Tuesday, June 20, 2017

C. difficile as a Hospital Acquired Condition: Time to Give it a Rest

As is well known, C. difficile infection is classified as a CMS Hospital Acquired Condition (HAC). 

The current state of infection prevention science can likely prevent 55-70% of device associated infections and surgical site infections, as cited hereC.difficile is different. Although a compendium of strategies to reduce C.difficile in the hospital was recently published by my colleagues at SHEA, the extent to which hospital acquired C.difficile is truly preventable is unknown and highly debatable.

First, the paradigm that most C. difficile is hospital acquired was challenged by the New England Journal of Medicine article by Eyre et al, demonstrating that diverse reservoirs of C. difficile exist outside of the hospital setting, likely contributing to the rise in current cases.

Recently, our Swiss colleagues demonstrated that to C. difficile can be controlled without the use of contact precautions, an intervention which is held as sacrosanct by many.
Even more recently, it was reported that heightened disinfection had no impact on hospital acquired C. difficile. Aggressive antibiotic(fluoroquinolone) restriction may be the way to go, however, this is not salvation.

These are troubling times in infection prevention as paradigms are challenged.

Until we have a better understanding of the extent to which C.difficile is both acquired and reliably prevented in the hospital, CMS should not penalize healthcare systems for C.difficile HAC measures.

How can we fairly penalize what we cannot (yet) reliably prevent?

Sunday, June 18, 2017

Congratulations VCU Infectious Diseases Fellows: Graduation Day

Congratulations VCU Infectious Diseases Fellowship graduates Drs. Salma Abbas and Scott Anderson, who received their training certificates last evening at a party in their honor. Also, congratulations to Dr. Dan Markley who finished the third year fellowship in infection prevention and who was recently awarded a Master of Public Health degree.

Dr. Abbas will remain with us as a third year fellow in hospital epidemiology and will complete a Master of Public Health degree. Dr. Anderson will return to Louisiana to practice infectious diseases and Dr. Markley will join us as an Assistant Professor of Medicine and epidemiologist at the McGuire Veterans Administration Hospital.

Below are a few images from the event.

Drs. Salma Abbas and Scott Anderson

With Dr. Jane Cecil- VCU ID Fellowship Director

VCU ID Faculty and Fellows

Thursday, June 15, 2017

Tuesday, June 13, 2017

Procalcitonin Use in the Real World: Like the Difference Between a Rock Music Studio Recording and a Live Performance

The Who: Rock is Dead! Long Live Rock!
The use of procalcitonin in the real world is much like the difference between rock music recorded in the studio versus a live performance. Studio recordings can be heavily produced, with multiple tracks, special effects and dub-overs. Live performances are more organic, spontaneous and sound different, sometimes not quite like the original track. Only the really talented can do both well.

I really like this recent article on the real world use of procalcitonin in critically ill patients, published in Clinical Infectious Diseases. The article is an important reminder of the differences between randomized controlled trials and real world implementation. Although randomized controlled trials support the use of procalcitonin for improved antibiotic use, the implementation of procalcitonin in non-study settings is poorly structured, inconsistent and not associated with antibiotic use improvements or clinical benefits.

This underscores the importance of per protocol fidelity for the reproducibility of results.

In my opinion, when attempting to implement an evidence based infection prevention intervention, the key question is as follows: will the strategy (modeled on studies supporting the intervention) play out in the real world, and, can it be done to scale with fidelity? 

If not, do not bother.

Monday, June 12, 2017

Chronic Antibiotic Suppression of Infected Cardiovascular Devices: Data from the Real World

Kudos to this group from the Mayo Clinic for publishing this paper on the outcomes of patients receiving chronic antibiotic suppression for infected implantable cardiovascular electronic devices. This is a real world clinical problem, and requires a real world analysis, one that may not be optimal but that may just satisfice.

Much of what we do is based on little evidence and many knowledge gaps exist.  Many clinical questions simply cannot be answered by randomized, prospective, blinded trials.  I mean, what industry or government agency would pay for a prospective, randomized trial of chronic antibiotic suppression for implantable devices? 

There is no academic glory, by way of grant prestige, in studying this or other vexing, non-research fundable clinical questions.  

Well done.

Friday, June 9, 2017

Meandering in Upstate New York: Random Images

I am away off topic here, but, I took several days away from the office and set off on a road trip to Upstate New York (Syracuse).  The drive up and back (500 miles each way) was an adventure on the back country roads in a two seated roadster.  As the traffic dissipated, the humming engine and the open road fostered a present mindedness that was devoid of daily distractions.  A proper driving experience for a driving enthusiast.

