Medicine and the Cheesecake Factory- An Evolving Model of Medical Care?

Source: The New Yorker

Healthcare is an incredibly complicated system with many moving parts. Coordination of care is increasingly more challenging.

Physician practice has traditionally allowed for near complete autonomy. The result? Significant variation in practice and little standardization of care. This can result in costly care with a high risk of error and adverse events.When clinical pathways, safety checklists or other standardized practices are suggested, there is frequent push back from practitioners.

Medicine is nuanced and all patients are not the same, yet, there is a role for standardization of care. By using clinical pathways, safety checklists and comprehensive unit safety programs (CUSP), medical care can be made more appropriate, better coordinated, efficient, less costly and safer.  Even with greater standardization, medicine will undoubtedly remain an art, as providers will still need to recognize and respond to nuances in patient condition and deviate, accordingly, from routine care.

Here is an article by Atul Gawande, published in the New Yorker, exploring the Cheesecake Factory model of medical care.

The argument is persuasive and the model proposed may represent the future of medical practice. 

Copper for the Prevention of Hospital Acquired Infections

Copper- source: ECOTEXTILES

There is always much excitement about new technology in medicine, particularly when infections are potentially preventable by scientific breakthroughs. Here is a state of the art review article on the use of copper impregnated textiles to limit hospital acquired infections.

It is now well established that copper has antimicrobial effects in vitro. Clinical trials support the claim that copper impregnated surfaces can decrease bacterial counts, including MRSA and VRE.

Clinical trials are now ongoing to assess the impact of copper impregnated surfaces and textiles on the rate of hospital acquired infections. I am very excited to learn the results.

Several key elements need to be defined.

• What is the minimum standard of copper impregnation on a surface/textile that would render it effective in a clinical setting?
• Which surfaces in a hospital should be optimally targeted for copper impregnation?
• What impact will copper surfaces have on spore forming organisms such as C.difficile?
• Superimposed on infection prevention best practices, what would be the incremental impact of copper impregnated surfaces and textiles on hospital infections and is it cost beneficial?

These are all critical questions that must be answered before universal adoption of copper impregnated technologies for infection prevention. 

HIV Testing in the ER- A Good Start

Source- adi-news.com

I have blogged before about the need for aggressive HIV testing to identify the 200,000+ Americans who are infected yet unaware of the diagnosis.

The University of Alabama Birmingham is putting theory into practice. Here is an article in Infection Control Today reporting on the UAB experience on HIV testing in the ER. Over the last year, their ER has performed 20,000 HIV tests and has diagnosed 31 new HIV infections. A novel twist in the story is that that ER utilized new HIV testing methodology which allowed for diagnosis of chronic infection (antibody test) AND acute infection ( HIV antigen), by the  ARCHITECT HIV Ag/Ab Combo test. It is believed that about 10% of  HIV infections can be missed in high risk populations if only antibody testing is employed.

Per the American College of Physicians practice guidelines, HIV testing should be offered to all patients so testing in emergency rooms, an area of high patient volume, gets us one step closer towards identifying previously undiagnosed and untreated HIV infection.

With early diagnosis comes treatment and treatment is prevention.

Reduced Chlorhexidine Susceptibility- Implication for Infection Prevention?

Chlorhexidine is a chemical antiseptic widely use in the hospital. It is effective in killing a wide range of pathogens, is safe and used as a primary agent of skin antisepsis.  Here is a recent report, published in the Journal of Hospital Infection in drug resistant isolates of Klebsiella pneumonia. 

We have observed the emergence of extremely-drug-resistant (XDR) strains of Klebsiella pneumoniae. The author's hypothesized that reduced susceptibility to chlorhexidine may contribute to the endemic nature of this strain.

The minimum inhibitory concentration (MIC) of chlorhexidine was determined in 126 XDR K. pneumoniae clinical isolates using agar dilution.

