Friday, August 29, 2014

What Can Fourteenth Century Venice Teach Us About Ebola?

Plague Doctor's Mask
What can fourteenth century Venice teach us about Ebola? 

Here is an interesting perspective published in Environment Systems and Decisions. Venetian authorities focused on managing physical movement, social interactions, and data collection for the city as a system. This included the creation of lazarettos (quarantine stations) on nearby islands, quarantine periods, and wearing protective clothing (plague doctor's mask).

With the present Ebola outbreak, we are reminded of the importance of emergency preparedness, patient isolation for infection prevention, the use of personal protective equipment and the need for cultural/practice changes in African countries (limiting both contact with sick individuals and post-mortem contact) so as to further limit person to person cross transmission.

Plague and Ebola, different illnesses, different pathogens, some historical parallels.

Monday, August 18, 2014

Flashing Lights and Alcohol-Gel Dispensers- Improving Hand Hygiene Compliance

I am always looking to new approaches for increasing hand hygiene compliance. Here is an article published in the American Journal of Infection Control that caught my eye.

The investigators used a simple red light flashing at 2-3 Hz affixed to the alcohol gel dispensers, within the main hospital entrance.. Baseline and intervention observations were completed over five 60-minute periods (Monday-Friday) from 7:30 to 8:30 AM using a covert observation method.

Baseline hand hygiene compliance was 12.4%. The intervention increased compliance to 23.5% during cold weather and 27.1% during warm weather.

Really? Do we think that this will have a significant and lasting impact of hand hygiene compliance and infection prevention outcomes? 

I doubt it.

In my opinion, hand hygiene programs should preferentially focus on staff, use education, prompts, maximize accessibility of hand sanitizers, employ observation and feedback, and if feasible, employ automated hand hygiene monitoring technologies.

The blink red light is not sufficient.

Saturday, August 16, 2014

Ebola Virus Preparedness in US Hospitals- An Emerging Disconnect

As the Ebola outbreak continues to evolve and as US hospitals prepare for the imminent arrival of additional cases stateside, a disconnect is emerging between recommendation and practice. 

For example, the Centers for Diseases Control recommends that health care workers treating Ebola patients need only wear gloves, a fluid-resistant gown, eye protection and a face mask to prevent becoming infected with the virus. Patients should also be placed on contact and droplet precautions.

Where I work, and elsewhere, the fear of Ebola infection by HCWs is driving more aggressive infection prevention measures. The phenomenon is nicely summarized in the NY Times article. In addition to the isolation of patients in airborne and contact precautions, we have dedicated personal protective equipment for the care of Ebola infected patients, this includes Tychem suits, double gloves, PAPRs and fluid resistant booties over the Tychem suit.

Although the minimal standards for isolation and personal protective equipment set by the CDC for the care of Ebola infected patients is likely sufficient, the cross transmission of Ebola from a patient to a HCW in a US hospital would, in my opinion, result in near mass hysteria.

A heightened infection prevention strategy for the care of Ebola infected patients may not be unreasonable.

Monday, August 11, 2014

Ebola Preparedness- VCU Interview

I have been asked by some about where to find my recent Channel 12 interview on Ebola preparedness.

The interview may be found here.


Monday, August 4, 2014

What Not to Wear (In the Hospital)!

What not to wear (in the hospital)! The VCU School of Medicine will launch a new glossy publication (print and web) this Fall. One of the featured articles will be on healthcare worker attire.  

This piece is partly motivated by the SHEA Expert Guidance Paper of Healthcare Personnel Attire in Non-Operating Room Settings which I co-authored with various colleagues from the Society for Healthcare Epidemiology of America.

In the photo shoot, we captured images of traditional physician attire and that of bare below the elbows approach for inpatient care.  At VCU Medical Center, the Infection Control Committee recommends bare below the elbows for inpatient care. The aim is to promote hand hygiene to the level of the wrists and to prevent infrequently laundered items, such as lab coat sleeves, from coming into contact with patients and the patient care environment.

For many, the white coat has a utilitarian function with its pockets. We have learned, from a study in our institution, that the need for carrying capacity is an ongoing motivator for wearing a white coat. The black vest, with its pockets, serves as a reasonable substitute to the white coat and allows for a bare below the elbows approach to inpatient care.

The concept of the black vest as the new white coat was originally conceived by my friend and colleague Dr. Michael Edmond, and is neatly summarized here.  

Stay tuned.





Thursday, July 31, 2014

The Fist Bump - A More Hygienic Salutation?

The handshake is firmly rooted in Western culture as salutation. It is well known that many
pathogens, particularly respiratory viruses, can be cross transmitted by contact.

Could the fist bump be a more appropriate salutation as an infection prevention measure? Here is an intriguing read on the fist bump recently published in the Journal of Hospital Infection.

The authors suggest that implementing the fist bump in the healthcare setting may reduce bacterial transmission between healthcare providers by reducing contact time and total surface area exposed when compared with the standard handshake. In the small study, significant differences in contact surface areas were observed between the palmar surface area, contact time of the handsake was 2.7 times longer than a fist bump and total colonization of the palmar area of the hand was four times greater than the fist after incubation at 72 hours. 

Some important limitations should be noted, specifically, the bacteria were not speciated so the presence of MRSA, VRE and gram negative rods is speculative, and, the study did not target outcomes such as hospital acquired infections. Regardless, the idea of encouraging a fist bump is not ridiculous as it is supported by biological plausibility.

Changing hospital culture is tough enough, changing social norms, such as changing a hand shake to a fist bump, may even be more challenging. 

Friday, July 25, 2014

Yogurt and C.difficile Infections in the Hospital

Here is an intriguing report in The Hospitalist on encouraging the consumption of yogurt by hospitalized patients receiving antibiotics. The health system performing this intervention reported a significant decrease in the rate of C.difficile associate diarrhea.

I have multiple reasons to be skeptical. First, I cannot find this report cited in any peer reviewed, medical journal. How can one be sure that introduction of a 'yogurt diet' was causally related to a change in C.difficile rates? What about other important factors such as changes in antibiotic stewardship, hand hygiene practices, length of stay, changes in room disinfection? Too many unanswered variables and the study design was not rigorous.

Also, the largest, most recent probiotic trial failed to show benefit on preventing C.difficile associate diarrhea. 

Yogurt will likely not impact  C.difficile in acute care settings.