Below are some images from my former hometown of Oneida, NY, just east of Syracuse. The  images include the music store where I brought my 1st drum kit in 1983 (picked up some new drum sticks there the other day, too),  homes from my former neighborhood and various other random stops including the local newspaper where I got my first job (in 1983) and Oneida lake.

Back to work next week, with more appropriate blog material to come.

Friday, June 2, 2017

'Street Cred' and Medical Leadership: It is Not Trivial

I just recently reviewed a paper for PLoS One, a systematic and comprehensive review of medical leadership in hospital settings. I truly hope that the paper sees the light of day and is published. Of course the paper highlighted the personal and context specific features of medical leaders, none of which were really different to leadership in non-medical settings. However, the authors highlighted that medical leadership differs from general leadership most crucially in the quality and perception of credibility- clinical credibility. Without it, the ability to persuade, influence and role model is diminished.

I have previously explored the importance of physician leaders maintaining a clinical practice.

Clinical 'street cred' is a necessary (yet not sufficient) ingredient for successful physician leaders. 

Talk the talk and walk the walk. The rest is noise.

Tuesday, May 30, 2017

The Potential Perils of Mandatory Infection Prevention Efforts

Surgical caps- non grata here!
This is a subject that I have been pondering for quite some time- the potential negative consequences of mandating infection prevention interventions that are based on little (if any) evidence.      

We have been criticized about our bare below the elbows (BBE) initiative at VCU Health.   Admittedly, there is little high quality evidence to confirm that bare below the elbows results in few or hospital-acquired infections.  Bare below the elbows is based on biological plausibility, simplicity and likelihood of not causing harm. There is one important nuance: BBE is not mandatory at VCU Health.  It is an infection prevention adjunct, a recommendation.  By way of nudges, reminders and the modeling of BBE by influential team members, the practice has taken hold and has become essentially normative behavior, with compliance typically > 70%.

Surgeons are understandably upset about the banning of skullcaps in the OR, as recommended by AORN. Non-compliance with this AORN standard potentially exposes health systems to regulatory action from JCAHO or CMS. Skullcaps have been banned at VCU Health and the move has not been popular.

A recent paper published in Neurosurgey from the University at Buffalo (my medical school and internal medicine residency alma mater) assessed the pre/post  impact of banning skull caps on surgical site infections.  Not surprisingly, the absence of skullcaps (substituted by bouffant caps) did not impact the surgical site infection rate.  Mike Edmond recently posted a clever blog on the skullcap feud on the HAI Controversies site.

Infection prevention, in my opinion, is as much a science as it is and art.   The science should dictate and prioritize the interventions.  Implementing infection prevention strategy requires a more artful approach- one  that is heavy on dialogue, collaboration, reciprocal relationships and the ability to persuade, otherwise nothing gets accomplished.       

Mandating poorly supported infection prevention practices potentially jeopardizes relationships, the collaborative mission of patient safety and undermines the credibility of an infection prevention program.  

Mandates should be used selectively and when truly supported by high quality evidence. 

Pick and choose your battles wisely, collaborators and allies matter.

Monday, May 29, 2017

The Hospital Microbiome- Dynamic and Vexing

I am spending this fine Memorial Day in the hospital doing consults and blogging, particularly as I await the return of my patient from the CT scanner.

Credit to this group for a very sophisticated study on the dynamic and changing hospital microbiome, published in Science Translational Medicine. By way of thousands of bacterial cultures and metagenomic analyses, the evolving microbial ecology of a newly opened hospital was characterized.  The bacteria in patient rooms, particularly in high touch areas, resembled the skin microbiome of the patient and changed over time.The inanimate environment is dynamic and hospital rooms reflect the flora of the occupant. 

Our understanding of the inanimate environment is growing yet significant knowledge gaps continue to vex us.         
What is the true proportionate impact of the inanimate environment on hospital acquired infections and what is the most effective and practical (i.e.real world- otherwise it is essentially useless) way to measure and decrease bioburden for risk mitigation? We are still searching.

Back to the consults.


Friday, May 26, 2017

Cervical Cancer Screening in Rural, Mountainous Honduras

La Hicaca and environs. VCU GH2DP Site, Yoro, Honduras
Congratulations to Rachel Pryor RN, MPH, who collaborated with us in our VCU Global Health and Health Disparities Program (GH2DP) on the ground in rural Honduras. 

Rachel took us out of our comfort zone to study barriers to cervical cancer screening in rural, mountainous Central America and is the lead author in a paper published in the Journal of Rural and Remote Health.

Although cervical cancer screening exists in rural Honduras, misconceptions and gaps in knowledge and access abound, along with poor availability of testing results. With our Honduran community health partners we are working to make a change.

