Thursday, March 30, 2017

SHEA Spring 2017: CAUTI Controversies and The National Blues Museum

I am in ST. Louis at the SHEA Spring 2017 meeting. The highlight of the scientific program yesterday was the pro/con debate on CAUTI prevention. The post debate poll reflected the view that CAUTI prevention should not be a top infection control priority. I agree. Preventing other complications is more pressing.

At the end of the day I skipped off to the National Blues Museum. Although not a bluesman by any stretch of the imagination, my love of music and respect for the creativity, emotion and influential nature of the blues on pop and rock music made the visit personally meaningful.

Back to the conference today.

Tuesday, March 28, 2017

Standardization: The Way to Go in Patient Safety
Standardization is the way to go in patient safety. Granted, this is not a novel concept but worth reiterating as we focus the lens of safety on surgical management.

The Enhanced Recovery After Surgery (ERAS) project, an evidence based, peri-operative management process is both championed and neatly summarized in this JAMA Surgery review by my VCU colleague, Dr. Michael Scott. 

In brief, under ERAS, implementation of a standardized peri-operative process which targets smoking cessation,peri-operative antibiotics, glucose and temperature control, removal of urinary catheters and restrictive use of surgical site drains (to name a few items), coupled with performance audits, significantly decreases length of stay, complications and cost. The trifecta of patient safety. 

Excuses for not standardizing patient safety are no longer tenable.

I will be at the SHEA Spring Meeting for the rest of the week. 

Looking forward to it, stay tuned.

Wednesday, March 22, 2017

The Spleen, Everything You Wanted to Know and Then Some....

Not that many of us spend too much time pondering the spleen, however, should you have the desire for a deeper understanding of how medical knowledge of the spleen has evolved over the centuries, check out this engaging article (full length, PDF format).

Historically an enigmatic organ, the spleen was commonly associated with anger and emotion. By the 19th century, splenectomies were being performed for various maladies that resulted in an enlarged spleen. One 19th century surgeon performed a series of splenectomies with reckless abandon, reporting an 88% mortality rate! That did not seem to deter the practice of splenic removal.

Thank goodness that our understanding of the spleen has deepened significantly and that splenectomies are performed more cautiously and with much improved outcomes. 

Monday, March 20, 2017

Cognitive Bias, Clinical Practice and Hospital Epidemiology: We Need to Stay Open Minded and Nimble

Lately I have been thinking a lot about by bias in medical practice. A recent article on cognitive bias, published in The Pharos, neatly explores this concept. Bias can be pervasive in clinical care. The good news is that unconscious bias need not be permanent. Bias can be changed by intention, attention and reflection.  

Bias in medicine also spills over to infection prevention. In the book Pandemic, by Sonia Shah, the concept of paradigms in medicine is explored.   Paradigms are theoretical constructs that provide explanatory frameworks for scientific observations. However, paradigms create expectations which can limit perceptions and lead to confirmation bias and change blindness.

In many ways, we take a paradigmatic approach to the use of contact precautions, particularly for endemic pathogens.  Contact precautions are of unproven benefit and, at best, a low-value intervention that requires significant personnel engagement. This has been challenged recently, as published here. More recently, Widmer and colleagues have demonstrated that C. difficile can be controlled without the use of contact precautions, as summarized in this publication.

In the absence of high quality data, we should not be too dogmatic and biased about any infection prevention strategy.  We need to remain open mind and nimble, especially in the face of new data.

I will discuss this topic, with respect to controlling C.difficile, at the upcoming SHEA Spring 2017 meeting, in a plenary session with my colleagues Dr. Michael Edmond (University of Iowa) and Sivia Munoz-Price (University of Wisconsin).

Looking forward to it 

Wednesday, March 15, 2017

Drumming, Drum Making and Its Unexpected Perils

The Blogger: with his anthrax free pdp kit
People close to me know that I am a drummer. Over the weekend I plowed through the book Born to Drum, by Tony Barrell. The book is an entertaining read and explores modern drumming through the perspectives of various rock and jazz drumming greats.

A known peril of drumming, covered in the book, are repetitive strain injuries. Less well know is the risk from drum making, particularly, when using animal hides for the drum 'skin'. Animal hides may contain anthrax spores. Although the incidence is low, this is no theoretical risk, as highlighted by this 2007 MMWR report of cutaneous anthrax in a Connecticut drum maker who used imported West African goat hides.

