Career Exploration: So You Want To Be A Hospital Epidemiologist? Flashback from 2009

Wow! 

So you want to be a Hospital Epidemiologist? Featured in Career Exploration in the Richmond Times Dispatch in 2009....recovered from the dustbin today during an office clean out.

I am not so sure if this really worked out is a recruitment tool....

Humans: A Brief History of How We F****! It All Up

Kudos to Tom Phillips for a masterful book, one that is is equal parts an academic history lesson with a perfect blend of wit and comedy.

I particularly enjoyed the chapters on science and the age of discovery. To quote the author:

“Confirmation bias is our annoying habit of zeroing in like a laser-guided missile on any scrap of evidence that supports what we already believe, and blithely ignoring the possibly much, much larger piles of evidence that suggest we might have been completely misguided.”

Spot on.

This book is well worth reading.

The Kardashian Index For Scientists

Figure 1 from Hall, N. (2014). Genome biology, 15(7), 424

It is true that a journal's Twitter following is strongly linked to its impact factor and citations,  suggesting that higher quality research receives more mainstream attention.  This perspective is neatly summarized here.

However, just in case you were unaware, the Kardashian (K) Index (referenced here), is a measure of discrepancy between social media profile and publication record for scientists.

Although high quality scientific publications, particularly if newsworthy, are associated with increased Twitter activity, not all scientists with large Twitter profiles produce high quality scientific work.

Much like scientific inquiry, Twitter should be approached critically.

Merry Christmas.

Justinianic Plague: Beware of Scholarship From Untested Hypotheses

Source: Ancient-Origins.net

Every now and then, in my literary meanderings, I come across a truly intriguing read.

This paper, published in the Proceedings of the National Academy of Science, beautifully researches the socioeconomic impact of the Justinianic (Bubonic) Plague (circa 541 to 750 CE), an epidemic which presumably precipitated the Dark Ages.

The scholars reviewed papyri, inscriptions, coins (currency), pollen, Yersinia pestis DNA  and burials concluding that no convincing evidence exists to support the assertion that the Justinianic Plague reduced the population of Europe by one third.

No doubt, the Justinianic plague, also known at the "First Pandemic, was significant, yet not nearly as much as the Second Pandemic and the Black Death.

To quote the authors- "More broadly,  the scholarly treatment of the JP demonstrates the dangers of uncritical multidisciplinary." Bravo.

Beware the dangers of scholarship from untested hypotheses.

I Am a Specialist But I Seek Range

Yes, I am an infectious diseases specialist, however, I seek range, especially after reading the book Range by David Epstein.  A spectacular read.

There is an inherent danger to specialization, particularly too early in the process of development- whether you are an athlete, musician or even a physician.

Specialization has a limiting effect. Analogical reasoning comes from a diversity of learning experiences. This results in greater creativity and problem solving skills.

Stay curious.

Physician Burnout and Healthcare Epidemiology: Dual Implications Worthy of Greater Scrutiny

Physician burnout is a hot topic of discussion.

We explore the topic of physician burnout in hospital epidemiology, a nuanced subject worthy of greater scrutiny. Our research brief was just published in Infection Control and Hospital Epidemiology, available here (PubMed Indexed here).

Hospital epidemiologists face different pressures than front-line physicians, these may drive burnout. On the flip side, our demands for infection prevention standardization, checklists, time-outs, audits and feedback may drive burnout in colleagues, by way of a perceived erosion of autonomy.

Further studies are needed. 

Single Occupancy Rooms Required for Contact Precautions and ESBL? Maybe Not

Once again, a paradigm is challenged.

This time, it is the use of single occupancy rooms for  contact precautions and the control of ESBL pathogens. The study was published in The Lancet Infectious Diseases and employed a 16 hospital cluster randomized strategy for contact precautions in single bed room versus contact precautions with multiple-bed rooms for patients with ESBL-producing Enterobacteriaceae cultured from routine clinical samples.Transmission risk assessment was judged by rectal carriage of ESBL-producing Enterobacteriaceae  in at least one wardmate.

