Machine Learning in Infection Prevention: Not Quite Ready for Prime Time

This recent article on machine learning in digital epidemiology, published in Infection Control and Hospital Epidemiology got me thinking of an article we published nearly a decade ago.  

Our article on a clinical productive model for catheter related bloodstream infection prediction from the electronic medical record is available in open access format here. The publication admittedly lacks immediate clinical application, and like machine learning for infection prevention, it is not quite ready for prime time.

Machine learning in infection prevention could result in smart, individualized patient algorithms which allow for EMR based real-time central line use tracking, documentation of appropriate catheter dressing, CHG bathing and awareness of patient specific risk factors.  This would then generate individualized patient centered alerts and automated central line stop-orders (requiring provider override) in the face of escalating bloodstream infection risk.  

Individualized daily risk assessment, improved catheter maintenance and decreased catheter overuse likely means fewer catheter related bloodstream infections. 

That would be cool.

RVU Medicine, Technology and Physician Loneliness: The Dr. Richard Wenzel Perspective

For those that are concerned about the current practice of medicine, particularly in academic medical centers, I would strongly suggest reading this excellent perspective just published by our very own Dr. Wenzel in the New England Journal of Medicine.

As the physicians are pushed to ever greater productivity standards something is lost. That something is time for meaningful interpersonal interactions, thinking and self reflection.  Physician loneliness and burnout ensues.

Dr. Wenzel mentions the faculty lounge at VCU Health which he championed, one that allows for a retreat from the busy day to share both meals and ideas with colleagues. I could not be more supportive.

My experience as Chair of Infectious Diseases has made me hyper-aware of the clinical RVU expectations and physician well being.  Although only a partial victory with the compensation plan, we were successful in resetting the RVU expectation for VCU Infectious Diseases to a more reasonable target, taking some pressure off of our faculty.  Recent changes also include significant decreases in documentation requirements (attestation statements) and centralized inpatient billing (not requiring us to 'drop a bill') effective March 2019. These should further minimize the burdens of clinical care.

Nothing will substantively change until leaders boldly redefine physician value in compensation. Simple economic incentives, such as RVU based compensation systems, fall way short.

Venturing Out of Your Academic Comfort Zone and Cultural Distress at the Point of Clinical Care

Source: Redbooth.com

The conclusion of this project, recently published in the Journal of Transcultural Nursing,  serves as a personal reminder of synergy when collaboration extends beyond your academic comfort zone. The output is frequently greater than the sum of the individual parts.

More importantly, thank you Dr. Christine DeWilde (PhD) for including me in this novel project that explores the emerging paradigm of cultural distress in healthcare, one that potentially results in increased psychological symptoms of stress in the clinical environment.

Through structured interviews with validated assessment tools of 100 patients at VCU Health, including the infectious diseases clinic, we learned that cultural stress, in part defined by structural stressors (gender, age, ethnicity, religion, income, sexual orientation etc) had no influence on psychological stress but was associated with perceived discrimination in the healthcare setting.  

How to best counter perceived patient discrimination remains unknown but certainly not irrelevant in this day of patient centered care , where the expectation is to provide the right care at the right time and at the right place.

Decreasing Antibiotic Overuse: Some Mercifully Brief Thoughts On a Vexing Issue

I am no expert in antimicrobial stewardship however I do oversee an infection prevention program so I am modestly conversant in the matter.

An article that I handout to all the students, residents and fellows is this 1990 paper titled  Antibiotics:The Antipyretics of Choice? by DiNubile.  This paper is brief, to the point and timeless as it argues against knee-jerk antibiotic prescriptions for febrile patients. Pulling the trigger on antibiotics is appropriate for neutropenia with fever, sepsis and a confirmed/highly probable bacterial infection.  For nearly all other scenarios, there is time to pause for a proper assessment prior to initiating antibiotic therapy.

This recent article, hot off the press and published in JAMA provides a prescriptive framework, to be used in bedside clinical decision making, for re-thinking how antibiotics are prescribed. The key questions are:

• Does this patient have an infection that requires antibiotics?
• Have I ordered appropriate cultures before starting antibiotics?
• After 24 hrs can I stop antibiotics or narrow therapy or change to oral therapy?
• What is duration of antibiotics needed for this patient's diagnosis?

If the above were applied consistently, no doubt, antibiotic use would improve.

So here is my final comment:  To truly impact antibiotic use we need an aggressive multi-modal approach, one that provides a simple clinical decision making model with aggressive antimicrobial stewardship programs that employ formulary restriction and prospective audit and feedback. 

Anything less will fall short.

Fall 2018 / Winter 2019 Medical Literary Messenger Has Published!

As the Editor in Chief, I am proud to announce that the Fall 2018/ Winter 2019 Medical Literary Messenger has published. 