The VCU GH2DP team will be back  in Honduras the first week of June 2017.

Thursday, May 25, 2017

The Knowledge Illusion

Most of us have no real understanding of how little we know.  

This topic is beautifully explored in the book The Knowledge Illusion, by Peter Fernbach and Steven Sloman.  We
have individual ignorance yet collective wisdom.

Many of us rely on intuition, which is a simplified analytical perspective. Intuition can be 'good enough' in many situations. Unfortunately, intuition gives us the illusion that we know a fair amount when we actually don't. When asked to explain things we often cannot. This is the illusion of explanatory depth.

Deliberation allows for more thought, reflection and analysis and is commonly achieved by suppression of the more immediate intuitive explanation. Deliberation reveals how little we individually know about most things. It is collective (group) knowledge that allows humans to excel and flourish. There is no cure for the superficiality of our individual knowledge. Awareness of its existence is the treatment.

Recently I was giving and infection prevention lecture to high ranking folks in my institution. The focus was evidence based interventions, process of care and outcome measures in infection control. A gentlemen (a physician) interrupted me and suggested that we look into the tile grout of the main floor in the hospital, as grout is porous and seemingly teeming with bacteria, thereby posing an imminent infection control risk. This was intuitive (yet misguided) and certainly not deliberative. If pressed on the mechanisms of hospital acquired infections- the illusion of explanatory depth would have been revealed.

Know your limitations and know your knowledge gaps. Be aware.

Wednesday, May 24, 2017

Visual Abstract-Saying More With Less.

Source: Mike Edmond- HAI Controversies Blog
Why do we habitually pack so much information in dense power point slides or poorly designed posters? The end result is often challenging to follow and even more difficult to retain.

During our weekly staff meeting, we recently discussed the pitfalls of power point as outlined by Edward Tufte in Beautiful Evidence . We also discussed strategies for optimizing presentations as championed by Chip and Dan and Heath in Made to Stick.

In our profession the visual abstract is the way to go. Simply, a visual abstract is a visual summary of the information contained within an abstract with particular attention to the key findings. An excellent example, by my friend and colleague Mike Edmond, is embedded in this blog. Note: the findings are neatly summarized and succinctly explained.

For a cool listing of visual abstracts check out this twitter link #visualabstract.

Here  is a informative primer on visual abstracts for the uninitiated.

I strongly feel that scientific presentations should be analytical, concise, simple yet granular and most importantly, persuasive

Monday, May 22, 2017

UVA-VCU Clinical Case Conference Spring 2017

Today we had the pleasure of visiting the University of Virginia for our combined spring clinical case conference. The previous case conference, in the Fall of 2016, was hosted at VCU. Today's event was at the Colonnade Club of the University  of  Virginia.

The topics of the day: Leishmaniasis in an immigrant (VCU) and Listeriosis in an immunocompromised patient (UVA).

The purpose? To share cases, engage in clinical discussion, meet colleagues and learn something new. Perfect.

A few images from earlier today are below.

Dr. Scott Anderson- VCU

Colonnade Club

The Rotunda- University of Virginia

Thursday, May 18, 2017

Pagers vs Smartphones: Which One is Superior?

How would you rather be contacted for clinical matters? By pager or directly to your smartphone?

This intriguing article suggests that direct clinical communication by dedicated smartphone, rather than pager, resulted in quicker response and intervention times by the residents .  The study did not assess clinical outcomes.

This all sounds fine and well, particularly in this age of  hyper-availability and hyper-responsiveness.

As we move towards more consult requests via smartphones, I just do not want to get messages in text speak! " R U available 4 Sepsis Cnslt?"


As some suggest, in this NY Times article, U can't talk to Ur professor like this.

Friday, May 12, 2017

Congratulations Nadia Masroor and Dr. Dan Markley- Newly Minted Master of Public Health Graduates

Kudos to Dr. Dan Markley (3rd year infectious diseases/hospital epidemiology fellow) and Nadia Masroor, who received their Master in Public Health degrees today from the Virginia Commonwealth University. Making us proud!

Dr. Markley will join my team as an Assistant Professor, with clinical responsibilities at the Richmond McGuire Veterans Administration Medical Center. Nadia will continue as the full time project and research coordinator for the VCU Health Hospital Infection Prevention Program.

Thank you both, for your stellar work, and for being part of my team.


Monday, May 8, 2017

VCU in National Hospital Spotlight- American Hospital Association

Below is a quick clip from the American Hospital Association National Hospital Week video that spotlights VCU. 

I make a mercifully short appearance.

