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.

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.                

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.

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

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.

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.

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.                                                           

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