Friday, March 28, 2014

Congratulations Dr. Wenzel! 2014 Martin S. Favero Award Recipient

Congratulations to our own Dr. Richard Wenzel for being recognized with the International Federation of Infection Control’s 2014 Martin S. Favero Award.
Dr. Wenzel is highlighted here in VCU News.

Dr. Wenzel has been an inspiration and mentor to many of us in infection prevention. 

We are greatly honored to have him as one of our own at Virginia Commonwealth University.

Thursday, March 27, 2014

State of Infection Prevention Efforts in US Hospitals

Here is the  latest CDC release on the state of infection prevention in US Hospitals. We have further work ahead to reduce hospital acquired infections and most, if not all, hospitals cannot claim uniform implementation and adherence of infection prevention best practices.

To quote Dr. Frieden of the CDC:

"Although there has been some progress, today and every day, more than 200 Americans with healthcare-associated infections will die during their hospital stay” 

It should be clear though that all infections are likely not preventable. The current state of infection prevention science cannot eliminate all infections. For the interested reader, I will refer you to this paper on estimating the proportion of healthcare associated infections that are preventable .

Infection prevention science is not yet salvation from hospital acquired infections.

Monday, March 24, 2014

Contact Precautions- More May Not Be Better

The uncertainty and controversy about how best to apply contact precautions, particularly for endemic
pathogens, continues.

Here is a recent publication in Infectious Diseases and Hospital Epidemiology that assessed contact precautions across eleven university hospitals. As the proportion of patients in contact isolation increases, compliance with contact isolation precautions decreases. 

Of particular interest was the finding that placing 40% of patients under contact precautions was a tipping point for noncompliance with contact isolation precautions.

To me this further suggests that we should be thoughtful and judicious in the application of contact isolation precautions for our patients.

No doubt there will be more coming on this subject.

Friday, March 21, 2014

Humanism and the 5th White Coat

There is a shift in medical education towards patient centered learning, a pedagogy that
promotes an integration of science and clinical practice with an emphasis on humanism.

I came across this thoughtful essay by a medical student titled The Fifth White Coat. No, this does not explore white coats as potential vehicles of contagion, rather, the essay addresses the symbolism of the white. In this case, the white coat represents the detached, scientific aspects of medicine that create an artificial barrier between doctor and patient, possibly impacting humanism.

The author's goal is  to ''wear a white coat, not become one.''

Monday, March 17, 2014

Is the Infectious Diseases Community ready for PrEP?

One new strategy for HIV prevention is pre-exposure prophylaxis (PrEP) with antiretrovirals. I have previously commented on PrEP via this blog.

How ready for adoption of PrEP is the infectious diseases community?

Here is a recent publication in Clinical Infectious Diseases that reports ID provider opinion and real world use of PrEP in the USA and Canada.

Although many of us support the concept of PrEP, few infectious diseases specialists (9% of survey respondents) actually provided it. One major provider concern is compliance.  

As someone who has worked for years in an HIV clinic, my biggest concern about PrEP is that it will be misused by patients in lieu of condoms. PrEP may prevent HIV transmission but it will not halt the spread of syphilis, gonorrhea, chlamydia, herpes and genital warts. 

PrEP is by no means salvation from sexually transmitted infections.

Friday, March 14, 2014

Needlestick Injuries and Medical students

Here is an article published in the American Journal of Infection Control on needlesticks and sharps injuries among medical students.

Surveys were completed by 1,214 students in 2009 and 917 students in 2010. The injury rate was  21.4% per year. The most common needlestick injuries were from venous punctures, surgical procedures, and instrument disposal.  Of greater concern was the 53% rate of under-reporting.

The majority of all sharps and needlestick injuries occur in operating room settings. Not unexpectedly, trainees are at highest risk. What will help reduce the risk of exposure to blood and body fluids (BBF) is making safety practices normative behavior. In this respect, the routine use of blunt tip suture needles for the closure of muscle and fascia, hands free zones for passing instruments and routine double gloving are known risk reduction practices.  This is supported by the American College of Surgeons statement on sharps safety. A recent Cochrane Review reported moderate quality evidence for the use of double gloves for the prevention of BBF exposures.