Multiple-bed room contact precautions for ESBL-producing Enterobacteriaceae  was not inferior to contact isolation in a single occupancy room.

This provides valuable information for a more pragmatic approach to the use of contact precautions for the control of multidrug resistant organisms, particularly when a scarcity of single occupancy rooms exists. A very Satisfice approach to infection prevention.

Quality and Safety in Healthcare: What Defines a Struggling Organization? Time for Reflection

Source: PeaceLabs.org

It is typically more common for publications to identify what is required for select positive outcomes.  

I like this alternative approach, a publication which defines the characteristics of organizations that struggle with quality and safety.   The paper is PubMed indexed here.

Although the results may not be Earth shattering the findings are important.  The five domains consistently reported by struggling organizations include:

1.  Poor organizational culture
2.  Inadequate infrastructure
3.  Lack of a cohesive mission and vision
4.  System shocks- such as high level personnel turnover, particularly in leadership
5.  Dysfunctional external relations

Although no prescriptive plan is offered, these domains provide a comparative reference and a reflective focus point for organizations struggling to meet safety and quality goals.

All change starts with self (organizational) reflection.

2019 Delaware Communicable Diseases Summit

Thank you to the 2019 Delaware Communicable Diseases Summit organizers for a hugely successful event.  The meeting was held at the Christiana Care Health System.The turnout was spectacular, standing room only.

My colleagues, including Drs. Karyl Rattay, Gary Marshall, Karen Ravin, Deborah Kahal and Karen Lopez, expertly covered a lot of ground on vaccine hesitancy, emerging ID threats, infectious diseases and the opioid epidemic and One Health.

It was an honor to give the lecture on the prevention of healthcare associated infections and to participate in the panel discussion.

As always, I learn more than I contribute.

Sympathy for the Drummer: Why Charlie Watts Matters

I am off topic yet again, no medical writing today, rather music, or drumming to be more specific.

Sympathy for the Drummer: Why Charlie Watts Matters, by Mike Edison, is a book that resonates with those who are rhythmically inclined. Charlie Watts, the legendary Rolling Stones drummer, is a jazz virtuoso turned great rock drummer for The Greatest Rock Band in the World. Once I started reading this book I could scarcely put it down.

Charlie putts the 'roll' in rock and roll, with a minimalist drum set, amazing beats, fills and grooves that both push and pull the rhythm of a song. No need to be flashy, just consistently unique. The Stones need Charlie Watts more than Charlie Watts needs the Stones.

If you think it is easy, try playing along to a Rolling Stones song, beat by beat.

I am in Wilmington, Delaware for the 2019 Communicable Diseases Health Summit tomorrow (12/9/2019). Very much looking forward to it.

Stay tuned.

Re- visiting the panculture and other thoughts

I really enjoyed this clever article titled Re- Visiting the Panculture, available here. The authors, Valerie Vaughn and Vineet Choprak, highlight the waste associated with reflexive panculturing of febrile patients. The call for a more 'mindful' approach to the evaluation of fever  is spot on.

The above concept is applicable to this more recent publication titled Knowledge and practices of physicians and nurses related to urine cultures in catheterized patients: An assessment of adherence to IDSA Guidelines.

So, can we be more mindful when assessing a febrile patient?  

Yes, but education and feedback to  providers only goes so far in my experience. This must be coupled with electronic medical record decision support mechanisms which prompt physicians to practice more guideline concordant care. Sometimes, forcing functions are needed, such as an electronic medical record hard stop on Clostridium difficile test ordering for patients with diarrhea and on laxatives.

Erosion of  provider autonomy is not inconsequential, and should employed selectively at most,  such as when patient safety and resource stewardship is on the line.

