Wednesday, October 18, 2017

Discontinuation of Contact Precautions: Back in the Literature

Like a recurrent bad dream for some, the discontinuation of contact precautions for the control of endemic MRSA and VRE is back in the medical literature.  

A meta-anlysis, published here, by Alex Marra, once again suggests that the cessation of contact precautions for the control of endemic MRSA and VRE is without adverse consequences.

My colleague Mark Rupp also published this manuscript in ICHE summarizing the University of Nebraska's positive experience with the discontinuation of contact precautions for the control of endemic MRSA and VRE.

I am off to the University of Nebraska Medical Center tomorrow, to give an invited medical grand rounds lecture on infection prevention- policies, pragmatism and controversies.

I might just talk about the discontinuation of contact precautions too.

Friday, October 13, 2017

Are We Serious About Limiting Presenteeism?If So HR Policy Changes Are Needed

Presenteeism, or working while sick, is a cross transmission risk. With the looming respiratory virus season this is increasingly relevant. Not all risks related to presenteeism are ascribed to respiratory viruses. Here is a reported cluster of Group A streptococcal skin infections in a skilled nursing facility, likely related to a 'present' healthcare worker with Group A streptococcal pharyngitis. It has also been argued that reducing presenteeism is more effective than mandatory influenza vaccination in reducing hospital acquired influenza.

But how can we effectively reduce presenteeism? 

I have found no published reports of successful strategies for presenteeism reduction in healthcare settings. 

Staff education of the dangers of presenteeism is a good start but likely insufficient. A change in human resources (HR) policy is likely needed such that sick leave is different than paid time off, as summarized in this pro/con article. Healthcare workers would thus not feel 'penalized' by losing vacation time when out sick. Of course, sick leave could easily be abused, thus requiring policies and mechanisms to better manage absenteeism.

Bottom line, we can talk about limiting presenteeism but this commitment will ring hollow without changes in HR policy. This has been done, as neatly summarized in this blog post by Mike Edmond.

I get a sense that for many healthcare systems the policy of mandatory influenza vaccination is easier and more expedient than making substantive changes in HR policies.

Tuesday, October 10, 2017

Eminence Front! Eminence Based Medicine and Other Options to Evidence Based Medicine

What to do when high quality evidence is not available to guide decision medical making?

I dug this one out of the archives of the British Medical Journal after hearing a reference to 'eminence based medicine' at ID Week 2017.

Strategies include 'eminence based medicine"- where experience is worth any amount of evidence, and may actually trump evidence in many cases.It's an eminence front! Other strategies include 'eloquence based medicine' and ' providence based medicine" where decisions are best left in the hands of the Almighty.

In the absence of evidence all may not be lost. Weigh the risks, benefits, consider the opportunity costs and be pragmatic.

Sunday, October 8, 2017

ID Week 2017: Parting Shot- Pay Us More Than Minimum Wage!

In a moment I will en route to Virginia.

Here is a parting shot from ID Week 2017, from the IDeas Wall. Note the comment at the bottom. In the USA, where procedures are lucrative, cognitive specialties suffer and have the lowest reimbursement.

"Pay us more than minimum wage." 

Infectious diseases is a very exciting, low paying job.

Saturday, October 7, 2017

ID Week 2017: Congratulations to Drs. Nicole Vissichelli and Oveimar De La Cruz

Dr. Nicole Vissichelli at ID Week 2017

ID Week 2017 is coming to an end. really great week with high quality presentations and posters.

Congratulations to Drs. Nicole Vissichelli and Oveimar De La Cruz on their bone marrow transplant and infectious diseases related abstract.

Dr. Visichelli will present her work next month at VCU's Gordon Archer Annual Research Day

Stay tuned.

Friday, October 6, 2017

ID Week 2017: With the Agent Provacateur- Mike Edmond

'Jane, you ignorant Slut!' From Saturday Night Live Skit to ID Week pro/con debate theme.
Learning with Levity.

With friend and former VCU colleague Mike Edmond, the Agent Provocateur of hospital infection prevention, prior to his arguing against universal influenza vaccination of HCWs.

Lively and spirited.

ID Week 2017: Guide to Infection Control In the Hospital with the International Society of Infectious Diseases

Drs. Doll, Stevens and I caught up with Chris Trimmer and Laurence Mialot of the International Society of Infectious Diseases, where we continued to plot the next steps for the 6th edition of The Guide for Infection Control in the Hospital.

The new edition will be launched at the International Congress on Infectious Diseases, Buenos Aires, 2018. Expect new content and new web-based format, with e-pub and portable app, all in the making.


