Prevention in Portland

Last week, several of your friendly neighborhood bloggers (Hilary, Scott, Mike, and yours truly) were among the attendees at this year's SHEA Spring Meeting, held in Portland, OR, and it was great to see how this iteration of the meeting has matured in just a few years.  The Planning Committee, headed by Matt Linam and Judy Guzman-Cottrill (who also hooked us up with some awesome Gram-positive and Gram-negative tailor-made SHEA Voodoo Donuts), did an outstanding job weaving the three traditional training courses (Healthcare Epi, Antibiotic Stewardship, and IP in Post-Acute and Long-Term Care -- check them out next year if you've never attended!) with many general meeting sessions that included important updates, pro-con debates, and impressive science.  The theme of the general track focused on communication, and the plenary sessions included pragmatic discussions of messaging to diverse stakeholders, to the media (with NPR's Joe Palca), and to government stakeholders through advocacy. 

I'm still unpacking everything I enjoyed about the meeting, but to highlight a few things:

• The meeting size was just right to network with old colleagues well as the growing number of new faces in the field
• The posters were held in a converted parking garage, which felt very old school SHEA ("We don't need no fancy ballroom to learn science!")
• Antibiotic stewardship remains very hot, and it was great to see the innovation and engagement on this very important issue (and the continued presence of our pharmacy colleagues at this meeting).  Also nice to see the emergence of diagnostic stewardship at the meeting.  There were several posters on reducing unnecessary urine cultures and C. difficile testing, for example.
• Not to be outdone by stewardship, infection prevention topics hit on some key challenges, including how to influence and change behavior (including the first? ever pro-con where a vegetable was introduced as a dueling weapon), barriers and innovations to improving use of PPE and hand hygiene, and discussions about risk-adjustment of reported HAI data, the limitations of surveillance definitions, and the possibility or folly of "chasing zero."
• Seeing the finalists for the SHEA Epi Competition expertly field many tough questions about their proposed projects -- and congrats to Valerie Vaughn from Univ. of Michigan on winning the $20,000 award for her project entitled "Antibiotic Overuse at Hospital Discharge."
• Getting to watch Scott's son, Daniel, present  like a pro as probably the youngest SHEA presenter in history (on an impressive look at CRE and transfer networks in Atlanta)

There's so much more to hit on, I invite my co-bloggers to jump in! Suffice to say it was a very successful meeting and a very nice partner to our fall extravaganza, IDWeek (Oct 3-7, 2018 in San Fran - register now!).  Next year, it's in Boston (April 24-26, 2019), so block your schedules!  Perhaps Eli will host a 10th blogiversary celebration?

A Research Agenda for MDRO Prevention

Of course, I don't need to explain the clinical importance of multi-drug resistant bacterial pathogens to readers of this blog. I probably don't need to remind you that "more research is needed" either - that's why we have controversies! But, I should probably point you to five papers recently published in ICHE that outline the future research agenda for MDRO prevention in the US Veterans Health Administration (the VA).

For our non-US readers, the VHA is the largest integrated healthcare system in the United States with over 130 acute care facilities, 1000 outpatient clinics, numerous long-term care facilities and 9 million enrolled patients. The VA has been a leader in medical and health services research for decades and has been well-ahead of the curve in application of interventions to prevent MDRO including its MRSA prevention bundle and antibiotic stewardship initiative.

To continue the VA's success in MDRO prevention and link future research questions to the greatest clinical need, we invited a multidisciplinary group with 37 participants to Iowa City in September 2016. The aim of the panel was to outline the VHA's research agenda for MDRO prevention. Dan Livorsi describes the process we used to identify the domains and research questions in an introductory editorial. The outlined research agenda was broad in scope and included efficacy, effectiveness and implementation questions. In addition, many of these questions are broadly applicable to study in non-VA and non-US hospitals. We are all more alike than different.

Research questions fell into four domains:

1. Transmission dynamics: Resistant pathogens are spread via human hands and environmental surfaces. Disrupting this transmission is essential to controlling MDROs.

2. Antimicrobial stewardship: Strategies to reduce and improve the use of antimicrobials will slow the emergence of resistant pathogens.

3. Microbiome: There may be ways to manipulate or augment the human microbiome to eradicate or prevent colonization with resistant pathogens.

4. Special populations: Strategies need to be tailored to patient populations with distinct underlying conditions and in nontraditional care settings.

All 5 papers are open access. Thanks ICHE!  And thank you to the brilliant group of VA investigators, clinicians and operational partners who traveled to Iowa City and contributed to this effort. We all hope it's helpful.