Safety strategies exist. The time to implement them is now.

Monday, March 10, 2014

What if Antibiotics Stopped Working?

Source: Women's Health
What if antibiotics stopped working? This is an important clinical care and public health question. 

Here is nice article written for the public in Women's Health magazine, featuring my good friend and colleague Dr. Michael Edmond.

Here is a recent publication in the MMWR on the overuse of antibiotics in hospital settings. Tackling the aftermath of antibiotic overuse, particularly in hospitals, will require us to get our house in order. The development of new antimicrobials will also be of paramount importance in the fight against drug resistant bacteria.  

Not to sound too doom and gloom, but the sad truth is that some people will die of antibiotic resistant pathogens. 

Friday, March 7, 2014

Whither the White Coat Ceremony?

White Coat Ceremony at Virginia Commonwealth University
Along with the current media frenzy about the fate of the doctor's white coat, largely in response to the SHEA expert guidance paper on HCW attire, here a is a posting on Kevin MD by Dr. Richard Levin on the hallowed white coat ceremony.

I am in full agreement with Dr. Levin that the caring, humanistic provider likely yields a better patient experience and better health outcomes with the added benefit of supporting the practitioner to be more resilient and avoid burnout.

I also believe in the power of symbolism. Like the stethoscope, the white coat  is a symbol of the medical profession and humanism. For most medical students, white coat ceremonies are transformative experiences. 

However, humanism in medicine transcends the symbol of the white coat. 

No one is calling for the white coat ceremony to be abandoned. Perhaps our use of the white coat as both a symbol and a utilitarian garment should be more nuanced. Attire and stethoscopes may become heavily colonized with bacteria during routine patient care (for recent stethoscope bacterial contamination study click here). There is theoretical and biological plausibility that practitioner attire may play a role in bacterial cross transmission. Coats sleeves and ties, unlike hands and stethoscopes, are not easily washed or wiped down in between patients. Rolling up the sleeves or hanging up the white coat for inpatient care is simple and not likely to cause harm. Patients do not perceive physicians to be less professional in the absence of white coats, particularly when they are informed about the potential infection risk of infrequently washed white coats.

Rest assured, white coats still have a role in the outpatient setting where the risk of healthcare associated infections is exceedingly low and where much of medicine is still practiced.  There also may be suitable alternatives to the white coat such as scrub uniforms and cool black vests.

So press on with the white coat ceremony as a rite of passage that promotes professionalism and humanism in medicine but dismiss the notion that the doctor is unprofessional or lacks humanistic qualities in the absence of the esteemed white coat. This is particularly true for medical students who feel that they will be judged as unprofessional when not wearing a lab coat on inpatient clinical rounds.

In the name of patient safety, wash your hands, tuck in your tie and roll up your sleeves or hang up the coat during inpatient care.

Wednesday, March 5, 2014

JAMA: Time to Hang Up the White Coat?

Source: JAMA

It is not often that I get to share the spotlight with such prestigious friends and colleagues such as Mike Edmond and Dan Diekema, both of the the HAI Controversies blog fame.

Here is our recent interview published in JAMA on hanging up the white coats. 

As stated in the article, ditching the white coat for inpatient care will require a significant culture change.

Monday, March 3, 2014

Using Medical Students as Covert Hand Hygiene Observers

The observation of hand hygiene (HH) compliance is subject to the Hawthorne effect, particularly if the compliance monitors are easily recognizable.

This recent study reports the use of medical students as covert observers of HH. Of note, the study summarizes the medical students' perceptions of their role as HH monitors. Generally, the findings are positive in so fas they gained considerable knowledge on  HH compliance by nurses, physicians, and surgeons. In addition, the nine students studied were responsible for significant total of 17,742 HH opportunities during the study period.

The use of medical students as covert HH monitors may be feasible, however, this must be done cautiously. Students should volunteer and must be adequately trained. Also, because of a hierarchical asymmetry between student, nurse and physician, students should not be expected to intervene to correct deficiencies in HH. This would result in an uncomfortable situation.