SHEA 2011: En Route

With Drs. Edmond and Stevens at the Airporrt

The VCU Infectious Diseases Trio is back on the road, this time to Dallas, Texas for the Society for Healthcare Epidemiology of America (SHEA) annual meeting.

If you are attending the conference, come and visit our posters and presentations.

We are off.

Whoosh-

Medical School: Clinical Clerkship and Total Immersion

The third year of medical school is a year of total clinical immersion. The experience is critically important, and transcends the acquisition of medical and patient care knowledge. It is a time for humanism, empathy, professionalism, service and resiliency in the face of personal, academic, and at times, emotional challenge. Self reflection is paramount for a truly enriching and transformative experience.

As the director of the 3rd and 4th year Internal Medicine rotations at VCU, I have witnessed the clinical and professional growth of many students.

I thoughtful perspective can be found here.

911! MRSA in Ambulances!

Not on my Lego set-  MRSA in the ambulance.

The concern about MRSA is widespread, so it is no surprise that investigators studied the environmental burden of MRSA in ambulances and published a recent report in the Journal of Hospital Infection.


Ambulances were analysed for the presence of MRSA immediately after transport of MRSA-colonised or -infected patients. Eighty-nine of 100 transport events were analysed. Eight ambulance cars (9%) were contaminated. Transport time of 11–20 min did not result in a higher contamination rate than shorter transport time of 1–10 min. MRSA was detected only on the stretcher and not in the ambulance cabin walls.


Thus, ambulances are contaminated with MRSA even at short transport times. 


This is merely another reminder that the inanimate environment is not sterile. This can only be mitigated by proper and routine disinfection (to reduce microbial burden) AND by hand hygiene, to limit cross transmission via the hands of the healthcare provider.


As always, back to the basics.

VCU Basketball and Infection Prevention: Making us Proud

There has been much ado about Virginia Commonwealth University lately, mostly because of the basketball team's upcoming NCAA final four appearance. Kudos to them.

But did you know that the basketball and infection prevention teams at VCU share similar fates?

Fellow colleague and blogger, Eli Perencevich, gives us a succinct and proper time line on VCU's history, with, of course, references to our infection prevention stars, Drs. Richard Wenzel and Michael Edmond.

I was fortunate enough to join the winning team (infection prevention, that is, and not basketball) in 2003.

Although it is not the Final Four, visit us and our posters at the upcoming Society for Healthcare Epidemiology of America annual meeting, next weekend.

We will be in black and gold.

Chlorhexidine Bathing:The Wonderstuff

Patient Bathing: No Chlorhexidine Here!

Here is  another article on the efficacy of chlorhexidine patient bathing, this time in a general medical patient ward. The investigators compared routine patient bathing with soap and water vs chlorhexidine impregnated cloths. Study size was large and included nearly 15,000 patients.

The result: daily bathing was associated with a 64% decrease in the rate of hospital acquired infections, namely with MRSA and VRE.

We have always advocated common sense, broad based infection prevention measures such as hand hygiene, central line checklists, head of bed elevation, avoidance of femoral site for central venous lines AND chlorhexidine bathing of our patients.  The latter is gaining acceptance, albeit slower than I fancy.  

 
Despite scientific evidence, medical culture (the way we have always done things) can be difficult to change.

Residents Work Hour Restrictions: Is Less Worth More?

The cult classic about residency training:-before work hour restrictions

Ok, so I was an Internal Medicine resident in the 1990's and the work hour restrictions were supposedly at 80 hours weekly. It is fair to say that enforcement was lax, at best.


These are new times and there are new rules, not only in the USA, but also in Europe. They pivotal question is: does work hour restriction promote better training and safer care? According to this news report, the jury is still out.


I am paraphrasing, but the new resident duty hour restrictions in the USA set an 80 hour work week as the maximum and add further limits such as 16 hour shifts for interns and 24 hours for residents, with 5 hours of 'strategic napping'. Some European countries limit work hours at 48 hours per week.


I am not necessarily against these changes, however,  the limiting of work hours should be robustly studied to assess impact on training and patient safety. As such, I am cautious about concluding that the impact will be uniformly positive.


Now....if only work hour restrictions, especially the 48 hour limit, applied to attending physicians, then I would be very optimistic.

HIV and Sexually Transmitted Infections Risk Behaviors in the USA

I came across this interesting paper in the American Journal of Preventive Medicine- on trends in HIV and sexually transmitted infections risk behaviors among U.S. high school students.