The MIC of chlorhexidine was higher for K. pneumoniae ST258 (N = 70) than other K. pneumoniae sequence types (N = 56); 99% of ST258 isolates had MICs >32 μg/mL, compared with 52% of other K. pneumoniae sequence types (P < 0.0001).  Also, chlorhexidine-resistant subpopulations were observed independent of the bacterial sequence type or the MIC.

The suggestion? Reduced susceptibility to chlorhexidine may contribute to the success of XDR K. pneumoniae as a hospital acquired pathogen. This is a small study  and definitely not conclusive. However, further surveillance of chlorhexidine  susceptibility is definitely warranted to track its clinical significance.

Evidence Based Control of Multi-Drug Resistant Enterobacteriaceae Needed

Source: CDC

Here is a publication on the need for evidence based policies to limit and control multi-drug resistant enterobacteriaceae (MDE) in hospitals. Much of our strategies to currently control MDE is ad hoc and not fully driven by high quality evidence or formal guidelines. 


Noteworthy points include:

• The degree of transmissibility of MDE is unclear, hence further work is required to better understand where, when and how transmission occurs
• The optimal screening frequency has yet to be determined.
• There is no consensus on how long patients may carry MDE, thus the freqency of re-screening is unknown
• Although oral gentamicin for decolonization of MDE has been reported, optimal strategies for decolonization of MDE do not exist
• Environmental decontamination strategies and antibiotic stewardship (restriction of extended spectrum cephalosporins in particular) may also be effective interventions to limit the spread and appearance of MDE.

As we gather more experience on the control of MDE, attention must be given to both the positive and negative consequences of our infection prevention interventions.  The example MRSA active surveillance and its pros/cons is insightful and underscores a look before you leap approach.   

CUSP and Surgical Site Infections

A Comprehensive Unit Safety Program (CUSP) in the OR can result in positive outcomes as published recently in the Journal of the American College of Surgeons.

One year of pre- and post-CUSP intervention SSI rates were collected using the high-risk pilot module of the American College of Surgeons National Surgical Quality Improvement Program. Surgical Care Improvement Project process measure compliance was monitored using standardized methods. 


The surgical best practices intervention were as follows:

• standardization of skin preparation
• administration of preoperative chlorhexidine showers
• selective elimination of mechanical bowel preparation
• warming of patients in the preanesthesia area
• adoption of enhanced sterile techniques for skin and fascial closure
• addressing previously unrecognized lapses in antibiotic prophylaxis. 

The results? Not surprisingly, the SSI rate improved. The mean baslinee SSI rate was 27.3% (76 of 278 patients). Following the intervention the the rate was 18.2% (59 of 324 patients)-a 33.3% decrease (95% CI, 9-58%; p < 0.05).  There was no difference in surgical process measure compliance as measured by the Surgical Care Improvement Project during the same time period, suggesting that this was not a coonfounding variable.


One paper does not define science, however, this quasi-experimental study suggests that evidence based interventions can help reduce the rate of SSIs. The challenge is to implement and sustain the interventions. The CUSP model is a viable implementation strategy, even in the OR.

Letra de Medico and Narrative Medicine

Source: Cordoba.com.ar

I returned today from my native Cordoba, Argentina. Not surprisingly, I spent much of my free time lying about the house and reading books.Not idle time at all! I even managed to write and submit another essay. Keep your fingers crossed on its acceptance for publication.


I fortuitously came across a title, Letra de Medico, by Argentine physician Carlos Presman. The book is a collection of essays and reflections on medicine and on doctoring. Presman is by no means the first physician to turn to narrative and written reflection as means of understanding either the human condition or the doctor-patient relationship. Many of the stories are rich and full of humor, underscoring the beauty and importance of humor as a healing art.


Most importantly, Presman reminds us that each patient is more than a mere clinical encounter. Every patient is a biography and a unique personal narrative, where the physician's role is to astutely read, understand, comprehend an take part in the 'story',  so as to better appreciate the experience of illness and to employ healing as an art and not merely a science.


I fully believe in the importance of narrative medicine as a model for medical practice. A insightful article on narrative (free and online) was published in 2001 in Journal of the American Medical Association (JAMA). I highly recommend it.