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?

And another reason to hate contact precautions...

There's a new paper in the Journal of Trauma and Acute Care Surgery that adds to the concern regarding the safety of contact precautions. This retrospective two-year study evaluated approximately 4,400 trauma patients and compared the incidence of venous thromboembolism [VTE] (as detected by active surveillance via duplex ultrasound) in patients who were isolated versus those who were not. I should note that there is an error in the title of the paper as isolated patients also included those on droplet and airborne precautions. However, in most hospitals contact precautions account for the vast majority of patients who are isolated, and even more so in the hospital studied since they performed active microbiologic surveillance for MRSA via PCR. VTE occurred in 17.7% of the isolated patients and 3.5% of the non-isolated patients. After controlling for a number of confounders, isolation remained an independent predictor of VTE (odds ratio 2.6, CI95 1.7-4.0).

Increasingly, hospitals are scaling back contact precautions for MRSA and VRE, and with good reason!

Reader Survey: White coats contribute to the unsafe hierarchical culture in healthcare

Following on the heels of Mike's bare-below the elbows debate at IDWeek, I posted a quick survey to gauge your impression of the level of acceptable harm associated with white coats. I'm still working on the power calculations that will be informed by the survey, but wanted to say thank you to the many who answered the questions. In the meantime, I also wanted to post the comments left by you, our readers. I've posted almost all of the comments thus far apart from those with swearing or those that mention their answers to question #1 of the survey.

One thing that struck me when reading the comments is that the white coat is a symbol that perpetuates hierarchy and is part of an unsafe culture. We need to create healthcare systems without hierarchy and it seems that the white coat contributes to a system where 58% of nurses that see harm are afraid to speak up "and people need to be able to speak up." Thus, even if you are in the minority who believes that white coats are not involved in pathogen transmission, your white coat might be harming patients by contributing to an unsafe hierarchal culture.

An interesting patient-centered quote that seems to run counter to the current thinking associating white coats with professionalism: "If there are better options that would reduce transmission of infection then burn the white coats. As a patient I dislike them - intensely. Reminds me of a butcher shop or auto mechanic- not reassuring at all."

Pro White Coat:

"Not an issue as long as changed daily and sleeves rolled up above the elbow and they don't carry medical equipment in the pockets"

"The white coat continues to be an important identifier of the profession, and symbols are important"

"It is certainly useful to carry things but also represents antiquated power hierarchy. Although there is no evidence, it plausible that they could transmit infections. Then again so could stethoscopes which have more direct patient contact."

"Can't prove it is causing resistance-- and I think patients like it"

"Needs an RCT. Anything else is nonsense ... unless we say all healthcare providers put on and remove scrubs at work"

"We have white coats with short sleeves. This is no problem in my opinion. BUt bare below the elbows has become the standard in most Dutch hospitals. Probably the turning point was a documentary with a hidden camera showing that healthcare workers knew that handhygiene was important that they should not wear jewelry, but they just didn't take the rules serious. Sometimes we don't need science but a good mirror and public response"

"Fashion item"

Pro Bare Below Elbow (OK with eliminating White Coats):

"It's merely a badge of authority and seniority masquerading as cleanliness and something "sciencey"

"A disease-ridden, antiquated symbol. They project the same professional and scientific insecurity as when doctors started wearing them to appropriate the public legitimacy of science."

"I appreciate that for many, the white coat is a status symbol and helps create an instant first impression on patients. That being said, times are changing. The physician is not the most important person in the room. The healthcare team is what should be the focus now. Tear off the coat and tear down the hierarchy"

"I understand white coats as a part of PPE when you don't want to get something on yourself or to prevent things on you from spreading. But when the white coat goes EVERYWHERE you go, it doesn't maintain it's protective qualities. Also, as a pharmacist, I'd much rather have normal, professional or consulting coversations as a professionally dressed human than a white coat."

"If it's a vector for microorganisms, eliminate it. Simple"

"Not necessary. Wear scrubs like everyone else. If your ego needs the coat, get therapy"

"I hate it. Adds to elitism and difference. Separates us from our humanness"

"White gets filthy too quickly"

"In the past, it was a status symbol for physicians; this is now translated to our students, ancillary staff and physician extenders. It is not represent amount of fundamental knowledge or the ability to care for patients. It was an extension of the laboratory part of our profession transitioned from black coats earlier in the last century. Currently, it is nothing more than a status symbol or accessory"

"White coats offer no benefit. We should try to prevent infections by any means necessary"

"I don't think white coats are necessary, but then I'm also not American!"