I practice safe drumming! My pdp kit is animal hide free.

Back to the beats.

Thursday, March 9, 2017

Buy In versus Ownership in Infection Prevention

I am becoming increasingly wary of hearing the term 'buy in' when it comes to evidence based practice in infection prevention.

These differing concepts are neatly summarized here by Henri Lipmanowicz, former Chairman Merck International and President of the Plexus Institute

"Buy in" connotes that others have done the thinking and have come up with the prescriptive recipe for you to implement. "Ownership" means that key and critical players are involved in either the idea generation or development of the implementation plan- so that they understand it, believe in it and make it happen.

In infection prevention, as new knowledge guides improved safety measures and outcomes, the challenge is to assemble the right team, to develop and own the implementation plan.

"Buy in" is not needed.

Wednesday, March 8, 2017

Improving Practice and Reducing Risk Through Documentation: Why Not?

I have heard the criticism that we should not allow documentation to drive practice in healthcare. Why not?

A recent example is improving patient chlorhexidine bathing practice via documentation in the electronic medical record. Regular audits and consistent feedback lead to greater awareness, increased compliance with patient bathing and improved documentation. I recently came across this interesting publication titled Improving Nursing Documentation and Reducing Risk.  To quote the author, Patrica Duclos-Miller MSN,RN: " As professional nurses, we are held responsible for ensuring safe, quality patient care. The only proof of this is through nursing documentation."

Critics may argue that documenting the completion of a patient bath in the electronic medical record does not prove that the bath was done properly. This is true. However, direct observation of patient bathing is not feasible, at least not to scale. Also, patient skin calorimetry testing for chlorhexidine residual post bathing does not play out in reality. Documentation of chlorhexidine bathing in the electronic medical record satisfices, that is, it is a satisfactory and sufficient solution for a more realistic world, as I have previously discussed.

We must demand documentation solutions for things that truly matter, to minimize task burden and competing priorities. With respect to infection prevention and safety, top priorities include surgical and procedure time outs, central line checklist completion, daily review of urinary catheter need and chlorhexidine patient bathing.

In the end, these safety initiatives, no matter who burdensome they may be perceived, are the right thing to do.

Monday, March 6, 2017

Prevention of C. difficile Infection In The Hospital- Challenging Orthodoxy

I personally think that is very exciting when new data challenges our practice in infection prevention.

In 2013, Eyre and colleagues published a paper in the New England Journal of Medicine demonstrating, by whole genome sequencing, that slightly more than a third of C. difficile infections were transmitted from symptomatic patients. Most infectious were likely not hospital acquired and emerged from diverse (non-hospital) reservoirs. 

More recently, Widmer and colleagues have challenged the use of contact precautions (standard of care) for the control of C. difficile.  In a very recent publication, contact precautions for C. difficile were discontinued except for patients with hypervirulent strains or fecal incontinence. After 10 years, no outbreaks were observed and the transmission rate was 1.3%, very low. Robust hand hygiene and single occupancy rooms likely played a large roll in limiting transmission. 

These may be the beginning of a paradigm shift, with greater emphasis on higher value interventions to limit the risk of C. difficile in the hospital. First, most cases may not be hospital acquired. Aggressive use of contact precautions may not be the answer. Good hand hygiene and minimizing the use on unnecessary antibiotics, which significantly predisposes to clinical C. difficile disease, may be the first approach. Improved disinfection (with bleach, UVC light) may help, however, the impact may not be as great as expected.

I will be at the SHEA 2017 Spring Conference, formally debating and discussing C. difficile control strategies with my esteemed colleagues Drs. Silvia Munoz-Price and Michael Edmond.

I am looking forward to it and plan to learn a lot.

Saturday, March 4, 2017

CATCH- A Short Film About Failed Antibiotics in a Dystopian Future

I just recently learned about a new short film, titled CATCH , where a lethal pandemic
ravages a country in a dystopian future. Antibiotics have failed and widespread quarantine is in effect.

Seems far fetched?

Antibiotic resistance is growing, many of the quarantine measures depicted in the film have been used over the years. Presently, drug resistant bacteria kill nearly 700,000 people across the world annually.

Anything that raises awareness of antibiotic resistance is likely good.

The official film trailer can be seen here.