Ebola Preparedness- VCU Interview

I have been asked by some about where to find my recent Channel 12 interview on Ebola preparedness.

The interview may be found here.

What Not to Wear (In the Hospital)!

What not to wear (in the hospital)! The VCU School of Medicine will launch a new glossy publication (print and web) this Fall. One of the featured articles will be on healthcare worker attire.  

This piece is partly motivated by the SHEA Expert Guidance Paper of Healthcare Personnel Attire in Non-Operating Room Settings which I co-authored with various colleagues from the Society for Healthcare Epidemiology of America.

In the photo shoot, we captured images of traditional physician attire and that of bare below the elbows approach for inpatient care.  At VCU Medical Center, the Infection Control Committee recommends bare below the elbows for inpatient care. The aim is to promote hand hygiene to the level of the wrists and to prevent infrequently laundered items, such as lab coat sleeves, from coming into contact with patients and the patient care environment.

For many, the white coat has a utilitarian function with its pockets. We have learned, from a study in our institution, that the need for carrying capacity is an ongoing motivator for wearing a white coat. The black vest, with its pockets, serves as a reasonable substitute to the white coat and allows for a bare below the elbows approach to inpatient care.

The concept of the black vest as the new white coat was originally conceived by my friend and colleague Dr. Michael Edmond, and is neatly summarized here.  

Stay tuned.

The Fist Bump - A More Hygienic Salutation?

The handshake is firmly rooted in Western culture as salutation. It is well known that many

pathogens, particularly respiratory viruses, can be cross transmitted by contact.

Could the fist bump be a more appropriate salutation as an infection prevention measure? Here is an intriguing read on the fist bump recently published in the Journal of Hospital Infection.

The authors suggest that implementing the fist bump in the healthcare setting may reduce bacterial transmission between healthcare providers by reducing contact time and total surface area exposed when compared with the standard handshake. In the small study, significant differences in contact surface areas were observed between the palmar surface area, contact time of the handsake was 2.7 times longer than a fist bump and total colonization of the palmar area of the hand was four times greater than the fist after incubation at 72 hours. 

Some important limitations should be noted, specifically, the bacteria were not speciated so the presence of MRSA, VRE and gram negative rods is speculative, and, the study did not target outcomes such as hospital acquired infections. Regardless, the idea of encouraging a fist bump is not ridiculous as it is supported by biological plausibility.

Changing hospital culture is tough enough, changing social norms, such as changing a hand shake to a fist bump, may even be more challenging. 

Yogurt and C.difficile Infections in the Hospital

Here is an intriguing report in The Hospitalist on encouraging the consumption of yogurt by hospitalized patients receiving antibiotics. The health system performing this intervention reported a significant decrease in the rate of C.difficile associate diarrhea.

I have multiple reasons to be skeptical. First, I cannot find this report cited in any peer reviewed, medical journal. How can one be sure that introduction of a 'yogurt diet' was causally related to a change in C.difficile rates? What about other important factors such as changes in antibiotic stewardship, hand hygiene practices, length of stay, changes in room disinfection? Too many unanswered variables and the study design was not rigorous.

Also, the largest, most recent probiotic trial failed to show benefit on preventing C.difficile associate diarrhea. 

Yogurt will likely not impact  C.difficile in acute care settings.

The Rushed Doctor

I am a bit off topic as this is not related to infectious diseases.

Here is a telling editorial published in the New York Times on the rushed doctor. The bottom line, in attempt to accommodate the growing numbers of patients, encounter times are decreasing. This may not be the best for patient safety, satisfaction and outcomes.

In my institution, we have yet to feel the time pinch as acutely. We still are allowed 30 minutes for a follow up visit and 60 minutes for new patient. Owing to overbooking of cases, admittedly self imposed to accommodate the clinical demand, time pressure does become a factor

Another recent editorial refers to the bottleneck in training doctors.

Challenging.

Hand Hygiene and Video Observation in the Operating Room

In my institution, we are launching into an initiative for enhancing hand hygiene (HH) in the OR. Although the surgical hand scrub is an inviolate ritual in the surgical arena, hand hygiene in and around the OR is much less robust. The body of literature on HH in the OR is much smaller than in non-OR settings.  Here is an article on the use of video observation for HH monitoring that was recently published in the the American Journal of Infection Control.

The investigators used video observation in the OR to map patterns of anesthesia provider hand contact with anesthesia work environment (AWE) surfaces and to assess HH compliance. The World Health Organization criteria for HH was used as the HH standard. Serial bacterial cultures of high contact objects were performed to characterize bacterial transmission over time.

A low rate of HH compliance by anesthesia providers was observed (mean, 2.9%). Most importantly - an inverse correlation was observed between provider hand hygiene compliance during induction and emergence from anesthesia (3.2% and 4.1%, respectively) and the magnitude of AWE surface contamination (103 and 147 CFU, respectively). 

We need better mechanisms to both encourage HH and to make it feasible in an OR, particularly at the anesthesia work station. This will require education, promotion and feedback.

The benefits of improving HH in the OR is based on biological plausibility. The real impact of HH on surgical site infection remains unknown. This knowledge gap poses a problem for implementation and ''buy in'' from healthcare workers.

An uphill climb looms.

VCU MIDPH 2014- Congratulations to VCU Medical Students Sarah Hughes and Tammy Tran

Congratulations to VCU Medical Students Sarah Hughes and Tammy Tran, who presented their Microbiology, Infectious Diseases and Public Health Program (VCU MIDPH) summer research on July 7, 2014.

Sarah's work focused on infection prevention strategies in the medical ICU and Tammy studied Lyme disease ecology and climate patterns.

Kudos to both.