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

Lack of Financial Incentives for Preventive Interventions

One of the barriers to infection control and antimicrobial stewardship is the lack of financial support from third-party payers, such as insurance companies and medicare. For example, wouldn't it be great if we could bill for hand hygiene every time it was practiced correctly? The end result of this lack of support is that society is willing to pay thousands for a CABG surgery, for example, but not willing to spend a penny on preventing a surgical site infection.

There is a new perspective in the NEJM by two physician behavioral economists, Katherine Pryor and Kevin Volpp, that examines barriers to putting preventive services on equal financial footing with treatments. While their comments largely focus on patient-targeted (vs population targeted) preventive services like lifestyle-modification for diabetes prevention or smoking cessation, they highlight many barriers that could apply equally to population-level interventions like infection control. I've highlighted a few:

"...treatments determined by the Food and Drug Administration (FDA) to be safe and effective are usually covered by insurers regardless of their cost, but preventive services have been held to a higher standard: they are often assessed on the basis of whether they generate a positive return on investment and save money in the short term. This disparity leads to overprovision of treatments and underprovision of preventive services"

"Even Medicare — which typically covers beneficiaries for life — holds preventive services to a higher standard, applying cost-effectiveness analyses when making coverage decisions about preventive services but not treatments. This double standard has resulted in coverage of cost-ineffective therapies with prices of up to hundreds of thousands of dollars per quality-adjusted life-year, including treatments of questionable benefit"

The perspetive is worth a careful read. Would also be nice to see a similar commentary describing these barriers from an infection control perspective too.

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?

Essential reading on Candida auris

During my intern rotation on the University of Virginia bone marrow transplant unit, I convinced myself that a Candida krusei epidemic was brewing. One of my patients was infected, and the bug was (and is inherently) resistant to fluconazole, a drug that had only recently been introduced (yes, I’m old—the year was 1990). This never really came to pass—despite 30 years of widespread fluconazole use, C. krusei still accounts for < 5% of invasive candidiasis, and outbreaks are rare. 

Now, a Candida species that wasn’t even described a decade ago is emerging as a major problem in ICUs around the world. The Candida auris story is fascinating, puzzling, and concerning. For reasons nobody understands, the species emerged (or began to recognized) almost simultaneously on three different continents. Although risk factors for invasive C. auris are similar to those for other causes of invasive candidiasis (ICU stay, antibiotic exposure, device use), it also features high rates of antifungal resistance, persistence on environmental surfaces, resistance to commonly used disinfectants, frequent transmission in ICU environments, and has thus caused several large, difficult-to-control outbreaks.

If you want to catch up on this emerging pathogen without spending hours on a literature review, there’s an excellent summary publication now out in Clinical Microbiology Reviews from Anna Jeffery-Smith and colleagues. See Table 4 for a summary of infection prevention recommendations from UK, US, EU and South Africa.

Holiday gift idea!

Anyone who practices hospital infection prevention knows how many “data gaps” exist—gaps that make it very difficult to decide which approaches ought to be implemented in your own facility. Should we institute a no-touch disinfection technology? Implement universal decolonization? Use gowns and gloves for all ICU patients? Spend money on an automated hand hygiene monitoring system? Establish a bare-below-the-elbows attire policy? Invest in antimicrobial impregnated textiles (curtains, scrubs, etc.)? Recommend probiotics for selected patient populations?

In the absence of definitive studies, we want carefully considered opinions from smart people who have a wealth of experience in infection prevention. Right?

So if you’re looking for holiday gift ideas for your favorite hospital epidemiologist or infection preventionist, check out this new textbook: “Infection Prevention: New Perspectives and Controversies”, edited by our friends Gonzalo Bearman, Silvia Munoz-Price, Dan Morgan and Rekha Murthy. The text is a nice companion to this blog—in addition to covering all the above questions (and more), the chapters are generally concise, well-written and appropriately referenced. The emphasis is not on being encyclopedic, but on addressing the top-of-mind issues that hospital epidemiologists and infection preventionists deal with most often.

Playing Nice: Infection Control and Clinical Microbiology in the Pay-For-Performance Era

As it's probably clear, it's been a great honor for me to work (and blog) with Dan and Mike over the past 8! years. One of the things that stands out when talking shop is their ability to see both sides of an argument even while pushing for the changes they support. Many times, their ability to see both sides clearly is possible because they've lived both sides - Mike has been an ID chief and hospital epidemiologist and is now our CQO and Dan is an ID chief, hospital epidemiologist and clinical microbiologist. You know, if I was a fellow or faculty member looking for a hospital epidemiologist position with great mentorship and support, I would move to Iowa...but I digress.

