Top Priorities in Infection Prevention- From A European Perspective

What are the top priorities in infection prevention?  

From a survey of European infection prevention experts, published here, the rank (top to bottom) includes microbial epidemiology/resistance, surveillance and decolonization/disinfection/antiseptics.  In fourth place was organizational and behavioral change.

The list would likely be similar for North America.

I personally feel that organizational and behavioral change should be at the top of the list, under the gamut of infection prevention implementation. Although infection prevention is not a perfect science, if known, data driven risk reduction strategies are implemented reliably, consistently and to scale, this would result in a massive patient safety boon.

We need to prioritize implementation of best practices, as I have previously explored. 

Anything less will fall short of our patient safety goals.

At the Existentialist Cafe

Although I am at work this holiday week, the clinic and administrative schedules are relatively light. I have been delving into books with enthusiasm (and with time to spare).

At the Existentialist Cafe by Susan Bakewell is no boring read on the history and characters of existentialism, in fact, it reads like a novel.

Thank you Jean-Paul Sarte for reminding us that existence and 'being' comes with options, that our day to day tasks need not be pre-ordained, overly encumbered and rigid.

Food for thought.

Good read. 

Fall / Winter 2016 Medical Literary Messenger Published!

I am exceedingly proud to announce that we have just published the Fall/Winter 2016 edition of the Medical Literary Messenger (MLM).

The project website is : www.med-lit.vcu.edu. The MLM can be downloaded in PDF or e-book format via the website. The PDF can be found here.

As always, thank you to my Associate Editors, Dr. Megan Lemay, Dr. Michael Stevens, Patricia Dodson and Celeste Lipkes. Additional heartfelt thanks to Brie Dubinsky (Managing Editor/Web Designer) and Rachel Van Hart (Design and Copy Editor), without them this project would come to a grinding halt. I also owe a huge debt of gratitude to all of the reviewers. Last, It goes without saying that without the contributors, the MLM would simply not exist.

Happy Holidays.

Cell Phone Text Message Reminders for Enhanced Hand Hygiene Performance

It is a well known fact that hand hygiene practice in the hospital is nearly always suboptimal.The literature on hand hygiene is replete with strategies to improve practice.

In this article published in American Journal of Infection Control, a hand hygiene reminder with either a congratulatory message or an encouragement message (for those with less than optimal hand hygiene compliance) was sent once weekly to staff in a 15 room infectious diseases ward in a French hospital.The unit employed an RFID automated hand hygiene monitoring system. Hand hygiene rose from a baseline of 15% to 23% following the alert notification.  

In my opinion the hand hygiene adherence pre/post intervention is concerning and low, especially in an infectious diseases ward! This was possibly secondary to poor capture from the RFID automated adherence technology.  What I found most interesting was the acceptability of the once weekly text message reminders by the frontline healthcare workers. There was little to no alert fatigue reported! This is promising.

If we can deploy a hand hygiene technology that accurately captures hand hygiene compliance (foam in/foam out), is coupled to targets with feedback and accountability, and, if that feedback can be automated (via text message once weekly) and tied to performance and encouragement, we may be on to a game changing strategy.

The quest for optimal hand hygiene enhancement continues...

Grit: Passion and Perseverance

I have been reflecting on the concept of grit as explored in a scholarly fashion in this book by Angela Duckworth. Her TED video on grit is available here.

Simply put, grit is the cultivation of passion with purpose and perseverance. The concept really resonated with me, particularly in my career as a physician and university professor.

Although grit is in part innate, it can be cultivated and developed. If you want to be grittier, join a group with a culture of grit. Also, leadership can breed a culture of grit through setting standards and providing motivation and support.

The theme is clear. High achievers are not necessarily the smartest or most connected, they are the grittiest of the lot.

Science Museum of Virginia Lunch Break Science Presentation on Infection Prevention and Safety

Thank you to the Science Museum of Virginia for hosting me today for a public-oriented lecture on infection prevention and safety at the Lunch Break Science series.

The event was well attended and the lecture was seemingly well received. I truly enjoyed the Q+A. Thank you to Mr. David Olli of the Science Museum of Virginia for the generous invitation and kind introduction.

Pictures from the event are below.

In February 2017 there will a Lunch Break Science lecture by a local distillery on the art and science of whisky. 