Nationally representative data from the 1991–2009 biennial national Youth Risk Behavior Surveys were analyzed to assess trends in HIV- and STD-related risk behaviors. Surveys were anonymous, self-administered and assessed risk behavior participation.

Decreases were observed in the percentage of U.S. high school students who ever had sexual intercourse, had multiple sex partners, and who were currently sexually active. 

The prevalence of condom use increased during 1991–2003 and then leveled off during 2003–2009. 

 Am J Prev Med 2011;40(4):427– 43

Changes in risk behaviors were not observed in some black and hispanic student groups.

As an infectious diseases physician, this is particularly important to me especially as we are seeing increases in syphilis and new HIV diagnoses in young men. 

Sexual education, particularly for the prevention of sexually transmitted infections, must be evidence based . An excellent resource is the CDC Compendium of Evidence Based HIV Prevention Interventions.

Glove Removal- Doing it Properly

There is actually a correct way to remove contaminated examination gloves so that hand and environmental contamination are minimized.


For a very brief yet informative video- click here.


Chinese investigators recently published a study comparing hand and environmental contamination rates between two glove removal methods. Fifty healthcare workers performed a personal glove removal method  and a Centers for Disease Control (CDC)-recommended glove removal method  at distances of 2 feet and 3 feet from the trash bin after the application of fluorescent solution (the simulated contaminant) onto their gloved hands.


The incidence of contamination on the front of the removed gloves was significantly lower when using the CDC glove removal method.  The incidence of contamination on the front of the removed gloves and on the cover of the trash bin was significantly lower at 3 feet than at 2 feet. There was no significant difference in hand contamination rate in either removal methods based on distance from the trash bin and type of HCW.


These are interesting findings, however, the message remains simple: wash your hands before AND after glove removal as hand and environmental contamination is not eliminated by glove use.

Community Acquired MRSA and Healthcare Workers

It has been a quiet weekend for me, with a self imposed ban on all sort of real work for 48 hours. Somehow, I managed to survive without being in the office, the hospital or tethered to my laptop. 

Back to business.

We often hear of CA-MRSA (community-acquired methicillin resistant Staphylococcus aureus) outbreaks in either the medical literature or the lay media. Here is an interesting descriptive study on a CA-MRSA outbreak among healthcare workers, with transmission to a patient.

Skin and soft tissue infections (boils) typify CA-MRSA infections. Healthcare workers are not immune to this phenomenon.  The authors mention that  identification of colonized healthcare workers is important in successful control of MRSA transmission, particularly in an outbreak. 

Even though aggressive screening, decolonization, and treatment of HCWs seem justified in MRSA outbreaks, we are back the same tried and true message: educational programs, proper hand hygiene, and strict adherence to universal precautions remain essential for controlling the spread of MRSA.

Wash your hands.

H1N1 Vaccination: Ball of Confusion

There is a letter to the editor in press in Journal of Hospital Infection titled: Vaccination against 2009 pandemic H1N1 influenza among healthcare workers in a tertiary hospital: rates, reasoning, beliefs.


The authors describe the H1N1 healthcare worker vaccination experience in a Greek hospital. The vaccination rate of healthcare workers for H1N1 influenza was low (17%). The authors identified a mistrust of the motives of pandemic vaccination campaigns and refer to negative expert opinions expressed in public (which attracted particular attention by the media) as frequently listed among the reasons for non-vaccination.


We will soon present a study at the upcoming SHEA Annual Meeting on our experience with H1N1 vaccination. Predictably, fears about efficacy, side effects and concerns about active illness from the vaccine were expressed. There are healthcare workers who received the seasonal influenza vaccine but not the H1N1 vaccine. Others simply refused both.


Confusion and mistrust abound.


If you will be at SHEA, come and visit our posters.

Music and Medicine: A Convergent Perspective

I came across a thought provoking perspective in Annals of Internal Medicine on the parallels between musicians and doctors. One need be neither an audiophile nor a musician to appreciate the similarities.

Like music, medicine is a learned discipline, and clinical practice is very much a form of performance. Hence, you have blend of technical skill and art.

The authors suggest that 10 features of the professionalization of musicians may offer us lessons on how medicine might be learned, taught, and performed more effectively.

These 10 features are:

Performance

Coaching

Stardom

Talent

Time

Art

Practice

Teamwork

Repertoire

Specialization

All are important. Two that struck a cord with me, pardon the pun, were time and practice. Long hours and repetition (repeatedly performing histories, examinations and technical procedures) are essential for masterful and artistic clinical performances.