Thursday, October 5, 2017

New Perspectives and Controversies in Infection Prevention. Published!

L-R: Drs. Morgan, Murthy, Munoz-Price and the blogger.

Thank you to my co-editors Drs. Dan Morgan (University of Maryland), Silvia Munoz-Price (Medical College of Wisconsin) and Rekha Murthy (Cedars-Sinai/ UCLA) for their invaluable collaboration on this newly published book, New Perspectives and Controversies in Infection Prevention (Springer).  More importantly, thank you to the many contributors for their high quality submissions.

As the name suggests, we did not shy away from controversy, which is how we like it!

We caught up at ID Week 2017 (San Diego) for a group photo.

Tuesday, October 3, 2017

Portable Bedside Equipment: An Infection Prevention Nuisance

I generally enjoy reading small articles that probe commonplace infection preventions issues. 

This recent article underscores the potential and likely under-recognized threat of portable equipment (bedside ultrasounds, EKGs etc) in the transmission of pathogens in the hospital. After inoculating portable equipment with a DNA marker, a substantial proportion (about 20%) of areas sampled, including common areas, patient rooms and portable equipment, were positive for the DNA marker, suggesting that both transmission across inanimate surfaces is possible (likely via HCW hands) and that disinfection is unreliable.

The solution is not simple. Hand hygiene is variable, most commonly at foam in and foam out of patient rooms, thus missing other opportunities for hand decontamination. More importantly, disinfection of portable devices is not standardized. Assigning this task to busy nurses simply will not work in the real world.

We need better processes for disinfection of environmental bioburden. Dedicated environmental teams or technologies are needed to regularly and consistently clean portable equipment.

I am en route to San Diego for ID Week 2017. 

Stay tuned.

Sunday, October 1, 2017

The Bad-Ass Librarians of Timbuktu! A Real Life Revenge of the Nerds.

The librarians of Timbuktu are bad-ass! No joke.

My penchant for seeking books (old and new alike) and hanging out in libraries was previously highlighted here . Naturally, a book chronicling the heroic rescue of ancient manuscripts (on medicine, religion, astronomy etc) in Timbuktu from imminent destruction by Al-Qaeda peeked my interest.

The  Bad-Ass Librarians of Timbuktu, a bookish and intellectual lot, organized a covert heist of over 350,000 manuscripts and smuggled them to safety in southern Mali. A real world thriller with a 'revenge of the nerds' flavor.

I will be spending much of the upcoming week at ID Week 2017. 

Expect pictorial updates on the blog.

Friday, September 29, 2017

Does Burnout Increase the Risk of Hospital-Acquired Infections?

I frequently hear and read that physician and nurse burnout is on the rise, that the levels of burnout in the modern healthcare facility are reaching epidemic proportions.    

I came across this interesting article that correlates nurse burnout with increased hospital-acquired infection such as catheter associated urinary tract infections and surgical site infections.  The postulated reason is that burned out staff are less likely to follow best practices and less likely to wash their hands.  I can neither confirm nor refute this claim.

In this day of duty our restrictions, increased time on the electronic medical record and growing stress and burn out, hospital-acquired infection rates appear to be decreasing, year in and year out.  This may be due to greater standardization and protocolization of infection prevention risk reduction interventions.  Ironically, this may be lumped into the many ‘odious’ tasks that drive burnout.

The field of healthcare worker burnout and safety is ripe for further study.

Monday, September 25, 2017

The Laws of Medicine, Bias and the Need to Be Nimble

Here is an interesting read, titled The Laws of Medicine- Field Notes from an Uncertain Science, by Siddhartha Mukherjee.

The laws of Medicine include:

1. A strong intuition is more powerful than a weak test
2. Normals teach us rules, outliers teach us laws
3. For every perfect medical experiment, there is a perfect human bias

This last point reminded me of bias with respect to paradigm rigidity. I have previously explored this theme in a recent blog.  In brief, we should not be too wedded to a strategy,  particularly if that strategy is not backed by robust evidence or if there is contradictory evidence in its support.  We need to be nimble and pragmatic, to satisfice in the real world of infection prevention. 

Therefore, I admit my bias: pragmatism. I am willing to be convinced otherwise.                

Wednesday, September 20, 2017

The Times They Are A - Changing! Bare Below the Elbows as Normative Behavior (Without a Mandate)

The Times They Are A- Changing! To quote Simon and Garfunkel.

Who would of thought that local community hospitals would now be exploring bare below the elbows (BBE)?