I definitely will attend that one.

Hand Hygiene: What happens Next?

WHO 5 Moments for Hand Hygiene

I have been thinking about hand hygiene a lot. Despite all of our efforts, we never seem to reach the highest level of compliance,

This recently published, high quality, cluster, randomized trial of hand hygiene with different levels of assessment and performance feedback underscores, in my opinion, an important point: that direct observation with assessment and feedback, even with patient participation as hand hygiene reminders, has limited impact. Overall, only modest improvements in hand hygiene were observed with enhanced feedback and patient participation.

Hand hygiene compliance monitoring via standardized observers remains the gold standard, as summarized here. This is our strategy at VCU Health.  We have observed significant improvements in hand hygiene, however, we are not yet at the desired level. If we continue to do the same things we will get the same results.      

Enter hand hygiene automated monitoring technologies.

Much like hand hygiene compliance assessment by direct observation, automated hand hygiene monitoring technologies capture the foam in/ foam out hand hygiene events. If these technologies can be deployed to scale, with consistency, reliability, goal setting and accountability, we may have a game changer on our hands, pardon the pun.
        
We are in the 2nd wave of hand hygiene technology pilot testing at VCU Health. The goal is to go 'house-wide.'

Exciting.

                                              

Overuse! Dr. Daniel Morgan at VCU Internal Medicine Grand Rounds

Today we had the pleasure and honor to host Dr. Daniel Morgan of the University Maryland for internal medicine grand rounds.

The topic was overuse-the endemic over diagnosis and over treatment in the U.S. Healthcare System. The results are increasing risk, patient harm and elevated costs. The presentation was masterful, scholarly and well received by the audience.

Here is an editorial article written by Dr. Morgan on the myth of more medicine and better health, published in the Baltimore Sun.

Below are some images from the event.

                          

Shakespearean Syphilis, The Libertine and the Ravages of a New World Disease on European Society

Here is an article that highlights the astute observations on syphilis in the many works of William Shakespeare. The article was published in Pharos, by the Alpha Omega Alpha society.

The Libertine, starring Johnny Depp, is about a 16th Century English nobleman (John Wilmot, The 2nd Earl of Rochester) who was notably afflicted by syphilis, among other ailments of debauchery.   

Both the works of Shakespeare and The Libertine document syphilitic manifestations in Europeans following the disease's introduction from the New World. These included gummas, alopecia, extremely painful osteitis, neuropathy and dementia.

Although we still see a lot of syphilis the cases are much less severe.  This is likely due to more rapid diagnosis and early, effective treatment.  Regardless, I have to suspect that reinfection (particularly in the brothels) and general poor health and nutrition likely played a significant role in disease progression. How could it not?      

History of medicine via literature and film! 

Cool.                      

The Digital Doctor Is In!

I am not a luddite! I believe in medical technology but as with many things, there is a force and counterforce, a yin and yang of sorts.

There is no doubt that the electronic medical record (EMR)has led us to new heights, such as immediacy of access and retrievability of data, images etc.  

There is a dark side, however. We spend more time tapping on our PCs, minimizing contact with our patients, the so called iPatient phenomenon, as explored in this New England Journal of Medicine article by Dr. Anthony Verghese. Also, the EMR minimizes the need for doctor-doctor in person consultations. Who makes radiology rounds anymore? This may not be a good thing.

Much of this is summarized in the Digital Doctor, by Dr. David Wachter, a book which I found quite enlightening.

I am back on the VCU Wenzel Academic ID Consult Service this weekend, will attempt to focus on the patients...and not the EMR.

Good Read: Sapiens- A Brief History of Humanind

I spent the last week plowing through Sapiens, A Brief History of Humankind by Yuval Noah Harari. 

This 500 page book is anything but a tome, rather, it is a gripping account of our history through the lens of the cognitive, agricultural, scientific and industrial revolutions that defines much of human history. 

As we further change the world for our purpose (environment, genetic engineering etc) we are left with the scary and challenging question of what do we want (or want to become)?

Now back to more mundane matters, such as my job in the hospital and getting people to wash their hands.

Quantity and /or Quality? The Importance of Publishing Many Papers

I have heard the comment that the quality of papers published is more important than the quantity. Who really knows?

