High stakes metrics and human nature

Eli didn't want to wade into the VA waiting-time crisis, so I'll just do it instead.  Because we’ve covered this ground before. Whenever a metric is tied to a high-stakes incentive or disincentive (monetary bonus or penalty, job security, etc.), gaming of that metric is inevitable. College test scores, crime rates, HAI rates, the dynamic is the same. 

So forgive me if I’m not shocked, shocked, that VA administrators used various ways to game their waiting-time metrics in response to what this NY Times report describes as “pressures to excel in the annual performance reviews used to determine raises, bonuses, promotions and other benefits.” Fudging dates, creating “ghost clinics”, keeping two sets of appointment books—all are being reported to have occurred in some facilities. If you think this is the scandal, you are missing the point. The scandal is that the VA has too few physicians to see an expanding number of veterans needing care (see Eli’s post for more on the trends contributing to primary care shortages).

So I hope lawmakers begin working to fix that problem, once they finish expressing their outrage for the cameras. The VA is an excellent healthcare system, one that matches or outperforms the private/non-VA sector in many measures of care quality and safety. I’m sad that this is getting lost in the current media frenzy—read this piece for a nice counterpoint.

The Primary Care Crisis in Three Wee Little Pictures

I don't intend to cover the current primary care, wait time crisis that's in the news. The topic, of course, is way beyond my area of expertise as a hospital epidemiologist.  However, as I've been reading the news reports, these three "trends" seem to be behind the crisis. There is nothing much we can do about trend #1. However, when you combine an aging population with huge pay discrepancies between primary care (Psychiatry, Internal Medicine, Family Medicine and Pediatrics) and other specialities (trend #2), you have a recipe for a crisis. Trend #3, requires more discussion, but paying more for healthcare over the past few decades doesn't seem to be gaining us more clinicians (the dark red area on the third image - use a magnifying glass if you can't see it).

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!

Hand hygiene: It's ginormous

An important new paper in the American Journal of Infection Control helps to put hand hygiene compliance efforts into perspective. The authors performed the study in 12 patient rooms in an adult medical ward in a 746-bed teaching hospital. Using video surveillance, they analyzed the number of hand hygiene opportunities using the World Health Organization My 5 Moments framework. The key finding was that there are approximately 72 hand hygiene opportunities per patient-day. Nurses account for 75% of the opportunities, while physicians account for 5%. Care of patients >65 years presented more opportunities than younger patients (80/day vs. 67 for those 50-64 years vs. 64 for those under 50 years). The proportion of opportunities for each WHO Moment is shown in the figure below:

Most hospitals that measure compliance using direct observation are primarily measuring Moments 1 and 5, about 65% of the opportunities. One might argue that these are the two most important moments in terms of overall magnitude of risk, but Moment 2 is also very important from the standpoint of transmission risk per opportunity.

If we assume that 72 opportunities per patient day is roughly the average (ICUs likely more, lower acuity wards likely less), and apply that to my hospital, which had 207,000 patient days last year, I can estimate that we have about 15 million hand hygiene opportunities yearly. This does not include procedural areas or the Emergency Department. Fifteen million is a lot better than my old nebulous estimate of infinitely many. Lord Kelvin would be proud. But it also means that we are directly observing <0.5% of all the opportunities. It's daunting to think that our goal is near perfect compliance with 15 million acts of human behavior, but like any other health-related behavior, change is incremental and reaching the goal typically requires decades of work. Infection prevention is not a pursuit for the faint of heart!

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!

Food for thought...

A few months ago I blogged about a study that explored the biologic plausibility for replacing the handshake with the fist bump from an infection prevention standpoint. Now there's a new opinion piece in JAMA (free full text here) by pediatricians at UCLA, which raises the issue of whether hospitals should become handshake-free zones. The authors propose alternatives to the handshake, such as the hand wave, the hand over the heart, the bow, and the namaste gesture. I suspect that many will scoff at this recommendation, but I think we need to be open-minded and critically look at all potential mechanisms of transmission in the healthcare setting. I find it very interesting how high tech solutions to infection transmission seem to be all the rage, even when they're ridiculously expensive and marginally effective, while very simple potential strategies are quickly dismissed.

Photo: ChristaInNewYork

Meager and unsatisfactory

It’s nice to see antimicrobial resistance featured in a Sunday NY Times editorial—nothing that we haven’t already covered in Eli’s recent post on the WHO report, but worth reading nonetheless. 

If you believe that “you can’t improve what you can’t measure”*, the most disheartening sentence in this editorial about the WHO report is “…few countries track and monitor antibiotic resistance comprehensively, and there is no standard methodology for doing so."

*This saying is a paraphrase of Lord Kelvin, who also said:

“When you can measure what you are speaking about, and express it in numbers, you know something about it; but when you cannot express it in numbers, your knowledge is of a meagre and unsatisfactory kind.” 

“Meager and unsatisfactory” is a great description of the status of our current response to the antimicrobial resistance threat.