Remember me if I forget (to blog)

#SHEA2018 has just started in Portland and since it's SHEA Spring, it's our blogiversary! Back in 2009, it all started with this post by Dan. We've been on quite a run - 1788 posts, numerous guest commentaries and a good share of controversy.

But you've probably noticed that we've been a little light on posts since around the end of 2016. This is for a variety of reasons, many of which you might guess - busy schedules, enrolling in degree programs, submitting grants etc. The biggest reason that I've rarely posted is that I deleted my twitter app. Since twitter is where I found many interesting ideas for posts, I've lacked some motivation.

But, 2018 is a new year - our 10th year  - and with new bloggers and light at the end of many tunnels, expect big things. I'll be off to Singapore for a good part of the year to learn about MDRO control there - I can imagine some "virtual postcards" from the Uncle Traveling Matt of the blog.

Finally, I saw the Tedeschi Trucks Band in Davenport last night. Amazing show. And Charlie Parr opened for them. Charlie is an amazing blues guitarist from Minnesota - he's a character in the coolest sense and told great stories. I can't get this song out of my head, so I thought I'd share it with you. Have a great time at SHEA - I can't be there. Please, remember me and remember our blog.

Great news from CDC! Help me to understand it...

Today our colleagues at the CDC’s Division of Healthcare Quality Promotion (DHQP) and the Tennessee and Iowa Departments of Public Health released an interesting MMWR Vital Signs report highlighting CDC’s efforts to control emerging antibiotic resistance (AR) phenotypes (main focus being carbapenem-resistance in Enterobacteriaceae (CRE) and Pseudomonas aeruginosa (CRPA)). The release is accompanied by a helpful summary of CDC’s efforts to better coordinate the detection and control of new and emerging resistance threats (including, of course, not only ESBL and CRE but Candida auris, colistin resistance, glycopeptide-resistance in S. aureus, etc.). Check it out!

My major takeaway: investments in laboratory detection of AR are beginning to pay off. By improving their diagnostic capabilities, more regional and state labs are now able to help health care facilities confirm, characterize and respond to pathogens that display unusual resistance phenotypes. This is unquestionably a good thing, though it still requires local facilities to be able to detect phenotypes of concern—for example, many hospitals don’t have ready access to MALDI-TOF or sequencing, and many do not identify Candida to species level routinely from non-sterile sources. How long might C. auris spread in such a facility prior to its detection? So although the AR Lab Network (ARLN) is a major step forward, we still need to emphasize that individual hospitals must invest in improved and timely AR diagnostics--and we ought to ensure they receive updated guidance about how best to detect new or emerging pathogens of concern.

Now for the data itself: the report presents NHSN CAUTI and CLABSI data from 2006-2015 on the percentage of all isolates of E. coli and K. pneumoniae with ESBL and CRE phenotypes over time. The ESBL phenotype was consistently detected in 16-19% of isolates over time, with no major change noted. However, the % CRE declined steadily, from a peak of 10.6% in 2007 down to 3.1% in 2015 (see Figure below). This is despite the fact that CLSI breakpoints for carbapenem susceptibility were lowered during the surveillance period, which should have caused more isolates to meet phenotypic criteria for resistance. And although the CDC published CRE-specific control guidance in 2009, the decline in %-resistant preceded this guidance (which would obviously not have been immediately implemented across the country, likely delaying any impact for 1-2 years). This also coincides with the spread of carbapenemase-producing Enterobacteriaceae (CPE) across the US. So I’m left wondering: why is the % CRE declining as a cause of CAUTI and CLABSI in acute care hospitals?

 

Is it related to the general improvements in infection prevention practices that have accompanied public reporting and pay-for-performance? Would such improvements differentially impact CRE over other pathogens (keep in mind this isn’t a rate, it’s a proportional decrease)? It’s clear that the epicenter of CRE/CPE seems not be in acute care but rather “post-acute care” as is also noted in the other part of the report (the results of CPE screening by ARLN labs for 9 months of 2017)….but I’d still expect increases in post-acute care or other health care settings to eventually be reflected in the NHSN CAUTI/CLABSI data. Granted, the NHSN data represents a relatively small number of organisms (for example, Clare Rock and colleagues demonstrated that CLABSI represent only 6% of all hospital-onset bacteremias).

I remain perplexed. And happy to hear any thoughts on this!

Metrics, Decision Makers and Hospital Epidemiologists

This is a guest post by Silvia Munoz-Price, MD, PhD, Enterprise Epidemiologist and Professor of Medicine, Division of Infectious Diseases, Froedtert and the Medical College of Wisconsin.

During the past few weeks I have been mulling over two issues related to Quality and Infection Control that have to do with metrics, their use, and the impact that they have in our hospitals. Two separate topics but related to a certain degree.