As I tell the students: there are no short cuts.

To quote the article’s author: “… health care might want to keep firmly in mind what all musicians and other performing artists take for granted: You're only as good as your last performance.”

Canine Trainer- Getting You Off the Couch

It is well acknowledge that obesity is on the rise in the USA. Many propose increased physical activity as a prescription for health.

Canine Trainer: Forcing you off the couch

For those that lack motivation to hit the gym, get a dog.

Researchers from Michigan State University recently published a paper on the effect of dog ownership and physical activity.  Sixty percent of dog owners who took their pets for regular walks met federal criteria for regular moderate or vigorous exercise and nearly half of dog walkers exercised an average of 30 minutes a day at least five days a week! Wow.

For a related perspective, check out this NY Times article.

Now, if I could only get our Boston Terrier to jog with me...........

Low Level Evidence Abounds

We pride ourselves in practicing evidence based medicine but who are we kidding?

Yesterday I met with colleagues from trauma and orthopedic surgery. The purpose was to develop standardized pre and post-operative antibiotic protocols for open (compound) fractures. Sounds simple, however, the current body of evidence on the duration of antibiotic use for open fractures is not backed by robust evidence.

But wait, don’t knock the surgeons. Physicians are plagued by similar lack of robust data. I refer you to this article, published in Clinical Infectious Diseases, on The Quality and Strength of Evidence of the Infectious Diseases Society of America Clinical Practice

Guidelines (Clinical practice guidelines are frequently adopted as the ‘standard of care’).

The conclusion: The IDSA guideline recommendations are primarily based on low-quality evidence derived from non-randomized studies or expert opinion.

Medical practice, even the standard of care,  may not be backed by strong, clinical data.

Placebo Effect- The German Way

Photo:http://newhealthadvances.com/archives/page/4/

Today is my first day in several weeks that I am not seeing patients. I have been knee deep in clinical medicine and infectious diseases consults so this brief article on placebos was timely. 

This is not to imply that I endorse placebos in clinical medicine, unlike in research, where there is informed, written consent. I found it quite noteworthy that half of Germany's doctors reported prescribing  placebos (vitamin pills and homeopathic medicine) for minor illnesses. I would delve into greater detail on the actual German Medical Association report but my German is not so good.

To me this raises two important issues: The ethics of placebos in clinical medicine (as there is a level of dishonesty in placebo use)  AND the potential efficacy of vitamins and homeopathic remedies for minor illnesses.

I would love to know what sort of response we would receive here were the American Medical Association to poll its members about the use of placebos in clinical medicine.

Go to the Gym, Work Out, Get MRSA. Not so!

No MRSA Here!

There is a nice posting in the HAI Controversies blog on the absence of MRSA on gymnasium equipment.

This reminded me of a study that we presented in 2008, at the annual SHEA conference. Despite extensive sampling of gym equipment, we were unable to recover MRSA from a nearby gym, frequented by health care workers and students.

So find another excuse for skipping your workout.

Unrealistic Optimism

Photo: NY Times

Well it has and continues to be an exceedingly busy several weeks on the Infectious Diseases consult service making for long days and nights. Accordingly, my posts have been brief.

I fortuitously came across this perspective by Dr. Pauline Chen. The article explores unrealistic optimism in medicine, human psychology and the ethics of informed consent in certain experimental trials. Well worth the read.

Off to work soon and hoping to come home tonight at a reasonable hour.......unrealistically optimistic, again.

Bias in Pharmacologic Trials: Meta-Analyses

Logo: http://jama.ama-assn.org/

I perused a paper today on conflict of interest. The paper, published in JAMA, investigated whether meta-analyses of pharmacological treatments published in high-impact biomedical journals reported conflict of interests disclosed in included randomized controlled trials.

Of 29 meta-analyses reviewed, which included 509 RCTs, only 2 meta-analyses (7%) reported randomized control trial funding sources; and 0 reported randomized trial author-industry ties or employment by the pharmaceutical industry. Information concerning primary study funding and author conflict of interest were rarely reported, if ever.

As conflict of interest seeps into a study, bias may ensue, impacting study outcomes and interpretation.  In pharmacologic studies, bias tends to result in an overestimation of a drug’s benefit and therapeutic effect.

This should be a concern for all critical readers.