Yesterday I had the pleasure of delivering an invited lecture at Sentara Hospital, Suffolk, Virginia, where hospital leadership is exploring an attire change. The topic was healthcare worker apparel and bare below the elbows as an infection prevention adjunct.

Barriers to apparel change include tradition, identity and the need for pockets (to carry instruments etc). This was formally studied and published here.

Apparel habits can be changed in favor of a BBE approach without a hard mandate. Bare below the elbows is an infection prevention recommendation at VCU and our compliance is > 70%. The trick is to provide alternatives to the standard white coats. This includes raising awareness, education, providing feedback  and encouraging the use uniforms and team vests with hospital/service line logos. 

The new white coat is a cool black vest, as written by Mike Edmond.

Get with the program.

Monday, September 18, 2017

The Lexicographer and the Archivist

Thanks to Google, I was informed that today is Dr. Samuel Johnson's 308th birthday. The man who wrote the first comprehensive Dictionary of the English language. No small accomplishment!

On a more local level,  I was back to the medical library today to visit the VCU Tompkins-McCaw archives.  I hope to forge ahead on a collaborative project (with an archivist), culminating in a published perspective on the role of the medical archivist in the modern medical library: challenges and opportunities.

Why? Because I like books and I like visiting the rare and limited collections.

Dr. Samuel Johnson

Benjamin Rush: Yellow Fever Observations

Vesalius De Humanis Corporis Fabrica

Friday, September 15, 2017

Antimicrobial Scrubs, New Evidence, Same Conclusion

We are learning more about the role of the inanimate environment and its impact on healthcare apparel. For some, antimicrobial textiles are promising. We studied the impact of an antimicrobial textiles in hospital scrubs and noted a decrease in MRSA apparel burden only. There was no impact on hand colonization, which was likely the most important finding. This study was published in 2012.

This excellent new article recently published by my colleagues at Duke University once again concludes that antimicrobial impregnated scrubs were not effective at reducing healthcare personnel contamination.The environment and patient were the principal drivers of healthcare personnel apparel contamination.

So, as we now know, apparel is contaminated in the healthcare environment (as is the stethoscope, bed rails,commode, keyboard, mobile phones etc).

We are back to the same message: wash your hands and wipe down instruments before and after patient care. Rolling up your contaminated sleeves probably would not hurt either.

Monday, September 11, 2017

Smoking Gun! Antimicrobial Stewardship Programs Work So Use Them!

Finally, smoking gun evidence that antimicrobial stewardship decreases the incidence of infection and colonization with antibiotic resistant bacteria and Clostridium difficile!  This excellent meta-analysis can be accessed here, in the Lancet Infectious Diseases.

Antibiotic stewardship has greatest impact when coupled with other infection prevention strategies such as hand hygiene, check list, chlorhexidine bathing etc.

Given the above, I think that the time is now for us to push for stewardship programs that go beyond business hours on Monday through Friday.  Mechanisms should be in place for 7 days a week stewardship 'full coverage'.  

You get back what you put in, use antibiotic stewardship to the fullest.

Friday, September 8, 2017

Naked Surgeons Shed Fewer Bacteria But Policy Change is Not Imminent!

Plague Doctor- Physician attire is steeped in culture 
Fact: many guidelines are based on expert opinion, incomplete evidence and at times even contradictory evidence. 

This article in Clinical Infectious Diseases neatly summarizes the debate on surgical attire and notes that surgeons who remain naked underneath the surgical gowns may shed less bacteria. This may not impact SSI rates but would almost certainly impact employee satisfaction.

Kudos to the authors for a witty perspective on the trials, knowledge gaps and potential pitfalls of mandating attire change in the OR.   Much like healthcare personnel attire in nonsurgical settings, changing the culture of operating room attire can strike a note of discord for various reasons not the least of which is that physician and surgeon attire is steeped in culture.

Before we get to aggressive in mandating change,  we should consider not only the evidence, but also whether the change is pragmatic, feasible and reasonable.   With respect to the physician white coat, we feel that the data does not support a hard mandate for its banishment. However, bare below the elbows, should be recommended and encouraged as it is simple, based on biologic plausibility and not likely to cause harm- as summarized here.

Back to the OR:  we should focus on maximizing mandatory interventions that improve patient outcomes-such as surgical time-outs,  the appropriate timing and dose of antibiotics and proper patient skin prep with chlorhexidine. 