1. My hospital has a strong Quality Department and a stronger culture of safety. For the most part we have very few serious infections and even fewer MRSA, VRE, and almost no multidrug resistant Gram negative rods. Our compliance with hand hygiene is 73% (as per >5000 observations collected over a couple of months by managers from units that are not their own and concordant readings obtained by the Infection Control Department. I am trying to tell you that 73% is probably close to accurate). From my perspective, if indeed true, this is an acceptable rate. I think we should concentrate on preserving this rate and maybe focus on areas/providers that need more attention. However, my hospital wants this number to be close to 100%. So, here are my questions: should we invest more time, effort, and money to push for higher compliance with hand hygiene? What would be the return on investment of increasing our hand hygiene compliance and how could we measure its impact? What type of infections would we prevent by increasing hand hygiene compliance? Yes, our CLABSIs and CAUTI rates could be better, but would they noticeably improve by pushing hand hygiene above 80%? (I’m intentionally not discussing C. difficile infections as these have a different etiology in my hospital). And most importantly what other interventions would we be overlooking by focusing so much on hand hygiene? Who decides where to allocate time, effort and money?

2. Over the past couple of decades I have observed a shift in Infection Control throughout the various places I have worked at from minimal interest/resources given to Infection Control, to a phase where more visibility was given to Infection Control matters --probably due to metrics--to the allocation of more interest/resources, to publicly reported metrics, to institutional notoriety and reimbursements linked to metrics, to a tunneled vision about metrics. On this topic, many years ago I observed a human behavior that since I have observed multiple times: when we started placing fluorescent powder on surfaces and giving feedback to providers on the degree of removal, cleaning rates improved (https://www.ncbi.nlm.nih.gov/pubmed/21460514). Feedback was then given weekly and in a public manner, with a substantial amount of pressure placed on EVS to improve. The numbers got much better. We eventually figured out that EVS providers bought their own ultraviolet lamps to find the fluorescent markers and spot clean them. What happened? The metric made sense at the beginning, initially it probably achieved its intended outcome (more frequent cleaning) but then a threshold was crossed, after which what mattered was the metric (as a number) and no longer the intended outcome (more frequent cleaning).  I think the same is happening to our hospitals. Metrics were beneficial initially (more resources for Infection Control, more visibility, more engagement of staff, lower infections) but I would argue that we are on the other phase of the metrics (unintended consequences).  All the pressure we are placing for lower and lower metrics (get to zero CAUTIs!) might be backfiring. We are deploying large teams and resources to decrease certain conditions which is shifting our capability to address issues that might be equally or even more important in our respective hospitals   (e.g. post craniotomy  SSIs).  So, who decides how to allocate our limited resources? I would argue that Quality is now the main decision maker and that these decisions are strongly guided by publicly reported metrics. Is this good or bad for our patients? I am not sure. Is this good for the field of Hospital Epidemiology? I don't think it is. Hospital Epidemiologists need to re-think their involvement in Quality and become their hospitals’ Chief Quality Officers. That is the only way I see that we will impart some sense to the decisions of resource allocation. However, the opportunity for our specialty to lead in this field might have already passed.     

Risk(y) Business, Part 3

I've posted before (HERE and HERE) about the need to improve risk adjustment for publically-reported HAI metrics that are increasingly used for reimbursement, rankings of hospital quality, incentives for hospital leadership, and (who knows at this point) may be part of the voting for Best Picture at the Oscars (I kid).  The group at the forefront of this issue with work examining potential methods to balance the playing field is from of U. of Maryland, having previously shown how the use of coded risk factors can improve risk adjustment for CLABSI and SSI.  They're back with a trifecta - a retrospective cohort study focused on the relationship between coded patient comorbidity variables and hospital-onset C. difficile infection (CDI) event risk.  After adjusting for antibiotic and proton-pump inhibitor use (both potentially controllable risk factors for CDI), the odds of having CDI significantly increased 1.26 times for every 1 point increase in the Elixhauser comorbidity index score.  The risk model that included the Elixhauser index score was a better fit than one with this information excluded.  There are some limitations, noted in the paper:  single center study, lack of control for patient severity of illness, and use of coding to capture comorbidity diagnoses (which is, however, a strength when looking towards ease of abstraction if these variables are included in reported HAI metrics).  Even with these limitations, this study provides further support for the need for improved adjustment for patient-specific comorbidities when using HAI outcomes to rank hospitals in order to provide our patients with accurate information about these important patient harms while also more equitably tying monetary incentives to facility HAI performance - an increasingly risky business indeed.

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?