"Don't wear them in Australia. If you're worried about getting dirty, wear scrubs"

"It's part of a bygone age"

"Given the association with pathogenic transmissions, I am appalled we are still handing them out to our medical trainees!"

"I work at a pediatric hospital where most physicians do not wear white coats. Anecdotally, pediatricians seem to eschew white coats in order to be more friendly and approachable. Don't know what impact this has on HAI at our hospital"

"Doctors don't walk around with head mirrors anymore; the white coat makes about as much sense to me. Why do we still have this thing that exists for no other reason than a vector for disease?!"

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image source: NYT

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 new healthcare epidemiologist

The April issue of Infection Control and Hospital Epidemiology has a white paper on skills and competencies for the healthcare epidemiologist. True to form, the paper reflects the rather timid approach that SHEA never seems able to shake. As a disclaimer, I should state that I sit on the Board of Trustees of SHEA, and I’m not saying anything in this post that I haven’t shared previously.

While the paper mentions that the healthcare epidemiologist should have an understanding of quality improvement and safety, and is a valuable partner to the Chief Quality Officer (CQO), what it should state is that the healthcare epidemiologist is uniquely qualified to be the CQO. Infection prevention was the first QI program ever to emerge and remains better developed than QI and patient safety. Many healthcare epidemiologists have advanced degrees in public health or epidemiology, and the skill set is directly transferable to QI and safety. Increasingly hospitals are developing CQO positions, but very few of these positions are held by healthcare epidemiologists. In some cases, CQOs may not have a true appreciation for the value of the healthcare epidemiologist, and some of us fear that healthcare epidemiologists as we know them may ultimately be replaced by less trained individuals. Interestingly, Dick Wenzel published a book on quality improvement in 1992, but unfortunately, SHEA chose to remain confined to infectious adverse outcomes rather than expanding into the quality realm.

So my recommendations are these:

1. SHEA should move aggressively and quickly into the quality and safety space.
2. To broaden the skillset of the healthcare epidemiologist, SHEA needs to sponsor education on leadership, implementation science, human factors engineering, Six Sigma, Lean, and other quality improvement and patient safety topics.
3. As much as I hate to talk about certification given the absolute mess the American Board of Internal Medicine has made of our certification processes, I continue to believe that healthcare epidemiology will never be seen as a valid entity until there is certification. Once certification occurs, then it becomes possible to build the requirement for a healthcare epidemiologist into payer’s conditions of participation, hospital accreditation, and hospital quality rankings. We need to make the healthcare epidemiologist indispensable. 
4. SHEA’s journal, Infection Control and Hospital Epidemiology, should specifically solicit papers focused on noninfectious adverse outcomes, quality improvement and patient safety. 

In a nutshell, SHEA should define the role of the healthcare epidemiologist more broadly, which in the long run will help its members more easily achieve leadership positions in hospitals and have a seat at the table when important decisions are made.

Graphic: Stratabridge 

The CHG, CareFusion, NQF, Journal of Patient Safety (and perhaps more) Scandal

For the past month there has been an emerging and evolving scandal involving several key players in patient safety. From what I've gathered, Jonathan Stempel broke the story on January 9th in Reuters. There was a federal court case (U.S. ex rel. Kirk v. CareFusion Corp et al, U.S. District Court, District of Kansas, No. 10-02492) settled by CareFusion Corp after agreeing to pay $40.1 million for kickbacks to boost sales of CHG pre-surgical scrub and promote its off label use. Where this gets interesting is that a specific physician, Charles Denham, was named and apparently paid $11.6 million to promote ChloraPrep.

There is more to the story and for those interested, you should head over to Bob Wachter's excellent post describing the scandal and ProPublica's post with links to key documents including internal National Quality Forum (NQF) meeting proceedings. Briefly, Charles Denham the named physician was a key member of NQF and co-chair of the 2009 committee charged with updating their "Safe Practice" guidelines. It appears that he attempted to use his position to push 2% CHG, which is a formulation favored and produced by CareFusion. In addition, he was editor of the Journal of Patient Safety, a member of the Leapfrog Group (since resigned) and was highly connected in the patient safety movement.

It is all very concerning and in some ways sad. My major question is how can such important groups (Leapfrog and NQF) rely on someone to lead such important efforts when they've almost no background in patient safety including almost no research publications prior to becoming editor of the Journal of Patient Safety? It seems like that patient safety movement needs to identify and promote faculty within its ranks with strong scientific backgrounds and those without such strong ties to industry. The safety movement can't be about money, it just can't. I also wonder about CHG. A letter to the editor in the August 2013 ICHE by Maiwald and colleagues does a nice job highlighting some limitations in the current CHG literature. It's worth a read.

Patient - Wash Thy Own Hands!