The publication is available for download (free and open access) here.

Thank you to our contributors and to our dedicated editorial team.

Dr. Michelle Doll: VCU Department of Anesthesia Grand Rounds January 17, 2019

Congratulations to our very own Dr. Michelle Doll for her scholarly presentation early this morning at the VCU Department of Anesthesiology Grand Rounds.

The topic was perioperative antibiotics and infection prevention in the OR. The session was well attended and well received, ending with a nice question and answer session.

Some of the material covered can be found in this expert guidance paper, available here. 

Images from the lecture are above.

The Butchering Art: From Animalcules and Maismas to The Germ Theory of Disease

I recently read a phenomenal book titled The Butchering Art by Lindsey Fitzharris. This a must for any infectious diseases aficionado.

The book chronicles the medical career of British surgeon Dr. Joseph Lister, the pioneer of surgical antisepsis.  The story reads like a novel and covers important concepts such as the evolution of the germ theory of infection from the now discarded theories of animalcules and miasmas as agents of disease.

Also, the book highlights the significant dangers of hospitalism, the Victorian term for hospital acquired infections. Fatality was significantly greater for patients treated in hospitals versus home.

Like Ignaz Semmelweis, Joseph Lister was relentless and attacked for his ideas and practices on antisepsis- on using carbolic acid (phenols) to prevent surgical site infections.

In the end, empiricism and outcomes prevail over paradigms and untested beliefs.

Blogging is Dead. Long Live Blogging: The Golden Age of Blogging Has Passed.

My medical blog launched in 2010. Blogging, however, is losing its relevance.

This intriguing article in the National Post (Canadian newspaper) titled The Brief Life of Blogging summarizes the meteoric rise and decline of blogging popularity. The same theme is also explored (briefly) in a book I recently read-  Anti-Social Media: How Facebook Disconnects Us and Undermines Democracy by University of Virginia Professor Siva Vaidhyanathan (book review by The Guardian accessible here). The golden age of blogging was from 2002-2007 per Professor Vaidhyanathan.

True. Blogging is less popular but not yet obsolete.  In a limited attempt to increase the relevance of my blog I have linked each new blog to a Twitter post. That is about the extent of my tweeting.

Although a blog is less academic than a peer reviewed journal article and although I have few if any followers, I find the exercise still personally enriching. Blogging allows me to publicly express my perspectives in concise, targeted posts with hyperlinked references, with hopefully some meaning and relevance, as I have previously explored here. 

Writing still matters.

Blogging is dead. Long Live Blogging.

Alternative Doffing Strategies Urgently Needed!

Congratulations to VCU medical student Kathry Osei-Bonsu and VCU associate hospital epidemiologist Dr. Michelle Doll on this recently published  paper in the American Journal of Infection Control.

Utilizing Glo Germ and fluorescing Staphylococcus epidermidis during observed personal protective equipment doffing, the authors reported that up to 16% of doffs resulted in apparent transfer (growth) of S. epidermidis- an important surrogate marker of live bacteria.

The one step doff of gowns and gloves, as highlighted in the article, was the least likely to result in self contamination.

Studies such as these are not exclusively done for academic purposes.

Next step: Train and measure performance to scale across a healthcare system.

The Sweet Spot of Safety

Thank you to my VCU colleague,  Dr. Michelle Doll, for the slide above, which she will use in an upcoming VCU Surgery Grand Rounds.

Not all guidance makes people happy.  There are many disgruntled surgeons when it comes to surgical attire policy.  Much of current policy is dictated by regulatory agencies and based on flimsy data. Here is a link from a cardiology discussion which challenges appropriate attire in the catheter lab. Heated to say the least.

Much of what we do in Medicine is based on poor evidence.  Do not let anyone fool you.  

The goal is to relentlessly pursue 'the safety sweet spot" that balances evidence and feasibility so as to play out in the real world.  This is summarized in the diagram above.

We have attempted to do that, in our expert guidance paper on infection prevention in the  operating room anesthesia work area,  published here. 

The document is not perfect but at least it is a reasonable start.

The Usefulness of Useless Knowledge

In my literary meanderings I came across the 1939 essay The Usefulness of Useless Knowledge (full text article available here), by Abraham Flexner.  

Yes, this is the same Abraham Flexner of the the famed Flexner Report. 

I believe in being deliberate and focused in most things.  However, this may not always be the best (or healthiest) strategy.  As argued in the essay, the pursuit of useless knowledge can be useful when this proves unexpectedly consequential , as with the genesis of new discoveries. This is explored recently in a NY Times opinion, available here.

So now I feel much better about seemingly useless pursuits. Most likely they will amount to naught but sometimes they may pay dividends and take me to new horizons.

Relief.