Saturday, May 6, 2017

2nd Annual VCU Infection Control Conference- Images

Yesterday (5/5/2017) we had the great honor and pleasure of hosting the 2nd Annual VCU Infection Control Conference at the Hilton Hotel and Spa, Short Pump, Virginia. The conference was a smashing success with over 160 guests, many from area hospitals.

Invited guest speakers were Linda Green, FR, MPS, FAPIC, President Elect of APIC, who gave a phenomenal lecture of the future of infection prevention. Also, Judie Bringhurst MSN, RN of UNC Chapel Hill delivered a masterful presentation on high level disinfection.

Of, course, our own team, including, Kaila Cooper, Michele Fleming, Ginger Vanhoozer and Dr. Mike Stevens rounded out the program along with a spirited panel discussion and a poster session. Select units and teams were formally recognized with awards for innovation and excellence in infection control outcomes and collaboration.

The purpose? To engage, raise awareness, educate and to recognize the infection prevention collaborators at VCU health. The momentum must never slow down. 

We are deeply indebted to all of the conference organizers, particularly Joni Greer of VCU Nursing Education and Professional Development. 

I am already looking to next year's event.

Images are below.

Linda Greene RN, MPS, FAPIC- President Elect of aPIC

Mike Stevens MD, MPH

VCU Infection Prevention Team with Linda Green and Judie Bringhurst (left of center-front row)

A tough question for the expert panel!

Monday, May 1, 2017

Patient Throughput- The New Holy Grail of Medicine

Maximizing patient throughput may be the new Holy Grail of hospital medicine. I hear a lot of talk about patient throughput, almost on a daily basis. Throughput First! Seemingly the sacred tenet of modern hospital medicine, after first do no harm. 

Maximizing throughput will require robust, evidence based standardization- including safety checklists, safety huddles, interdisciplinary rounds, and ensuring the availability of appropriate case management and support teams (example staffing the floors with social workers and making invasive procedure floor teams available 7 days a week).

This is not a pipe dream. A recent article on patient throughput in the ICU highlights that a structured process can maximize efficiency and not compromise safety.

All of this takes time, effort, accountability, institutional will and money. How could it not? Cutting costs and cutting corners will result in harm.

The resources must match our aspirational goals.

Monday, April 24, 2017

Accountability: The Elephant in the Infection Prevention Room

When infection risk is not fully minimized, this may not always be a systems failure, as I have previously written. I still stand by that. Accountability, for many, is the elephant in the infection prevention room.

Accountability, in my opinion, is one of the most critical components of patient safety. It is also one of the most challenging to uphold, particularly as many of us tend to avoid tough feedback conversations with colleagues.  

Like data collection and feedback, accountability can also be structured and formalized, as summarized in this report from Johns Hopkins University.  This formalized, transparent accountability structure calls for escalating levels of review corresponding to the numbers of months that an entity has missed a performance goal for a measure. Higher level leaders know the goal, know their role, and and ensure that lower level leaders have the skills, resources, time, and feedback (data) to improve. Making performance expectations clear and subject to formalized reviews makes the feedback process more objective, less personal and easier to execute.

Safety works best when it is standardized. Standardization takes effort and oversight. Optionalism is a major barrier to standardization in healthcare. 

Structured accountability can halt optionalism. 

Time to move forward.

Tuesday, April 18, 2017

Restrict Fluoroquinolones! Not so far fetched, But How Do We Do It Stateside?

There is mounting evidence that restricting fluoroquinolones significantly reduces C. difficile infections, particularly in the United Kingdom, as recently reported in Lancet Infectious Diseases. It is well known that fluoroquinolone use is unnecessary (>30% of the time) in hospitalized patients, as reported here in 2011.

Will this play out stateside, where restriction of antibiotics is not used as a primary C. difficile prevention measure?

If there is will there is a way. 

Fluoroquinolone restriction could be done but we would need to tackle the 'physician autonomy' ethos in US medicine. To do it right, we would need sound evidence based policies, clear education on the rationale for restricting fluoroquinolones, and, treatment pathways or alternatives to fluoroquinolone use either for empiricism or for specific diagnoses. That said, it still may not be popular.

So if anyone has been successful in restricting fluoroquinolones in a US hospital (other than the Veteran's Administration Hospitals where a top down approach seems to work), let me know. 

I am looking forward to any insights on the matter.

Wednesday, April 12, 2017

Clostridium difficile Control- Topic of Debate and Controversy

Above is a sound bite from Contagion Infectious Diseases Today magazine. The interview took place after the SHEA debate with Drs. Silvia Munoz-Price, Mike Edmond and me. Most enjoyable.