One specific area where understanding competing goals is critically important is the interplay between the increasing sensitivity and precision of microbiologic tests and the growing pressure to reduce HAI. As you can imagine, with 3% of CMS payments potentially at risk, anything that could impact HAI rates in a negative fashion is bound to be a flashpoint for hospital administrators. With that in mind, I point you to Dan's excellent commentary just published in JCM that examines the implications of advances in microbiological testing on HAI rates and provides specific suggestions for how hospital epi programs and clinical microbiology labs can work together to respond to these changes.

Initially, Dan provides three scenarios where changes in the micro lab could directly impact HAI rates (1) The effect of MALDI-TOF on CLABSI rates (2) The shift from EIA to nucleic-acid amplification tests (NAAT) for C. difficile detection and (3) Pressure to block urine culture ordering to reduce CAUTI. After delving into the current CMS reimbursement landscape, the unintended consequences of improvements in diagnostic testing and the use/misuse of surveillance definitions, he provides six valuable recommendations that clinical microbiology labs (CML) and infection prevention programs (IPP) should consider:

(1) CML leadership should select diagnostic approaches with the goal of improving individual patient outcomes

(2) Hospital and IPP leadership should not pressure the CML to alter diagnostic practices based on the need to demonstrate lower HAI rates for pay-for-performance measures. 

(3) Public health authorities (CDC/NHSN) must be proactive in adjusting HAI metrics to changing CML technology

For recommendations 4-6, you're gonna have to read his commentary. But a hint at #6 -  CML and IPP leadership need to collaborate and advocate for their needs, because, unlike at Iowa, both sides aren't always present in the mind of a single person.

Time, Power and Infection Prevention

With the increased attention to infection prevention and antimicrobial resistance globally, we now have more seats at the table. In fact, many of us are or will soon be at the table in positions of leadership (power) in our hospitals or organizations. We can include our colleagues at CDC, who are being asked to do more and manage larger research portfolios. The time we imagined 10-20 years ago, where our clinical and research roles would be appreciated is now, but with the now comes an overwhelming urgency - we are overworked.

With that in mind, I read a very interesting post by Maria Popova on UC Berkeley psychologist Dacher Keltner's book, The Power Paradox: How We Gain and Lose Influence. Two quotes in particular struck me as they applied to our current situation as hospital epidemiologists and infection preventionists:

"The power paradox is this: we rise in power and make a difference in the world due to what is best about human nature, but we fall from power due to what is worst. We gain a capacity to make a difference in the world by enhancing the lives of others, but the very experience of having power and privilege leads us to behave, in our worst moments, like impulsive, out-of-control sociopaths"

"But in reading these alarmingly consistent studies, I had to wonder about one crucial confound(er) that remains unaddressed: People in positions of power also tend to be busier — that is, they tend to have greater demands on their time. We know from the now-iconic 1970s Good Samaritan study that the single greatest predictor of uncaring, unkind, and uncompassionate behavior, even among people who have devoted their lives to the welfare of others, is a perceived lack of time — a feeling of being rushed. The sense of urgency seems to consume all of our other concerns — it is the razor’s blade that severs our connection to anything outside ourselves, anything beyond the task at hand, and turns our laser-sharp focus of concern onto the the immediacy of the self alone."

I encourage you to read her full post and ponder how the Power Paradox might (or might not) apply to our new and larger roles in infection prevention. For example, I've noticed during discussions at national meetings and in peer-reviewed publications that we're blaming healthcare workers if they don't wash their hands or criticizing physicians if they overprescribe antibiotics. Keltner suggests that the Paradox can be handled by putting our focus on other people including empathizing, giving, expressing gratitude, and telling stories. It might seem that our focus on others (patients) might protect hospital epi folks, but what about the people we need to work with if we're to be successful - other healthcare workers?

Infection Prevention Thoughts of the Day

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

E is for...Enterovirus 68

Never a dull moment. Just as facilities have begun wrapping up their Ebola preparation plans, there's gathering evidence that several US states may be facing large clusters of acute respiratory illness associated with human enterovirus 68 (EV68).