Ethical Implications of Recruiting Universal Stool Donors for Fecal Transplants

Source: Yale Global Health Review

Although I have performed multiple fecal transplants for recurrent Clostridium difficile

infections, with donor stool coming from OpenBiome, I have not given much thought to the ethical implications of recruiting universal stool donors. My focus has been on the risk/benefit of the procedure to the patient.

Kudos to my colleague Dr. Susy Hota and her collaborators on this truly unique prospective on the ethical implications of recruiting universal stool donors, published in Lancet Infectious Diseases.

For example, informed consent for stool donors should take into consideration that the microbiome may convey sensitive personal information such as travel history, past exposures and sexual practices and may act as a pressure on various aspect of a donor's lifestyle. The intestinal microbiota is also a source of health information that may guide clinical decision-making in the future. Mechanisms to deal with these issues should be developed. Further consideration should be given on what is appropriate compensation for stool donors.

The role of universal stool donor is not as simple as it appears.

UVC Light Disinfection: Our Experience in BMT and Oncology

Let me be clear, UVC terminal  disinfection of hospital rooms is no panacea, especially when it comes to the prevention of Clostridium difficile infections.

Our biggest impact on reducing Clostridium difficile at VCU Health comes from minimizing over testing through electronic medical record decision support. This includes hard stops on  Clostridium difficile test orders for patients receiving laxatives.

Our experience with UVC light terminal room disinfection, particularly in bone marrow transplant and oncology populations was recently published, PubMed indexed here. Using an interrupted time series analysis, we observed a significant decrease in Clostridium difficile infection rates following the deployment of UVC light disinfection in these specific wards.

The next frontier in Clostridium difficile reduction is class restriction of antibiotics.  This is only feasible with expansion of antimicrobial stewardship programs to 7 days a week coverage.

Stay tuned.

The Learning Hospital: From Theory to Practice

As described by the Institute of Medicine, the learning hospital is distinguished by ceaseless evolution of erudition, enhancement, and implementation. A learning hospital, where “science, informatics, incentives and culture are aligned for continuous improvement and innovation,” need not be supported by additional funding from the healthcare system.

No published examples of the learning hospital exist, until now. Kudos to Colgate University student Olivia Hess and the rest of the VCU Hospital infection Prevention Program on this publication titled The learning hospital: from theory to practice in a hospital infection prevention program. The manuscript is PubMed indexed here.

To quote Dr. Santiago Ramón y Cajal, Nobel Prize winning Spanish Physician:"Discovery is not necessarily a function of special talent, but a function of hard work, which creates talent, and, low achievement is less commonly from a lack of time and resources, it is more from a lack of willpower."

Dr. Enrique Gerszten: VCU Physician, Teacher, Icon and Compatriota Argentino

Icon: Dr. Enrique Gerszten (Source: VCU News)

It is a great honor for me to post this blog about my close friend, VCU colleague and Argentine compatriot, Dr. Enrique Gerszten. 

I refer you to this wonderful VCU News article celebrating his 6 decades of inspiring 
physicians in training. The article speaks for itself.

Dr. Gerstzen, now in his 90s, is still going strong and still working.

Icon.

Moxifloxacin: In Verse

I came across this poem, titled Moxifloxacin, in the New York Review of Books, on my Amtrak train ride back to Richmond, Virginia.

I leave the interpretation of it to you.

2019 Southern New Jersey APIC / ID Society Lecture: What an Honor!

Thank you to the Southern New Jersey APIC (Association of Professionals in Infection Control) and Infectious Diseases New Jersey for their invitation to speak at the 2019 November conference. I discussed the SHEA Expert Guidance on infection prevention in the operating room anesthesia work area, available here.

From the Q+A it seems like we are experiencing the same issues such as what to do with those surgical skull caps that are infrequently (if ever) laundered. Vexing.

It was an honor to share the stage with such prestigious colleagues, including my friend and colleague, Dr. Arjun Srinivasan of the CDC.

As always, I learn more that I contribute.

