who are employed to make us prepared, and perhaps a little scared. A physician colleague who works in the IT world tells me that the constant fear mongering by IT security specialists is in part a job security tactic. So the folks who work in preparedness stand ready to help, perhaps in a more aggressive way than necessary this time.

Ok, anyone still surprised we've cranked it up to 11? I'm with Dan in hoping that we'll be able to dial it down to 8 this week.

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!

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!

My on-again, off-again relationship with the white coat

Silvia Munoz-Price, MD

This is a guest post by Dr. Silvia Munoz-Price, Associate Professor of Clinical Medicine at the University of Miami Miller School of Medicine and Hospital Epidemiologist at Jackson Memorial Hospital.

All the comments after the SHEA attire guidance paper made me reflect a lot, in particular about white coats. So here are my two cents on the topic based on my very personal, and thus very biased experiences.

In a piece like this, I am forced to start with my first conscious experience with white coats, which came from my dad. He would come home –all dressed in white-- after his OB/GYN overnight calls, sit on the sofa with me on his lap and tell me about all his challenging cases. I wanted so badly to be as good of a doctor as he was…but especially, I wanted to look like him…wearing pristine white clothes. Thank you dad for those special moments you shared with me…they were very meaningful.

Let's fast-forward a decade or so to the first clinical rotations in medical school. Wearing the white coat…felt really good. Let’s pause here and give you some context: I did medical school during the nineties in a Latin American inner city public hospital. During my early clinical rotations I had one of my most profound realizations about gender and the medical profession: patients would address any male technician wearing a white coat as a Doctor. Here I come (very young, I admit, less than 20) wearing my white coat. How am I addressed? You guessed right, Miss…which was an accurate description and would have been ok if all my male classmates wearing their white coats wouldn’t have been addressed as Doctors. Those inequalities never ended throughout med school. I thought it was unfair but highly reflective of a male dominated society.

Let's move forward another 5 years, Internal Medicine residency in the US. There are two issues related to attire that I think are worth sharing. One: How often did I launder my white coat? Well, I think it was whenever my sleeves turned disgustingly gray and I could not possibly bear wearing it any longer. Two: nobody ever told me how frequently I was supposed to launder my white coat. While I write this piece I am trying to think if I ever thought the sleeve test was adequate or not…to be honest, I don’t think I ever thought about it. I was too busy and too tired to bother thinking on those alien thoughts.

Fast-forward 5 more years…my period in private practice in the Midwest. It was amazing to me how so few docs wore white coats across the many community hospitals I cross-covered. White coats were substituted by nice—and in some cases, expensive—clothes. During my first year I wore white coats but soon this faded into suits. This is interesting…not wearing a white coat was done by most and accepted by all. No attire guidance, no white coats, no fuss. I am not saying this is right or wrong, after all, it is indeed hard to do hand hygiene with the sleeves of a suit in the way. I just find it interesting how cultural this “white coat” or “no-white coat” phenomenon is.

Another 5 more years: my life in academia. There are at least three points that I frequently reflect on about white coats in this setting:

-One: white coats are a symbol of power. I see this every month in my hospital’s Board Room…towards one side of the table, Department Chairs predominantly males, in their late 50s to early 70s, all wearing impeccable and sparkling white coats (even though many do not see patients any time around that particular meeting)…on the other side, hospital administrators wearing suits. Interesting dynamics. Why do Chairs feel compelled to wear white coats to a meeting if there are no patients around? I understand that some medical professionals think that white coats provide reassurance to patients…but who gets reassurance with white coats in a board meeting? Themselves!