There has been increasing attention over the past decade in engaging patients in patient safety. In infection control this trend has manifest through efforts to have patients monitor and encourage hand hygiene compliance among health care workers. In a related trend, there is also increased interest in patients washing their own hands in a framework called "patient-centered hand hygiene." My understanding of this approach is that having patients clean their own hands could potentially increase their engagement in infection control initiatives including encouraging health care workers to practice hand hygiene. This approach might also have the additional benefit in decreasing the organism burden on patients' hands and interrupting direct or indirect transmission of MDROs in healthcare settings.

It is with this background that Kundrapu and colleagues at CWRU and the Cleveland VA completed a randomized trial of soap and water versus alcohol hand rub in reducing C. difficile spore burden on patients' hands. Forty-four infected or colonized patients were included in the study. Hand cultures were positive in 32% of patients with CDI and 38% of colonized patients prior to hand hygiene. As you can see from the figure below, soap and water significantly reduce the proportion of positive cultures and mean CFUs, while alcohol hand rub did not. Interestingly, around 10% of patients still had C. difficile recovered after washing with soap and water. Seems like a trial is in order to determine the role of patient hands in transmission and whether cleaner patient hands reduces the incidence of CDI and other MDROs in hospital settings. One major limitation is that this intervention could not be implemented in settings where the need is the greatest, namely ICUs, since most patients would be too sick to wash their hands.

Embracing science, continued...

Also out today, the Department of Health and Human Services announces a new initiative entitled, "Partnership for Patients: Better Care, Lower Costs". From my initial reading, it looks like a 1 billion dollar investment, mostly in implementation of existing prevention approaches.

I'm sure we'll comment further as more details emerge, but I would like to highlight this paragraph from SHEA's statement on this initiative, which appropriately focuses on the need to advance the science of prevention (italics, for emphasis, are mine):

As the Obama Administration moves forward, we urge officials to think beyond the changes that past practice has suggested can make a difference, as well as the financial incentives and disincentives that ostensibly prompt providers to modify how they work. To really be successful, both now and in the long term, the NPSI must invest in the medical research and technology that will identify how the nation’s health system can avoid errors in care. The initiative also must be able to track and validate improvements through standardized measures and solid data. If we focus on implementation without advancing the science, we will fall short of immediate goals and risk being equally unprepared for future exigencies.

Photo credit: Kathleen Sebelius, HHS director, with Elmo. From the NY Daily News.

Addendum: Don't miss Bob Wachter's post on this initiative, here.

National Patient Safety Awareness Week

This week is National Patient Safety Awareness Week. I especially like the AskMe3 campaign, a health literacy initiative that aims to improve patient-provider communication by encouraging patients to ask three basic questions of their healthcare providers:

1. What is my main problem?
2. What do I need to do?
3. Why is it important for me to do this?

I think we should each ask ourselves these three questions every so often.

More good reading for a winter weekend

The December edition of the Atlantic has 3 interesting pieces if you have any time left over after finishing Eli's weekend reading assignment.

• Carl Elliott has written a piece on ghostwriting in medical journals (free full text here). He notes that one large pharmaceutical company labelled it's ghostwriting campaign "Case Study Publication for Peer Review." Sounds like a boring campaign name until you look at the acronym (CASPPER). Not so friendly, this ghost, however.
• Megan Mcardle writes about information technology in medicine (or the lack thereof) in "Paging Dr. Luddite" (free full text here).
• An eye-opener by Robin Fields, "God Help You. You're on Dialysis," uncovers problems with quality and safety in outpatient dialysis centers and how little is being done about it (free full text here).

James Bagian on medical error

Kathryn Schulz has a wonderful Q&A with James Bagian, director of the VA national center for patient safety, at the Slate blog "The Wrong Stuff". Read it all, but I especially enjoyed his thoughts on blame, punishment, and the perverse incentives that can be introduced by public disclosure.

Kathryn Schulz is the author of the book, Being Wrong: Adventures in the Margin of Error. I haven't read it, but I think I'll check it out.

Keeping veterans safe

As we pause on Memorial Day to remember those who have died fighting our wars, it seems fitting to recognize the strides that Veterans Health Administration (VHA) hospitals have made in patient safety, including prevention of healthcare associated infections. Over the nine years I was hospital epidemiologist at the Iowa City VAMC, I became convinced that most U.S. hospitals could learn a lot from the VA system (beginning with their early implementation of an electronic medical record that remains superior to the one we have implemented in our university hospital). While I can nitpick about the way certain directives came down, overall I think the VHA has been ahead of the curve, which may also be a commentary on progress in the rest of our fragmented healthcare system.