I found this paper in PLOS ONE which aimed to answer the above question with a formal correlation analysis of author publications,citations and impact factor. The greater the number of publications (productivity) the greater the number of citations and the greater the impact factor.  

Like in many aspects of life, success begets success.

Recognizing that 'major impact publications' or scientific breakthroughs are rare events, perhaps the best strategy is to press on at a steady and consistent pace. This should ultimately result in a decent and reasonable contribution to the literature, an academic slow burn of sorts.

Back to it....

System Failure, Accountability and High Reliability in Infection Prevention- Striking the Right Balance

I am going to limit this commentary exclusively to hospital infection prevention. We are searching for high reliability in infection prevention, this means that evidence based risk reduction practices are implemented in a systematic and consistent way.    

To succeed, we need to standardize, educate, implement (this includes providing the materials and infrastructure to support the intended behavior) assess performance and provide non-punitive feedback (particularly when errors occur).

These efforts, without a doubt, improve practice and minimize system failure, but they only go so far.  The last critical step is accountability. Poor performers and recalcitrant outliers must be held accountable by institutional leadership for non-adherence to evidence based, reasonable infection prevention expectations. 

Low reliability infection prevention cannot habitually default to the 'system failure' excuse.

To borrow a quote: The culture of any organization is shaped by the worst behavior that a leader is willing to tolerate.

Satisfice! Let It Be So in Infection Prevention.

Herbert Simon- Nobel Laureate

Lately I have been obsessed with implementation science, heightened safety, infection prevention and high reliability. Those close to me have heard me talk repeatedly about solutions that 'satisfice', a term coined by the late Nobel Laureate, Herbert Simon. 

Satisfice comes from the fusion of two words, satisfy and suffice. Satisficing is a decision making strategy that seeks solutions that are 'good enough'- satisfactory and sufficient for a more realistic world.

We continue to implement many evidence based strategies in infection prevention- hand hygiene, chlorhexidine patient bathing, automated urinary catheter discontinuation orders, central line checklists, and deployment of UVC touchless cleaning technologies. How certain are we that the measures are implemented?

We are unable to ideally observe, document, feedback and cross-check implementation of all strategies as it is physically and logistically not feasible.

Using designated staff and /or electronic data mining, we are able to generate reasonable, automated and scheduled point prevalence reports on nearly all process of care measures and technology deployments. Assessment drives performance and leads to improvement in practice. All of our patient centered infection control outcomes continue to improve.

Infection prevention science must play out in the real world. 

Real life challenges require solutions that satisfice.

VCU Antimicrobial Guide- Coming to a (VCU) Smartphone Near You

We developed an institution specific (using our own antibiogram) online guide for antimicrobial use at VCU Health. 

This point of care guide is available as a link within our electronic medical record. Since its  launch, it has been accessed > 10,000 times over the past year. The project was spearheaded by Dr. Michael Stevens and 3rd year epidemiology fellow Dr. Dan Markley.

We formally assessed the need for transitioning this online guide to a point of care smartphone app, for all VCU providers. The manuscript is now in press at American Journal of Infection Control, available here (PDF).

The VCU antimicrobial smartphone app will launch in 2017.

The goal is to enhance antimicrobial stewardship through point of care, portable guidance, driven by the stewardship program and by the hospital's own antibiogram.

This is no ivory tower academic exercise.

2nd Annual VCU Gordon Archer Research Day

Today was the 2nd Annual VCU Gordon Archer Research Day, hosted by the Infectious Diseases Division at the VCU Larrick Center.

The oral and poster presentations were from infectious diseases, microbiology and immunology. The event was very well attended. 

Diverse and stimulating research ideas were presented spanning hospital epidemiology, bench research, global health, immunology and antimicrobial stewardship, generating discussion and thought, all under the spirit of celebrating Dr. Archer's career at VCU. Seventeen research papers were delivered at the podium and 16 posters were displayed at the lunch break.

A special thanks to VCU Infectious Diseases administrative assistant, Krystle Shaw, for coordinating nearly all of the event. 

Thanks, always, to Peggy Andrews, my executive assistant, for keeping me on track.

I am already looking forward to next year's event.   

L-R: Peggy Andrews and Krystle Shaw

UV light and Continuous Disinfection in the Hospital- The Next Implementation Frontier?

