Benefits of Universal Gloving

Last but not least in the May issue of ICHE, Gonzalo Bearman and our very own Mike Edmond from VCU in Richmond, completed a nice quasi-experimental study looking at the benefits of universal gloving for all patient contact vs. standard contact precautions in their 18-bed surgical ICU. In phase 1 from September '07 to March '08, only standard contact precautions based on passive (clinical culture-directed) surveillance were used while in phase 2 from March '08 to Sept '08 universal gloving with emollient-impregnated gloves was used without contact precautions. During both phases, admission and every 4 day surveillance cultures were performed for MRSA and VRE but for study purposes only and not shared with the clinical teams.

So what happened? Only good things. Universal gloving compliance was 78% in phase 2 and was associated with higher hand hygiene compliance on entry (5% higher) and exit (12% higher). It also appears that universal gloving was associated with reduced CLABSI and catheter-UTIs, but with p-values = 0.1 for both outcomes. C. difficile was also lower (2.0/1,000 patient-days down to 1.4/1,000) but this finding was not statistically significant, p=0.53. VAP rates were the same (1.0 vs 1.1/1000 device days) The most important finding, in my opinion, was that HCW were less likely to have MRSA and VRE contaminating their hands during the universal glove phase. Despite what the authors state (Mike don't be mad!), the study was not likely powered sufficiently to find reduced acquisition, given that MRSA acquisition was reduced by 50% with universal glove (2.9/1000 patient-days vs. 1.4/1000 patient days) but this had a p=0.2.

I think overall, that these findings suggest that universal gloving shows promise warranting further study. I wonder if they stopped universal gloving after the study period? If they did, this would make for a very epidemiologically sound quasi-study (roll-in and roll-out) which could be analyzed using more powerful segmented Poisson regression,which can detect a change in slope and intercept associated with starting or stopping the intervention.

The June ICHE just appeared online 5 minutes ago...more exciting evidence for us to review!

Rhinoceroses and Total Hip Arthroplasty

Distinctions are very important. I was just visiting Ohio last week and had the chance to visit the Columbus Zoo. It's a pretty cool place if you like zoos. I enjoyed reading about various animals and learned that the Black Rhino is endangered, while the White Rhino is not. Thus, it would make sense to spend your conservation money, if you have some, on Black Rhinos first, since time is running out. In infection control, we ought to do the same thing, but in reverse; spending our limited resources on preventing more common infections first. Also, with the rise of public reporting and other methods of interhospital comparison, efforts must be made to place hospitals on a level playing field. There is a nice study that highlights these two issues in the May ICHE by Surbhi Leekha and colleagues at the Mayo Clinic in Rochester, MN.

They examined at a 5-year cohort (2002-2006) of all total hip arthroplasties (primary and revision) and looked to see who developed SSI, using CDC definitions. After controlling for age, gender and NNIS index, patients who had a revision total hip arthroplasty had twice the odds of SSI compared to primary surgery (OR=2.2, 95% CI 1.3-3.7). The difference was even more stark when outcomes were restricted to deep or organ space SSI with revisional surgery associated with four times the odds of SSI (OR 3.9, 95% CI, 2-7.9). One note, they didn't appear to control for duration of surgery as a confounder, even though it was associated with both revisions and SSI. I think this is correct. They were not completing a risk-factor study, but were interested in outcomes.

The usual caveats apply to these types of studies including a single center study and a relatively unique single center at that. However, this is an important study and if these findings hold up at other institutions, which they most certainly will, this suggests that the case-mix of revision and primary hip arthroplasty must be taken into account when SSI rates are reported and hospitals compared. Perhaps an easier solution, as the authors suggest, is to treat them as two different animals, if you will, and report them separately. Also, if one wanted to target specific infections or high-risk procedures, these results suggest targeting revision surgeries over primary ones.

Note: Surbhi is joining the group at my old Maryland stomping grounds and I know everyone is excited for her to arrive.

Oxymoron of the Day

A new white coat design greeted me this morning when I arrived at the office. One that I'm sure Mike will call me about immediately to order for his hospital! We all know how much he loves white coats. (that's a joke if you are new around here)

I've already stated previously, that I don't know what a metaphor is, so it won't be a surprise to you that I'm not sure if this coat qualifies as a true oxymoron, a physical oxymoron or is just ironic. I do think it sums up my feelings towards infection prevention these days. We are driven by the desire for zero infections, which while good in theory, can have unintended negative consequences. This white coat is a perfect example: Good for education (although I suspect that is debatable) and bad for spreading pathogenic bacteria (MSSA, MRSA, Acinetobacter) from patient to patient.

Anyway, Dan's post below is more interesting, so please move along.

Does PowerPoint make us stupid? I have 4 bullet points on that….

There have been several critiques of PowerPoint over the years (one of my favorites, here, is a PPT summary of the Gettysburg Address). But the program remains among the most commonly used tools for disseminating information in health and medicine.