You can access a very neat play by play of the SHEA 2017 C.difficile control debate via Dr. Steven Pergam's Storify, here.

Monday, April 10, 2017

Give Stewardship of Culturing a Chance!

Give stewardship of culturing a chance! Please.

True: We order too many tests, in particular urinalyses (UA) and urine cultures. The consequences are the misdiagnosis of a catheter associated urinary tract infection (CAUTI) and the prescription of unnecessary antibiotics.

In a set of ICUs, a commitment to order UA and cultures per guidelines set forth by the American College of Critical Care Medicine/ Infectious Diseases Society of America resulted in a significant reduction in urine cultures and CAUTI rates. No harm was reported. The study can be accessed here.

We need a strategy change in CAUTI prevention. Aseptic insertion and proper maintenance are required. Daily review for ongoing need and electronic medical record prompted automatic discontinuation orders help too. Then, stop ordering unnecessary urine cultures. 

Stewardship of culturing-  the next challenge.

Wednesday, April 5, 2017

Infection Prevention and Control in Low and Middle Income Countries- The Next Frontier

Congratulations to my VCU colleagues, Dr. Sangeeta Sastry and Nadia Masroor, who lead the recently published  International Journal of Infectious Diseases manuscript on infection prevention and control for low and middle income countries. The manuscript was based on a workshop at last year's 17th International Congress on Infectious Diseases, Hyderabad, India.

The manuscript serves as a loose roadmap for the update of our book, Guide to Infection Control in the Hospital (5th edition), available here as a free download from the International Society for Infectious Diseases

In collaboration with international authors and editors, the updated Guide will have new chapters and an interactive website/smartphone application. The content will also focus on simplified yet effective infection prevention measures for better implementation in low and middle income countries. Portability and practicality are key elements.

We plan to launch the project at the 18th International Congress on Infectious Diseases, Buenos Aires, Argentina (2018).

Tuesday, April 4, 2017

Medical Society Meetings- Analog Works Best!

SHEA 2017: Closing Plenary
I have several times heard the comment that the conventional medical society meeting is expensive and may not be the most efficient way to share information. Some have called for 'virtual meetings' online. Fair enough, this would be certainly more direct and likely a cheaper mechanism for sharing new scientific discoveries but it is likely less impactful.

What's missing in the argument is the unwritten curriculum of a scientific meeting. Meetings allow for structured plenary sessions, but, more importantly, the face to face discussions, the networking and the 'off-line' discussion of ideas, concepts and implementation details are invaluable. New perspectives and inspiration frequently start here.

Last, attending a society meeting allows one to be present and immersed in the topic at hand. In this day and age of seemingly endless distractions, attending a meeting online from the comfort of your couch or hospital office chair will last until the next page, telephone call or patient care request arrives. Only the highly disciplined will resist the temptation to slip back into some 'pressing' office matter.

Thus, I prefer a medical society meeting in analog, not virtual. 

Call me old fashioned.

Saturday, April 1, 2017

SHEA Spring 2017: Days 2 and 3, Synopsis and Snapshots

Day 2:

It was a fine day at SHEA Spring 2017. I moderated and excellent, diverse section on infection prevention challenges.

The focus was on implementation strategies that work. Thank you SHEA! These are the practical considerations needed to make infection prevention successful. The day concluded at the SHEA Society Dinner, at the Forest Park Science Center Planeterium. A cosmic celebration of sorts.

Day 3:

Dr. Dan Diekema discussed test stewardship, a concept that is beginning to catch on and hopefully gain momentum. Minimizing overuse and over-testing (on all levels) are valuable goals.

I had the pleasure and honor to go toe to toe in a debate with Drs. Silvia Munoz-Price and Mike Edmond, on universal screening for C. difficile carriage. Spirited and most enjoyable. It was a three way tie. 

The closing plenary was a clarion call for greater activism by SHEA, IDSA and its members to meet the goals of heightened patient safety and antimicrobial stewardship. The speakers were Drs. Silvia Munoz-Price, Mike Edmond and Bill Powderly (IDSA President). Thoughtful and inspiring, to say the least.

I concluded the day with a media video-interview for Contagion Infectious Diseases Magazine, to be posted likely in the next several weeks. Stay tuned.

SHEA Spring 2017 has come to an end and I am already looking forward to the next one.

I leave you with some images from the conference (some clever slides) and from my meanderings in St. Louis to record stores and blues bars.

Back to Richmond. 

Mike Edmond, Silvia Munoz-Price, The Blogger

C.difficile stuffed toy.....charming.

Closing Plenary

Vintage Vinyl, St. Louis Missouri

Blueberry Hill Blues Bar. Need I say more?