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.
                                                   

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.


      

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.

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.

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. 

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

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?"

No!

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

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.

   

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.

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!

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.