Lately I have been discussing the inanimate environment. I have become more convinced that the environment is an important driver of hospital acquired infections (HAIs). Our means of consistently cleaning hospital surfaces is less than optimal.

Heightened cleaning, such as with UVC light, resulted in a significant decrease (25%) in C.difficile incidence, as documented in this study by Dr. David Pegues of the University of Pennsylvania. 

My colleague down the road at the University of Virginia, Dr. Costi Sifri, reported a decrease in hospital acquired infections (78% MRSA and C.difficile) after  introducing copper-impregnated composite hard surfaces and linens (continuously disinfecting surfaces) in the new wing of an acute care hospital. This was a quasi-experimental study so there are significant limitations. Regardless, the study adds to the body of literature on HAIs attributed to environmental cross-transmission. The results are tantalizing.

I still feel that hand hygiene and infection prevention bundles (central line checklists, ventilator bundles etc) are first and foremost in infection prevention. The next challenge is the targeted deployment of heightened cleaning (UVC light) and continuous disinfection strategies to minimize bioburden and lessen infection risk.

The 2nd Annual Gordon Archer Research Day is next week, 11/14/16, at the VCU Larrick Center.

I am greatly looking forward to it so stay tuned and check back for highlights.

Resuscitated UVA- VCU Case Conference- Hosted at VCU

It has been a packed two weeks with back to back trips to New Orleans (ID Week 2016) and Vienna, Austria (IMED 2016). I am back in the USA, back on the ID consult service and back at work.

Today I had the pleasure of hosting and resuscitating the Virginia Commonwealth University-University of Virginia Fall/Spring Semester case conference at the VCU Alumni House after about a 20+ year lapse. Along with my esteemed colleague and collaborator, UVA ID Division Chair, Dr. Bill Petri, we were able to pull it off. 

A special thanks (always) to my assistants Peggy Andrews and Krystle Shaw for taking care of the fine details.

The conference was very well attended. Two phenomenal cases were presented, one by VCU fellow Dr. Salma Abbas (monomicrobial, pyogenic Klebsiella pneumonia liver abscess) and one by UVA fellow Dr. Elizabeth Gulleen (Corynebacterium diphtheriae pharyngitis with heart block).

This conference went off in the true spirit of academia, with a sharing of cases, ideas and knowledge, all with thoughtful dialogue. That's what it is all about.

I am already looking forward to the spring semester event at UVA.

VCU Alumni House

Event

Left to Right: Peggy Andrews and Krystle Shaw of the VCU ID Team

Case Conference

IMED 2016: Vienna, Austria- Guide to Infection Control in the Hospital

Today I caught up with my colleague, Dr. Britta Lassmann from the international Society of Infectious Diseases (ISID) to discuss the upcoming e-version and website of Guide to Infection Control in the Hospital, which I edit. 

The Guide is already available as a free PDF and has been downloaded worldwide greater than 9000 times.

Exciting.

Back to the USA tomorrow.

IMED 2016: Vienna, Austria- Day 2

I am enjoying IMED 2016.

Many presentations today focused on climate and global health, rabies control in resource poor countries and emergency response to infectious diseases outbreaks. Perhaps that is why I attend meetings such as this, to get out of my hospital infection prevention comfort zone and to be humbled by how little I know.

Dr. Michelle Doll and Nadia Masroor made us proud by representing VCU at the first poster session.

Nadia Masroor and Dr. Michelle Doll 

IMED 2016: Vienna, Austria- Freud Museum and Opening Plenary

The official IMED 2016 program began this afternoon.

In the morning, I popped by the Sigmund Freud House and Museum, both the residence and medical office of the father of psychoanalysis.

To quote Freud: The times are gloomy. Fortunately it is not my job to brighten them.

The opening plenary session provided a rich roster of speakers offering unique perspectives on global disease surveillance and data collection to guide policy and better coordinate public health response to emerging pathogens.

More to follow, tomorrow.

IMED 2016: Vienna, Austria

I am currently ion Vienna, Austria, for the International Meeting on Emerging Diseases and Surveillance ( IMED ). We have a poster and a session to moderate. The official program starts tomorrow.

Below are some images of Vienna, from my meanderings.