VAP: Do you know it when you see it? (Again!)

There's a new paper on the utility (or lack thereof) of CDC's definition of ventilator-associated pneumonia. In this study 4 persons reviewed 50 cases of ventilated patients with respiratory deterioration >48 hours after intubation. Two reviewers were experienced infection preventionists who applied the CDC definition. A third IP used a modification of the CDC definition that was more quantitative, and the fourth reviewer was a physician board-certified in infectious diseases and critical care who used clinical judgment to define VAP. Using the standard definition, one IP assigned the VAP diagnosis to 11 patients and the other, 20 patients. The IP using the modified definition assigned 15 cases as VAP. The physician diagnosed VAP in 7 patients. The IPs agreed on 62% of cases (kappa=0.40). All 4 reviewers agreed on the VAP diagnosis in only 4 cases. This is not the first study to show how complex assigning the diagnosis of VAP can be.

Given that public reporting has raised the stakes to high levels, the CDC can no longer ignore this issue. Consumers cannot make choices on where to receive care if inter-hospital comparisons of infection rates are not valid. There needs to be a convening of IPs and hospital epidemiologists who use the definitions on a daily basis to thoroughly assess each of the HAI case definitions and begin to work on the development of new ones that will be fair to hospitals and helpful to consumers. Otherwise, it's garbage in, garbage out, and the entire concept of public reporting is undermined.

"Lessons of a $618,616 death"

I arrived at the gym tonight with nothing to read. Given that 30 minutes on the bike can seem like eternity, I went to check out whatever was left behind by those smart enough to bring along some reading material. I found only two recent but ragged magazines--BusinessWeek and Entertainment Weekly. My heart sunk--I was facing eternity on the bike. Then the BusinessWeek cover caught my eye: Lessons of a $618,616 death. The cover story was written by Amanda Bennett about her husband, who died after a 6-year struggle with kidney cancer. After his death, she read all 5,000 pages of his medical records, analyzed every medical bill, and tells the story of his illness in an incredibly honest way. She describes some of the fundamental flaws of the US healthcare system, the bizarre workings of the insurance industry, the moral hazard of having good insurance, and the desperation of the terminally ill that leads to a spare-no-expense mentality even when the odds of success are very, very small. In the end, she feels guilty about the fact that the resources spent on trying to save her husband could have vaccinated a quarter million children, yet she admits she would do it all over again. The entire article can be read online here. It's a must-read.   

Another tremendous hand hygiene video

Here is the video that Andreas Voss showed at the Decennial. This fun and informative piece, produced by the group in Geneva, may appeal to the more artistically inclined healthcare worker.

Cover that stethoscope!

We have placed a great deal of emphasis on hand hygiene in the healthcare setting over the past few years, but unfortunately little is said about the stethoscope. Found hanging from almost every doctor's neck, the device is used many times in the course of a day, but most physicians seldom wipe it down. Studies have shown it to be contaminated with common pathogens. So I was excited to see an article in the Boston Globe about Dr. Richard's Ma invention, a disposable plastic cover (shown in the photo). Do you think physicians are any more likely to use the cover than wiping the stethoscope down?

Photo: David Ryan, Boston Globe

Bundle up!

The New York Times is confirming that Don Berwick, president of IHI, is going to be named the new director of the Centers for Medicare and Medicaid Services. I recommend this thoughtful post by Dr. Bob Wachter on the appointment. As Bob points out, Don is very much on the "just do it" side of the equation regarding infection prevention and other patient safety issues, and his fame has arisen in large part from his amazing charismatic appeal. How this will translate into infection prevention policies at CMS is anyone's guess.

Religion vs. infection control: an update

We've blogged before about Muslim women who are healthcare workers in the UK facing disciplinary action for refusing to follow "bare below the elbows" on religious grounds. Now the National Health Service has made a concession: these women can now wear disposable sleeves with elastic cuffs when they have contact with patients.

A year in the blogosphere

Today the blog celebrates its first birthday! It's been great fun for all of us and we thank our readers. At the Decennial Meeting last week, we were stopped by many who just wanted to let us know they enjoyed following the blog.

The hottest topics of the year were (in order, based on the number of postings):
1.  H1N1 influenza
2.  MRSA
3. Active surveillance
4. Public reporting of healthcare associated infections
5. The role of white coats and clothing in infection prevention

Interestingly, the number one topic, H1N1, wasn't on our radar screen when the blog started a year ago, but it appeared suddenly and held our attention for most of the year.

According to Caslon Analytics, "the average blog has the lifespan of a fruit fly," with 60-80% of blogs not surviving past the first month. Of those blogs that survive past day 1, the average lifespan is 126 days. So, I guess we've beaten the awful odds of blog neonatal mortality.

As always, we invite you to post your comments.