Urgent, Serious and Concerning: CDC Antibiotic Resistance Threats in the USA 2019

Urgent, Serious and Concerning, the CDC threat classification of select resistant bacteria and fungi. For those who have not read this report, recently published by the CDC, the full text PDF is available here.

I applaud the CDC not only for their comprehensive summary, but for their meaningful call to action.The aesthetics of the document is also noteworthy. High quality.

Antibiotic resistance is not a looming threat, its presence is real, the time to act is now.

Psychological safety and Infection Prevention: Are You Comfortable Speaking up?

Psychological safety, AKA a culture of safety, represents one's comfort in speaking up in the name of safety.

This article in the American Journal of Infection Prevention neatly explores a snapshot  of psychological safety, as assessed by questionnaire, across multiple U.S. hospitals and correlates that with hospital self reported infection prevention processes.  Nearly 60% of 900 hospitals responded to the survey, which is no small matter.

A couple of things of note: Only 41% of hospitals reported the presence of a hospital epidemiologist in the facility! This is not surprising as most community hospitals do not have a formal hospital epidemiologist on staff.  Only 38% of respondents reported a "high psychological safety"  environment within the workplace.  High psychological safety was associated with more successful use of urinary catheter discontinuation orders and nurse driven urinary catheter discontinuation.  Most likely,  these healthcare workers feel more empowered to act in the name of safety.

So here is my take-  a true culture of safety starts with relentless messaging from the senior leaders that safety is first and foremost.  This is followed by a reporting mechanism with action oriented responses to hold systems and individuals accountable. Anything less is suboptimal.

Patient safety trumps patient throughput.

IRIS: Comparing Infection Control in a Dutch vs US Hospital

I read with great interest this article published in the American Journal of Infection Control on comparing infection control practices between a Dutch and U.S. hospital using the IRIS (Infection Risk Scan) method.

IRIS is a mechanism to measure the quality of infection prevention and antimicrobial use in a standardized way.  Sounds too good to be true.  

I encourage you to read the methods carefully to get a sense of how these processes were measured. In brief, IRIS  consists of cross-sectional measurements of appropriateness of medical device use, antimicrobial use, environmental contamination and hand hygiene compliance, along with other variables.

The data are summarized as improvement plots. This is where the study is most relevant.

The primary infection prevention goal to focus on improvement of modifiable risk factors to minimize all potentially preventable infections, as explored here.  Clear identification of areas for improvement is the 1st step towards greater patient safety.

Oral Vancomycin for the Prevention of Healthcare Onset Clostridium difficile: Choose Wisely

I read with interest this recent publication on the use of oral vancomycin for the prevention of healthcare facility onset Clostridium difficile infection during systemic antibiotic exposure.

Indeed, patients with a prior history of Clostridium difficile who require systemic antibiotic treatment for other infections are at high risk for recurrence.  The use of oral vancomycin prophylaxis is effective in reducing the risk of recurrent Clostridium difficile, however, this should be chosen wisely, preferably under formal infectious diseases consultation.

As always, the focus should be on minimizing the overuse of antimicrobials.  We argue for  limiting antibiotic overuse as the principal strategy for preventing Clostridium difficile infection, published here in BMJ Quality and Safety.

I am in the hospital this weekend,  attending the Infectious diseases consults, living the dream.

Would Sir William Osler Have Made His RVUs?

Health systems strive to reflect physician value in compensation plans.  However, we all know that patient care volume rules, as measured by Relative Value Units (RVUs).

A cheeky perspective on the matter is published in Annals of Internal Medicine, full text available here.

Sir William Osler almost certainly would not have met his RVUs. His value was in that of a teacher, educator, investigator and scholar. Patient care was not unimportant and served as the basis of his writings and teachings.

Greatness comes from contributions to healing and to the craft of medicine, not from the generation of RVUs. 

The Great Alone by Tim Voors: Recounting an Epic Journey on the Pacific Crest Trail

I am off topic again, this time to share a recent book that I read. 