I would be cautious on mandating infection prevention practices based on little or contradictory evidence.                                                           

Saturday, September 2, 2017

3rd Annual Summit of Experts on Hospital Acquired Infections- Riviera Maya, Mexico 2017

Last weekend was my OHS reunion soccer match, today I had the distinct honor present our publications and (VCU) vision for pragmatic infection prevention practice at the 3era Cumbre de Expertos en IAAS y Practicas Clinicas, Riviera Maya, Mexico. 

The program was top shelf with excellent speakers from Latin America, including my colleague and compatriot, Dr. Victor Rosenthal from Argentina.

Thank you to the conference organizers, especially Dr. Samuel Ponce de Leon. 

Images are below.

Press Conference

Press Conference

Dr. Samuel Ponce de Leon

Dr. Victor Rosenthal

Question and Answer: with Dr. Rosenthal

Sunday, August 27, 2017

Old Footballers Never Die....They Just Play in Reunion Soccer Games

This one goes out to all who appreciate the Beautiful Game and the value of lifelong friendship.

Old footballers never die they just play in reunion soccer games! 

Thank you to all who coordinated, participated and watched the 1st Annual Oneida High School Alumni Soccer Classic. 

More so, thank you to all soccer alumni and friends for the wonderful memories, both past and present.

We will be back in 2018!

1st Annual OHS Alumni Soccer Classic: Photo of Teams

OHS 1988 Varsity Soccer Team-L to R: Jon Pawlika, Camilo Bearman, The Blogger, Brent Elford, Jeff Reese, Mark Lundrigan, Lars Ljungkvist

Pre-game with Swedish Soccer Star: Lars Ljungkvist

Pre-kick Off Huddle

Regrouping at halftime
Back in the OHS Goalmouth After 29 Years

With Special Guest Nick Meskos: West Genesee Soccer Standout and 1988 Empire State Games Teammate 

Pre-event Greetings

A Loyal Fan
1988 OHS Varsity Soccer Team

Wednesday, August 23, 2017

Success in Medical Education in the Era of Alternative Facts

This thoughtful article in the New England Journal of Medicine, by our very own Dr. Richard Wenzel, argues for the critical importance of teaching, inquiry, observation and reflection in medical education, particularly in an era of alternative facts where sound bites and reverence for patient throughput reign. 

Clinician-educators work under the pressures of increased revenue generation, frequently at the detriment of important intellectual and educational pursuits. Thought and reflection are undervalued. 

I fully agree.

As a Division Chair much of my job is to function as a steward of educational and academic opportunities so as to protect faculty time (typically 20%) for non-clinical work.  Setting reasonable RVU generation benchmarks is also important.This is not easy yet achievable.These structural mechanisms, along with mentorship, are necessary yet not sufficient for academic success.

Intrinsic motivation is key. 

There is little that can be done to motivate someone. As explored in the book Driveby Daniel Pink, highly functional people are driven by autonomy, mastery and purpose. Extrinsic motivators, such as more pay, prestige and enhanced benefits work less effectively.         

Spanish Nobel Prize winning physician, Santiago Ramon y Cajal published Reglas y Consejos Sobre Investigación Científica (1898), wherein he summarizes his observations and perspectives on medicine and scientific investigation. Many of the observations still ring true. Discovery is not necessarily a function of special talent, but a function of hard work, which creates talent, and, low achievement is less commonly from a lack of time and resources, it is more from a lack of willpower.

Intrinsically motivated faculty should be recruited, selected and celebrated. This will be fruitless without the appropriate environment to flourish.

Monday, August 21, 2017

Book Nerds Visit the Stacks! Rare Manuscripts and Magnificent Reading Halls

This is of little interest to most except the nerdiest bibliophiles. 

I made an appointment with a VCU Tompkins-McCaw medical library archivist (not librarian) to visit some of the 16th, 17th and 18th century manuscripts and books from the special collections and archives. Much of the collection is from that of Professor Herman J. Flax's collection of rare physiatry texts such as a 16th century french translation of Galen (pictured below). A Vesalius manuscript is also available for viewing via the Virginia Historical Society.

These books are old, frail, out of date, worn out and of no practical use. Regardless, they represent our ability to seek, learn and share, an inspiration for ongoing reading, learning, experimentation and growth.

I spent much of my medical school years studying in the Austin Flint Reading Room of Abbott Hall  at the University at Buffalo (last picture below). Much like I am inspired to compete on the football pitch or exercise in the gym, the library encourages thought and reflection.

I have been repeatedly reminded by the medical students and residents that 'no one goes to the library anymore.'  

Their loss.

Austin Flint Reading Room, University at Buffalo