An interesting piece in today's NY Times discusses the military’s increasing use of PowerPoint, and the accompanying backlash. A good summary quote, here:

“[PowerPoint is] dangerous because it can create the illusion of understanding and the illusion of control,” General McMaster said…..“Some problems in the world are not bullet-izable.”

I agree that using PowerPoint can be detrimental when the objective of an interaction is to spur action or implementation….as it tends to convert the audience to passive recipients of neatly packaged information, rather than active participants and problem solvers. For example, if you are presenting plans for bloodstream infection prevention to your ICU staff, one of your slides might contain bullet points recommending “culture change” and “administrative engagement”. What does that mean?

On the other hand, if your purpose is to escort your audience into the 9^th circle of “PowerPoint hell”, then go for it!

"Senior officers say the program does come in handy when the goal is not imparting information......news media sessions often last 25 minutes, with 5 minutes left at the end for questions from anyone still awake. Those types of PowerPoint presentations, Dr. Hammes said, are known as “hypnotizing chickens.”

NHSN Definitions for CLABSI: Preventing the Unpreventable?

There is a nice Concise Communication in the May issue of ICHE out of the University of Michigan (Go Blue). The investigators were interested in the specificity of NHSN CLABSI definitions in their Critical Care Medicine Unit (CCMU) and their SICU during the period after implementation of CLABSI bundles. They excluded from review BSIs that were determined to be central line-related BSIs (CLRBSI) since they required positive cath-tip cultures or differential time to positivity. They then had all CLABSIs, as determined by unit-designated infection preventionists using NHSN definitions, reviewed further by two non-blinded ID physicians.

To cut to the chase, since this post shouldn't be longer than the original concise communication, there were 30 non-secondary BSIs in the CCMU, 10 were CLRBSI and 20 were CLABSI. Of the 20 CLABSI, 9 (45%) were considered to have central line sources, 9 were considered contaminated blood cultures and 2 were considered transient post-op BSIs. Of the 8 non-secondary BSIs in the SICU, there were no CLRBSI and 5 (63%) were intra-abdominal sources and 1 unknown non central-line source leaving 2 confirmed CLABSI. Thus, of the original 38 IP-reported CLABSIs in the two ICUs, ID physicians confirmed 21, leaving them with an positive predictive value of 55%; close to flipping a coin.

Now, I didn't read the discussion section of the paper (who has the time!), however, since they only looked at IP determined CLABSIs they can't report sensitivity or specificity; in fact they didn't calculate the PPV, I did that. Given that so many CLABSIs appeared to be contaminated blood cultures, efforts could now be directed to preventing those, but the clinical benefit to the patient would likely be small apart from a few avoiding unnecessary antibiotic exposure. Efforts spent limiting those non-BSI CLABSIs, I suspect will be undertaken since we all have to get to zero. It's just sad that those efforts won't help our patients.

How many chickens for a 7-day linezolid course?

Like many, I’m intrigued by the health care reform proposal recently put forward by a Nevada Senate candidate. The proposal calls for a return to the barter system for health care delivery. There are only a few problems. One recent analysis concluded that basing such a system solely on chickens would be impossible, given the sheer number of chickens required.

Another shortcoming--what to do about adverse events and nosocomial infections? Shouldn’t a patient also receive goods or services if he or she is harmed during the delivery of health care? I can see it now…returning home after a hospital stay complicated by a nosocomial infection, you discover that the hospital has sent someone over to paint your house…

Tracheotomy, VAP, p-values and death

There is a new RCT just published in JAMA by a large group in Italy looking at the benefits of early (day 6-8) vs late (day 13-15) tracheotomy completed in 12 ICUs. The primary endpoint was VAP. There is also a very nice accompanying editorial. There are several interesting findings. First, patients randomized to early tracheotomy were less likely to develop VAP by day 28, 14% vs 21%, but the p-value was 0.07. Since the p value was greater than 0.05, the authors were forced to say that there was no benefit from early tracheotomy.

Interestingly they also found significantly greater vent-free days, ICU-free days, successful weaning and ICU discharges in the early tracheotomy group. There was even a trend towards higher survival in the early vs late group, HR=0.80, 95% CI 0.56-1.15. The authors and editorial do a nice job of pointing out that 31% of early and 43% of the late group didn't even receive a tracheotomy due to impending extubation or death. The editorial even makes the point that selecting an early tracheotomy is really a strategy of more trachs. The study did not assess patient comfort, which may be associated with early tracheotomy.

What is always troubling to me is that scientists, editorialists, journals and clinicians are stuck in this p-value trap. Here we have a study, a very good randomized trial, which shows likely clinically significant reductions in VAP and potentially lower mortality, but since the study was underpowered we are forced to say "no difference." I wonder if you calculated how many patients are intubated each year in the US (or Italy) and reduced VAP rates by 33%, how many VAPs would be prevented and how many deaths would be prevented? I know this study should be repeated, but will it? You have a negative JAMA study, what's the incentive? I describe this phenomenon as "Death by p-value."