The Great Alone, by Dutchman Tim Voors, is an account of one man's solo walk across the entire Pacific Crest Trail. Voors battled, heat, wind, cold, thirst and intense isolation over the 2600+ mile trek. An inward look on an outward trail.

The book is also a visual feast with stunning photographs. 

I cannot help but envy Voors' courage and determination to escape the hyper-connectedness and over packed schedules of this day and age, albeit non-permanently. 

 To experience growth and overcome fear, look inward and seek a great alone.

University of Virginia-Virginia Commonwealth University 2019 ID Case Conference

Kudos to to our colleagues at the University of Virginia, including my ID Division Chair counterpart Dr. Eric Houpt, for a very successful, combined and highly interactive infectious diseases case conference, done today by telelink.

A special thank you to our clinical infectious diseases fellows, Dr. Nicole Vissicheli (VCU) and Dr. Bree Campbell (UVA) for their respective cases on HTLV1 myelopathy and Capnocytophagia canimorsus sepsis. Of course, none of this could have happened without our excellent staff who coordinated it all.

These events serve both to teach and to remind us of the value of academic collaboration.

I am already looking forward to the next combined ID conference between our institutions in 2020.

Perioperative Disposable Jackets for SSI Reduction: An Untested Hypothesis Tested

Kudos to Erik Stapleton et al for assessing  the association of disposable perioperative jackets  with surgical site infections. The study was performed in a large multi-center health care organization. This paper was recently published in JAMA Surgery. An untested hypothesis tested.

The AORN recommends mandatory adoption of disposable perioperative jackets for surgical site infection reduction. This trial with multi-variable analysis concluded that disposable perioperative jackets are not associated with surgical site infections in clean operative procedures. The finding is not surprising as most surgical site infections originate from the patient's own endogenous flora and not external factors.

Mandating an intervention based on little to no evidence is fraught with peril and subject to provider backlash.This is precisely why our policy of bare below the elbows (BBE) is an infection prevention recommendation and not a mandate. BBE is simple, safe, and cheap, unlike the wasteful and expensive disposable perioperative jackets. Over time, BBE transformed into normative behavior at VCU health, as published here.

As for mandatory disposable perioperative jackets, it may be time for a strategy reconsideration.

A Wandering Mind is an Unhappy Mind: Proven!

I came across this article (full text) in Science titled A Wandering Mind Is an Unhappy Mind.

The authors developed a web application for the iPhone to create a large database of real-time reports of thoughts, feelings and actions. The volume of data was impressive with a quarter of a million samples from approximately 5000 people, across 83 different countries.

Mind wandering is frequent, in greater than 46% of the cohort. Participants self reported less happiness when their minds were wandering. People were no happier when thinking about pleasant topics.

To quote the authors: A human mind is a wandering mind, and a wandering mind is and not happy mind.  The ability to think about what is not happening is a cognitive achievement that comes at an emotional cost.

We train our bodies for greater fitness yet commonly neglect to train our minds for greater focus. Let your mind wander and think of what we could achieve with greater attention.

Thank You Colgate University: 2019 Wolk Conference on Medical Education and Men's Soccer Alumni Reunion Weekend

Thank you Colgate University for the honor of presenting at the 2019 Michael J. Wolk Conference on Medical Education.

It was an absolute pleasure to be back on campus and to meet so many talented students. The alumni guests, all working in healthcare, were impressive and inspirational. What a delight.

Also, thank you to Colgate Men's Soccer Coach Erik Ronning, for hosting the soccer alumni reunion. I survived the men's soccer alumni game, managed to play well (enough) and not get injured.

Saturday afternoon was spent watching NCAA Division I soccer: Colgate vs Loyola.

Later, a stroll around the campus.

Memories, friendships and shared experiences, both in the classroom and on the soccer pitch. 

Colgate vs Loyola 

Colgate vs Loyola

Colgate vs Loyola

1992 Patriot League Championship Trophy- Senior Year Honor

Alumni Game: Sporting the 2019 Colgate University Goalkeeper Jersey