Approaches to Hand Hygiene Monitoring: From Low to High Technology Approaches.

L-R: Michelle Doll MD, MPH and Nadia Masroor, MPH

Congratulations to my research coordinator, Nadia Masroor, MPH and VCU Associate Hospital Epidemiologist and Assistant Professor, Dr. Michelle Doll, on their recent invited article in the International Journal of Infectious Diseases on hand hygiene monitoring- a perspective covering both low and high technology approaches.

For years we have had a hand hygiene direct observation monitoring program at VCU Health -a  strategy which is common place in North America.  We have begun the deployment of a wireless, blue tooth based hand hygiene technology badge carried by individual healthcare workers (nurses, care partners, residence and attending physicians).  This technology allows us to track hand hygiene - as measured by foam in and foam out of patient rooms at the individual and group level.  As with nearly all hand hygiene monitoring there are inherent limitations-  this does not capture all 5 moments for HH as defined by WHO. So far, two hospital units are near completion of the 1st phase. The house wide deployment will roll out in a step-wedged design over the course the next 18 months.

The volume of data is extraordinary.  Whereas the the hand hygiene monitoring team captured roughly 35,000+ hand hygiene opportunities per year, our technology  has thus far captured > 90,000 in 8 weeks in two units. Dr. Doll and Nadia Masroor are leading the project.

This technology does not represent infection control salvation, and, as with everything, the decision to employ it is subject to an opportunity cost. The new technology, however, will allow us to promote and track hand hygiene more vigorously, a step towards greater reliability in safety.

More to come.

Resistance: Film on the Threat of Resistant Microbes

For any of you seeking an engaging and well done documentary on antimicrobial resistance (suitable for the lay public), check out Resistance.  The film is available on Netflix.

The film neatly summarizes the antibiotic era and the drivers of antibiotic misuse in both medicine and agribusiness. A 'tragedy of the commons' is looming in the threat of a post-antibiotic era.

In medical practice, rapid  infectious diseases (PCR based) diagnostics minimize uncertainty and can curtail the use of unnecessary just-in-case antibiotics. The next frontier is the use of computer assisted decision support- clinical decision trees to maximally guide antibiotic prescription at in real time, as explored here in this recent Clinical Infectious Diseases article.

Antibiotics must be treated as precious resources. 

Primum Non Nocere, But First Length of Stay and Patient Throughput

The central tenet of medicine is primum non nocere, first do no harm. Compelling and resounding but not sufficiently convincing (to some) when it comes to infection prevention prioritization.

All hospitals have infection prevention goals and priorities. After all, preventing hospital acquired infections is primum non nocere on a population level. When coupled with evidence based risk mitigation strategies and an understanding of significant harms, this should be sufficient to drive infection prevention priorities.

Impact on length of stay and patient throughput  (as I previously discussed in a blog) is a critical driver for many decision makers in the hospital. Decreasing length of stay and maximizing throughput is the new Holy Grail of hospital administration, disregard this angle at your own peril if you seek to persuade and prioritize infection prevention strategies across your institution.

Raising Awareness of Antibiotic Resistance- Locally

Although I commonly do media interviews representing VCU on infectious diseases, yesterday was  the first time that I addressed antibiotic resistance on camera.

It am encouraged that awareness of antibiotic resistance and overuse is getting greater local attention. It certainly cannot hurt the cause of antibiotic stewardship. 

The interview and video clip can be accessed here.

What is trending in Infection Control? Seek Diverse Sources for a Greater Perspective

Read on and seek diverse sources......

What is hot infection control and where should you seek information?

This article, which was recently published in Infection Control and Hospital Epidemiology, explores trending topics and information sources in infection prevention. 

As expected, peer-reviewed journals play an important gatekeeping, elite role in the dissemination of knowledge. The material in published journals is not sensationalized, more rigorous, and, in theory, less biased. 

Websites, including advocacy sites, are unfettered from the peer review process and promote views or topics that trigger a more emotive response (i.e deadly superbugs.)

Blogs are a less elite mechanism for publication and information dissemination. These have a role particularly when an academic prospective is employed. Of course, these too can be biased. I strive to make my medical blog as academic as possible within the framework of my own professional perspective (or bias). One of the best infection prevention blogs is the one by my friends and colleagues- Controversies in Hospital Infection Prevention.

So read on my friends and seek diversity in sources.

