Rethinking the Prevention of Ventilator Associated Pneumonia

Ventilator associated pneumonia (VAP) is the least common yet the most dangerous of hospital acquired, device associated infections.

Selective digestive decontamination (SDD) works for the prevention of VAP. Many infectious diseases, including myself, have an aversion to prescribing antibiotics for preventive measures, largely owing to the fear of selecting antibiotic resistant organisms. For many, this is dogma. 

This recent paper, a systematic review and meta-analysis published in Clinical Infectious Diseases, summarizes much of the data in VAP prevention and challenges our hang ups. Current data suggests that SDD is one of the most effective measures to prevent VAP and reduce mortality.

We must rethink our objections to SDD for VAP prevention and push ourselves to study both the short and long term benefits of digestive decontamination. 

Interventions should be guided by data. Data trumps dogma. 

Patient Care, Interruptions and Breaks in Task- A Day in the LIfe

I spent much of the last 2 weeks covering the ID services in the hospital. The pace was fast and the patient load was heavy. These last few weeks had me reflecting on how my time is actually spent in the hospital and how often I am distracted by phone calls, pages etc.

I dug up this article, on how hospitalists spend their time. Much of it is on indirect patient care activities, such as charting and making phone calls, coordinating care. Per this publication, only 18% of the time in the hospital is spent on actual patient care. I believe it.

Next, I found this article on interruptions and breaks-in- task in an emergency department. An "interruption" was defined as event that briefly required the attention of the doctor but did not result in switching to a new task. A "break-in-task" was defined as an event that resulted in changing tasks. Not surprisingly, per each 180-minute review period, there were on average 40 interruptions and 21 breaks-in-task. Are airline pilots distracted as often when flying a plane?

We are driven to distraction and this certainly cannot be good for either efficiency or patient outcomes. The challenge lies in quantifying the impact of distractions on patient safety, and, in response, designing systems where patient care is both the primary focus and is insulated from unnecessary distractions. This would be huge. 

Fever- The Story of Typhoid Mary

For those of you looking for a good medical read, I would suggest Fever, by Mary Beth Keane. This medical novel focuses on the life of Mary Mallon, infamously known as Typhoid Mary.

The narrative goes beyond depicting the medicine and evolving understanding of infectious diseases at the turn of the 19th century. At its core is a deep and meaningful story about love and survival. 

Despite the sickness and death inflicted by a Marry Mallon, one cannot help but sympathize with her struggle and see her as a sadly forgotten heroine of an era long past.

Well worth reading.

University of Nebraska Biocontainment Unit Visit

I have spent the last few days at the University of Nebraska at the Ebola Training Course. This was an excellent experience and will definitely improve the finalization of the VCU Unique Pathogens unit, which is imminent.

Back to Richmond tonight and back to ID consults tomorrow.

What is the optimal number of infection preventionists for a hospital?

What is the optimal number of infection preventionists for a hospital? The conventional is estimate is that one infection preventionist is needed for every 250 acute care beds.  Here is a recent article in the American Journal of Infection Control that explores an alternative formula for calculating the number of infection preventionists in a hospital. The formula assigns an 'acute care bed equivalent' to different hospital variables (ICU bed, Long Term Care, Dialysis facility, ambulatory clinic, ambulatory surgery center). The goal is to adequately capture the increased work demand  through bed adjustment.

In my opinion, the times have changed. Now, the scope of infection prevention goes far beyond performing surveillance and reporting infection rates. The onus is on us to promote and engineer best practices for the healthcare system. In other words, we are meant to play a fundamental role in implementing, measuring and sustaining best practices in infection prevention (central line checklists, hand hygiene, head of bed elevation, chlorhexidine bathing, review of urinary catheter use, staphylococcal decolonization).Our role is active and much less passive than the historical norm.

The new paradigm is on preventing infections and that takes significant time and energy. Accurately capturing this effort may require more than infection prevention staffing by bed adjustment.

We are still searching for the optimal measurement of infection prevention staffing needs. 

Bare Below the Elbows Spoofed at VCU Medical Center

You can never to be too serious. 

Below is a funny spoof by VCU School of Medicine students on our bare below the elbows infection prevention strategy. All of the comments and actions are very tongue in cheek.

Medical Literary Messenger Fall 2014- Published!

The Fall 2014 Medical Literary Messenger is now published.

Message from the Editor:

Our adventure with the Medical Literary Messenger continues. We received the largest number of submissions to date and have selected a collection of essays, poems and images
that represent both the depth and creativity in which we hope to observe and understand the experience of medicine and disease.

Without you, both the readers and contributors of the Medical Literary Messenger, the whole of the project would be less than the
sum of its parts.