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.

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.

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.

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.

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).

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.

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?