-Two: As an attending in academia, wearing white coats serves as a gender (and maybe age) equalizer.[I think the same might happen with suits in private practice. This is hard for me to explain, so let me give an example and I will let you make your own conclusions. Imagine you are a consultant that comes to a particular hospital rather infrequently. Imagine a fifty-year old male comes into the unit wearing a white coat. Who do you think he is? Probably a doctor. Now imagine a fifty-year old female comes into the same unit wearing the same white coat. Now what do you think? Probably also a doctor. Now, lets get rid of the white coats and put a suit on the male and a dress on the female. What would you think now? Responses will be less homogeneous this time, but whatever you argue would be strongly influenced by your social context and your own personal experiences. White coats are indeed powerful symbols; unfortunately, they do not fully equalize genders. As an example, let me share with you what happened to me a few days ago despite wearing a white coat… here comes a cute old Hispanic lady … “Señorita [Miss], how do I get to 7East?” Yes, sadly, even now in my late thirties and with a second doctoral degree…that continues to happen…but…does it matter? Should it matter? Should I even put any thought into the way family members or families perceive me?

-Three: During 2010-2012 I did a couple of studies looking at contamination of attire. We found that white coats were more contaminated than scrubs and that hand contamination was associated with contamination of white coats, but not with scrubs. Also, in a survey among our providers we found that scrubs were laundered daily but white coats were laundered in average every 2 weeks. This was interesting as nobody had told providers how frequently to launder either piece, but they spontaneously performed laundering with different frequencies on these two types of attires. Why? One is in intimate contact with our skin [scrubs] and the other one is not [white coats]. One has to do with our individual comfort and protection [scrubs], and the other one is mostly in contact with patient’s surfaces [white coats]. The reason why this differential behavior occurs is so far unexplored. Regardless, I decided to start the trend at my hospital to wear scrubs and forego white coats for my teams and me. This lasted about a year and ended as we were writing the SHEA attire guidance, as I decided that I wasn’t going to agree to one thing in that publication and do something else in real life. I have to admit that I really enjoyed being able to wear the white coat again…being able to look and to feel like a real doctor again…and to blend in with my colleagues in academia. My fellows were ecstatic because now they would be able to carry all their stuff in their white coats.

I think the SHEA attire guidance paper had a measured approach to white coats. Even though there is no hard data that attire contributes to horizontal transmission of bacteria, we still felt that there was a need to provide some guidance on how frequently to launder our attire. A minimum of once a week sounded like a good compromise (I wanted this to be a minimum of 3 times a week!!). Regardless, I think this guidance is very helpful, as somebody needed to establish a minimum laundering frequency so that the sleeve test stops occurring.

White coats…such strong symbols of who we are…they not only reassure patients…they reassure us, physicians. Look inside of you…do you think white coats might be hiding some of your own personal and professional insecurities? To some degree…yes. Some of the passionate reactions against the attire guidance paper seem to indicate so. But, we should all be clear that when we discuss white coats, we are not doing this because of infection control reasons. If we used an infection control rationale solely, then there wouldn’t be any use for white coats, as they do not protect patients or providers, I would argue that it is the opposite for patients (we just haven’t proved this yet). Culture, social context, age, gender, and perception… these are all issues tied to white coats.

Let me end this piece with something that happened a week ago in the Board Room. That day I was already writing this piece. The room, as usual, was filled with white coats or suits, and had a marked older male predominance. I was sitting to the side pondering about these thoughts, wearing a white blouse and a red pencil skirt, getting ready to address the crowd. How will this crowd perceive me? A relatively young, Latin physician with an accent…would this perception be different if I were wearing a white coat just like them? And most importantly…should this matter? As I approached the podium and gave them my Infection Control update…I can honestly say that I felt fully confident on what I was saying and how I looked, of what I had accomplished so far, and of all the wonderful things I will accomplish in the future…and all this happened without wearing a white coat.

The Good, the Bad, and the Ugly

The good Dr. Diekema stopped by Dartmouth-Hitchcock last week to deliver medical grand rounds. He provided a wonderful update on infection prevention. You can click on the screen shot to the right or the link below to view a video of the presentation, which includes his full slide deck. Enjoy!

Source: Dartmouth-Hitchcock Grand Rounds 1/25/2013

TB Infection Control in Resource-Limited Settings

CDC has produced a new PEPFAR-funded video, as part of an implementation package, designed to assist with TB infection control. It's based on recent (2009) WHO guidelines. There is also an active discussion group that covers TB infection control. h/t Philip Lederer

 

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