Last week the Missouri Department of Health released an Alert describing increased cases in St. Louis and an outbreak of over 300 acute respiratory illnesses in a Kansas City pediatric hospital with 15% requiring ICU care. 19 of 22 specimens sent to the CDC from the Kansas City outbreak were positive for EV68. Many St. Louis cases were positive for enterovirus but specific typing is pending. Denver is seeing severe respiratory illness in very young children and children with asthma. Children's Hospital Colorado has treated 900 children and admitted 86 since August 18th, but so far the specific viral pathogen has not been confirmed. CDC reports similar cases have appeared in at least 10 states -- Missouri, Kansas, Illinois, Kentucky, Iowa, Colorado, Ohio, Oklahoma, North Carolina, and Georgia.

There are a few publications over the last 5 years describing EV68 associated outbreaks including an MMWR covering 2008-2010 clusters and individual reports from the EV68 emergence in the Netherlands, and an Indian Health Services (IHS) outbreak in children (both were already covered in MMWR). The Netherlands has seen the majority of cases in September to November (Figure above) with the highest prevalence in patients ages 50-59, while the IHS outbreak occurred in August-September in children with a median age of 4.8 years.

Clinical Findings: Signs and symptoms include cough, tachypnea, hypoxemia, and wheezing, particularly new-onset. In the Arizona IHS outbreak, at least half of the children had infiltrates on CXR and short hospital stays (median 1.5 days). The clinical presentations of the 18 IHS patients are listed in the table below.

Diagnosis: There are commercially available, FDA-approved, multi-pathogen detection systems including Luminex xTAG RVP, Idaho Technologies FilmArray Respiratory Panel. However, these non-specifically identify pathogens as "entero-rhinovirus" or "human rhinovirus/enterovirus." Most facilities can't currently perform enterovirus typing. Identification of EV68 requires partial sequencing of the structural protein genes, VP4-VP2 or VP1.

Treatment: There is no specific treatment for EV68. Care is usually supportive and only a minority of patients require brief hospitalization. Currently, there are no vaccines available.

Infection Prevention: The CDC currently (2007) recommends Standard Precautions for enteroviral infections but recommends "Contact Precautions for diapered or incontinent children for duration of illness and to control institutional outbreaks." However, most of the data that informed these recommendations were not derived from respiratory EV68 outbreaks. Recommendations from Hong Kong are very similar. 

I contacted a hospital epidemiologist in one of the states experiencing an outbreak, who has graciously shared their current protocol. Currently, they use symptoms to drive precautions so their respiratory patients are placed on droplet plus contact isolation for the duration of their hospitalization. In addition, they started their usual winter respiratory visitation restrictions last week so that children under 13 yo cannot visit and increased their focus on year-round routine screening of all visitors/family members for illness. Finally, they noted that this was the earliest they've ever started respiratory visitation restrictions.

Reality bites: human bites and infection prevention

Our posting has been slow, and will continue to be for a short time due to clinical service and travel schedules. However, I thought now was a good time to review the management of human bite wounds. There are summaries in Medscape and UpToDate, a literature review in this trauma journal, and even national (UK) guidance on management. There is not uniformity in the literature about the need for antibiotic prophylaxis, though most would use something like amoxicillin-clavulanate if the bite punctures the skin, particularly if it involves the hand or another joint capsule or tendon. Remember also to assess need for a tetanus booster, and to evaluate for bloodborne pathogen exposure. Rabies in humans remains rare in most parts of the world, and in the most recent case I’m sure there will be at least a 10-day observation period for the biter.

SHEA 2015 - New Format - Abstracts - May 14-17

I’m excited to announce that I will be co-chairing the 2015 SHEA meeting with Susan Huang. The new format will combine the highly regarded SHEA Basic Training Course in Healthcare Epidemiology with plenary, abstracts and symposia focused on infection prevention topics including long-term care, implementation science, science communication, MDROs, device infections and antibiotic stewardship. A strong emphasis will be placed on networking and mentoring sessions. The meeting will take place in Orlando, Florida (May 14-17th). The abstract site will be open from August 1, 2014 to January 16, 2015 and awards will be given to the top abstracts and posters at all career levels. So, get busy making science and look forward to seeing you in Orlando!

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!

Evidence-based infection prevention: A modest proposal

This is a special guest post by David Hartley, PhD who is a Research Associate Professor in the department of Microbiology and Immunology at the Georgetown University Medical Center.

I don't know if there are dedicated courses in schools of medicine and nursing in the US devoted specifically to hospital infection control and prevention, but if there are, I haven't found them. There are lots of training courses offered by trade societies, and many of these are great at conveying procedure, technique, and rationale, but I'm thinking about academic, didactic courses presenting a comprehensive picture of what is known, how it is known, and emerging ideas about infection control and prevention. Any science-based course should expose the learner to the continuum of theory, evidence, and practice. I think it could be done in a semester.