The VHA is the largest integrated healthcare system in the United States. It can and should serve as a model for healthcare-associated infection prevention.

Safe Patients, Smart Hospitals

I had some beach time last week so I read Peter Pronovost's new book, Safe Patient, Smart Hospitals. It's the story of his journey in patient safety, which starts with his father's death, likely hastened by a medical error. Parts of the story are probably familiar to those who work in infection prevention, but I think it's worth reading.

One of the major points he makes is that the checklist, while important, can really only work when the hospital unit embraces a culture of safety. An aspect of the book that I particularly liked is his criticism of some of the work in quality improvement because measurements lack validity. Like Pronovost, I've been accused of trying to do research by QI folks, when all I was asking was to measure a process or outcome accurately and precisely. He also points out how often ego gets in the way of doing the right thing. Over and over, I kept wondering why change is so difficult in  hospitals even when the data for a new intervention are compelling. And he reinforced my belief that infection prevention, like many other aspects of patient safety, is all about high levels of compliance with simple practices.

Unfortunately, I suspect that Dr. Pronovost is preaching to the choir. Those who might benefit most from his words are least likely to turn the pages of this book.

Patient safety education: Let's get it started!

I just reviewed the new white paper, Unmet Needs: Teaching Physicians to Provide Safe Patient Care, which outlines recommendations on incorporating patient safety concepts into medical education beginning at the start of medical school. Moreover, it even calls for incorporating questions on patient safety into the MCAT, and assessing medical school applicants for interpersonal skills that promote patient safety. We know that it's too late to begin teaching patient safety after medical school graduation, and it's too important for an incremental approach.

Make room for patient safety

The New York Times has a piece by two medical students that points out how little medical schools are doing to teach future doctors about patient safety. It's a shame that schools can't scale back biochemistry to carve out some time for concepts that would actually save lives. And wouldn't it make more sense to inculcate good practices at the outset rather than trying to break bad habits later?

Mandatory Influenza Vaccination

In the current issue of CID, investigators at BJC HealthCare in St. Louis report on a mandatory influenza vaccination policy instituted during the 2008-2009 season. All employees who were not vaccinated or who didn't have an approved exemption, where not scheduled to work beyond Dec 15 and were terminated on January 15th if still not vaccinated. They achieved an impressive true vaccinated proportion of 98.4%. Quite an achievement for patient safety. Only eight employees out of 25,561 were terminated and 321 (1.2%) had approved exemptions.

An editorial by Andrew Pavia provides a nice balanced summary of healthcare worker vaccination policies and successes. Mandatory vaccination policies have been implemented by several organizations including Virginia Mason Medical Center (Seattle, WA), Hospital Corporation of America, Johns Hopkins Health System, University of Iowa Hospitals, Hospital of the University of Pennsylvania, Children’s Hospital of Philadelphia, and the Department of Defense. Dr. Pavia is right to suggest that influenza vaccination targets should be set at 90% or higher; however, it's unlikely these targets can be widely achieved without mandates similar to what BJC has just described.

Balancing patient safety with patient safety

Mike has already pointed out the degree of uncertainty surrounding how to prepare for (and respond to) the spread of novel H1N1. One of the challenges is maintaining a focus on overall patient safety and the potential unintended consequences of our H1N1 response.

One example that comes to mind is the question of how long to keep ill health care workers (HCWs) at home after their symptoms improve. The current CDC guidance suggests HCWs stay at home for at least 7 days after onset of “febrile respiratory illness” (temp greater than 37.8 C and cough or sore throat).

This may not be a problem now, but soon there will be a multitude of circulating respiratory viruses (see here for a partial list). If it is a bad “respiratory virus season”, even if H1N1 represents a minority of the circulating viruses, then a very large number of HCWs will be staying home from work for at least a week. And we know that understaffing is a problem for patient safety.

What are the alternatives? Three that come immediately to mind include: (1) sending HCWs back to work once they are afebrile for 24 hours, as the CDC is now recommending for schools and other workplaces, (2) sending HCWs back to work once afebrile, but making them wear a mask until the 7 day point is reached , or (3) screening all sick HCWs with a test that has a rapid turnaround time and high negative predictive value, and sending those that are negative for influenza A back to work once symptom-free and afebrile. Investigators from Beth Israel-Deaconess in Boston recently reported a negative predictive value of 96% for the rapid DFA test.

As Mike alludes to in his post, the most important thing is to remain flexible, and nimble, realizing that the response to novel H1N1 will evolve with the pandemic. Many hospitals will try initially to adhere to CDC guidance, but must be willing to modify their approach if they begin to experience staffing shortages that threaten patient care.