Happy 90th Birthday-Feliz Cumpleaños Professor Enrique Gerstzen

Happy 90th birthday to Professor Enrique Gerstzen, colleague and argentine compatriot at VCU Medical Center. We should all be so lucky to be thriving and working at 90 years of age. A true living legend.

Feliz cumpleaños (90) al Profesor Enrique Gerstzen, colega y compatriota argentino en el centro médico VCU. Todos debemos ser tan afortunados de estar prosperando y trabajando a los 90 años de edad. Una verdadera leyenda viviente.

Images below. 

3rd Annual Gordon Archer Research Day- In Pictures

Today we hosted the 3rd Annual Gordon Archer Research Day at the VCU Medical Campus. 

The collaborative program highlights research in infectious diseases, allergy/immunology and microbiology. The diversity of topics included transplant infectious diseases, infection prevention, HIV care, global health, antimicrobial stewardship and bench research in microbiology and allergy/immunology. Presentations were at the podium and in poster format.

Thank you to Drs. Larry Schwartz (Allergy/Immunology) and Dennis Ohman (Microbiology) for their enthusiastic support and participation.

A very special thanks, always, to my assistants Krystle Shaw and Peggy Andrews. Without them, none of these projects and programs would be possible.

Images are below.

Dr. Salma Abbas

VCU Infection Prevention Nurses:L-R Amie Patrick and Michele Fleming

Graduate Student Kyle Rodino

Dr. Lawrence Schwartz- Allergy and Immunology Chairman

VCU Medical Student Karthryn Osei-Bonsu

VCU medical student Ian Lovern and VCU Infection Prevention Nurse Ginger Vanhoozer

Pharm D Resident Payal Kakadiya

L-R: Krystle Shaw and PeggyAndrews

With Nadia Masroor, MPH- VCU Infection Prevention Research Coordinator

Poster Session

Ebola and Emerging Infectious Diseases Preparedness Forum: Quote of the Day

I am spending the day on the campus of the University of Virginia at the Virginia Department of Health (VDH) directed Ebola and Emerging Infectious Diseases Preparedness Forum. Represented were UVA, VCU and other Virginia hospitals. Always a pleasure to dialogue on all things related to infectious diseases with colleagues, including Dr. Costi Sifri, my homologue at UVA.

To quote Dr. Marissa Levine, VDH Commissioner: Critical partnerships and collaborations are the secret sauce of emergency preparedness.

I agree, that's why we are here.

The best preparedness is when you believe that you are not yet ready.

Dr. Lisa Brath- VCU critical care specialist and director of our Unique Pathogens Unit

Infectious Diseases Physicians Add Value to Patient Care, Just In Case You Did Not Know.

As division chair I am commonly asked to justify program expansion with arguments such as RVU generation, improved quality, safety, outcomes etc. As a result, I am always on the lookout for articles to support any of these angles.

It is now well accepted that infectious diseases specialists improve outcomes with respect to Staphylococcus aureus bacteremia. I read this article in Clinical Infectious Diseases about the positive impact on reduced mortality (from 39% to 29%) of a dedicated ID sepsis consult team for an emergency department. Not unexpectedly, 24/7  infectious diseases consultation resulted in  greater compliance with the Surviving Sepsis Campaign bundle, including the prescription of appropriate and timely antibiotics. 

So, a dedicated infectious diseases consult service for patients with sepsis/ septic shock in the emergency department can improve outcomes.  

This sounds great, however, who really wants to staff sepsis consults in the emergency department 24/7?  

This may not be feasible in the long-term and may not play out to scale in the real world.

Goalkeeping and Medicine: Don't Just Do Something, Stand There!

The Blogger-slightly left of center-front row-as a goalkeeper on the Colgate University Men's Soccer Team

As a lifelong soccer player and goalkeeper this unique perspective in JAMA comparing soccer goalkeeping with medical decision making resonated with me.  

During penalty kicks, many of us reflexively pick a side and dive. Goalkeepers may be better off standing in the center of the goal, first reading the eyes, hip and feet of the shooter and then reacting to the kick. Without a doubt, quality goalkeepers develop a proficiency in positioning and reading the intentions of attackers. Good keepers hold their ground and react deliberately.

Much of modern medicine is practiced reflexively. A symptom or complaint results in a battery of tests readily ordered with the computer mouse in the electronic medical record. 

We should hold our ground, 'dive' less reflexively when evaluating patients and strive for a more thoughtful approach to diagnosis. 

Of course, this takes time, practice and reflection, just like the mastery of any skill, like soccer goalkeeping.