How best to approach such a course needs to be discussed and worked out, but one might, for example, begin with a survey of what we know about what people are commonly colonized and infected with, and how they got that way. This would entail examination of aerosol, alimentary, percutaneous, and other infectious pathways as appropriate, focusing upon important pathogens of concern in healthcare facilities. It could then go on to examine microbial life histories along each route of infection, and how common hospital practices act synergistically or antagonistically with each such route. Host response to infection would be important to cover, and a quantitative epidemiological component should also be included. To tie everything together, learners could undertake a final project assessing what current infection prevention practices are evidence-based and which aren't, and what evidence might be useful for better informing infection control practice. Such a course might be entitled Infection Control and Prevention: From Science to Practice. If done well, the course could help to train learners to think about infection within the context of a coherent, interconnected, evidence-based picture.

By and large, it seems like such an expansive, theoretical picture of hospital infection control and prevention is lacking at present. There are mathematical and computer models of varying complexity and realism that together have led to insights, though how to generalize and apply these is sometimes unclear to preventionists. There are also rules and guidelines, though some (many?) are not as well studied as one might expect (e.g., handwashing and contact precautions). There are increasing numbers of studies suggesting that this intervention works here and that intervention works there, but understanding how all this knowledge fits together to inform thinking and practice, in a truly robust way, remains elusive. A systems approach to both teaching and thinking about infection prevention may prepare the next generation of researchers and clinicians to think more holistically and progressively about infection in healthcare environments.

The hard work of infection prevention

It is Labor Day today in the U.S., which is meant to be “a yearly national tribute to the contributions workers have made to the strength, prosperity, and well-being of our country”. In that spirit, we recognize those who are on the front lines of infection prevention every day. Performing hand hygiene a hundred times per ICU shift, tracking checklists for device placement and care, carefully disinfecting the high touch surfaces in a patient room, meticulously reviewing medical records for HAI surveillance, analyzing scores of agar plates to find HAI pathogens among commensal flora—these activities don't sound particularly exciting, but all are part of the daily grind of infection prevention and require dedicated nurses, housekeepers, infection preventionists and laboratorians. As much as we need to advance the science in our field, new-and-improved HAI prevention approaches won’t make a difference without the continued hard work and attention to detail of these talented professionals. Happy Labor Day!

KPC (Yeah You Know Me)

Now that I have your attention, I wanted to point out a recent review in Lancet ID by Silvia Munoz-Price and colleagues. It's behind a paywall with a $31 charge, so hopefully you have access through your institution or can email one of the authors to request a copy. The co-authors do a wonderful job highlighting the emergence of KPC containing strains in the US (1996) and subsequent spread of these β-lactamases throughout the world. Importantly, they discuss treatment options (or lack thereof) and emphasize the important role that infection prevention will play for the foreseeable future. They also suggest that stewardship might be more relevant in plasmid (non-clonal) outbreaks.

More dirty laundry......

A new study in the American Journal of Infection Control by Dr. Silvia Munoz-Price and her team at the University of Miami provides additional insights on laundering of clothing worn in the clinical setting. In a convenience sample of 160 physicians and medical students, the Miami team found that white coats were laundered on average every 12.4 days, while scrubs were laundered every 1.7 days. I found it a little surprising that for scrubs the frequency wasn't closer to 1.0, but that's tremendously better than 12 days! For both coats and scrubs, faculty laundered their attire more often than housestaff or students. Interestingly, the major reasons given for wearing white coats were: (1) ego (makes me looks and feel like a doctor, 29%), and (2) storage needs (25%). Neither is a good reason.

Late last year, the same team published a study that found that white coats were more commonly contaminated with pathogens than were scrubs in the ICU setting. Moreover, if the hands were contaminated with a pathogen, white coats were more commonly contaminated than were scrubs. And all of the HCWs with negative hand cultures were dressed in scrubs.

Both studies were relatively small and performed in a single (though very large) medical center. Nonetheless, there is a body of evidence accumulating that clothing contamination in the clinical setting is a real phenomenon and probably should no longer be ignored by infection prevention programs. So I was delighted a few days ago to see that West Virginia University Hospitals is considering banning ties and white coats.

Photo:  Dr. Munoz-Price (far right), in scrubs!