Monday, August 24, 2015

Not your father's infection prevention program

I have recently been thinking about the many changes in the field of infection prevention that have occurred since I started my hospital epidemiology fellowship at the University of Iowa in 1992. So this post is framed by my perspective of serving two decades as an active practitioner of the day-to-day work of being a hospital epidemiologist, as well as the last year working as a Chief Quality Officer, where I serve as a member of the senior leadership team of an academic medical center and am responsible for overseeing the infection prevention, quality improvement and patient safety programs.

In the old paradigm, infection prevention programs (known then as infection control programs) focused on surveillance for infections, primarily in ICUs, calculating infection rates, and then feeding back the rates to the leadership of the ICUs. The thinking was that the unit leaders would review the data and develop ways to reduce the rates, though in reality this rarely happened. The infection prevention program wasn’t very interested in how to reduce the infection rates, except perhaps to elucidate what the risk factors for infection might be. Hands-on design and implementation of interventions was not seen as a part of the day-to-day work. Another core function was identification and control of outbreaks of nosocomial infections, which were not infrequent. But in a fee-for-service reimbursement model, there was no financial incentive for hospitals to reduce infection rates. Actually, the opposite was true—more healthcare-associated infections generated more services, which generated more income. So there was little pressure on infection prevention programs to demonstrate reductions in infection rates, which remained mostly hidden and shared with only a few individuals in the hospital. The hospital epidemiologist worked quietly behind the scenes, had few interactions with senior leaders, and the pace of work was rather slow. No one really knew or even cared about what the hospital epidemiologist did.

Fast forward 25 years. The hospital epidemiologist now oversees a much larger group of infection preventionists, spends significantly more time on the day-to-day administrative work of the program, and is held accountable for outcomes. The stakes are high, as are the expectations and the pressures of the job. Hospital administrators are increasingly focusing on clinical outcomes data, and requests for data from senior leaders are frequent with expected short turn around. While we’re still responsible for surveillance, we’re expected to detect increases in infections rapidly and intervene promptly  (i.e., we’re expected to provide near real-time surveillance). The more intensive management of the program, coupled with interventions and better products to prevent infections, have reduced infection rates and have made outbreaks uncommon.

The new paradigm forces introduction of interventions in parallel (bundled interventions), rather than in series, which is intellectually dissatisfying for the typical hospital epidemiologist who wants to develop a comprehensive understanding of the mechanism of prevention. And it requires intervening without all the data that we were typically accustomed to having. On the whole, hospital epidemiologists are poster children for the perfect being the enemy of the good. The personality characteristics that favored the selection of hospital epidemiology as a career choice--precision, careful attention to detail, and a methodical approach to problem solving--while still important attributes, can also now be dangerous for career success. Thus, it’s not surprising that transitioning to this high stakes, fast-paced environment has been difficult for some hospital epidemiologists.

So what drove these changes? Why are today’s infection prevention programs not your father’s? Three developments led to the intensive focus on healthcare associated infections. First, the mainstream media began reporting on HAIs, which led to greater interest by the general public. Second, HAI data has increasingly become publicly reported. High infection rates are widely visible and can harm a hospital’s reputation. Third, and most importantly, hospitals are now suffering financial penalties based on their infection rates. Whether that process is fair we'll save for another blog post on another day.

For sure, the job of the hospital epidemiologist is much harder today than in the past. But the good news is that finally all of the forces are aligned to reduce infection rates, and that’s a really good thing. Given the higher expectations, it’s all the more important that hospital epidemiologists have the protected time and resources to be successful and get the job done.

Friday, August 21, 2015

The Poop Cafe

Well, another week has gone by and we haven't posted much of significance. Summer is officially over around here with students piling back into Iowa City. There's no more parking, it's harder to find an open treadmill at the gym and lines at The Java House are much longer these days. Which brings me to a new coffee house craze sweeping (apparently) through Asia - the poop cafe. Who wouldn't want to drink a cappuccino out of a toilet-shaped mug or chow down on a poo-shaped scone all while wearing a poop hat?

So, in the spirit of the last summer weekend and as a reminder of how crappy we have been about blogging this summer, I give you these pictures least they'll be useful for you're next C. difficile talk.

Wednesday, August 19, 2015

Better than germ-zapping robots...

Joe Schlesinger, an anesthesiologist and critical care medicine colleague from Vanderbilt University, sent me this photo he took a few days ago at a hospital in Kenya. If only US hospitals were so forward thinking...

Saturday, August 15, 2015

The Times They Are A-Changin’, and we need better data to keep up….

I recently pointed to the need for more studies comparing different durations of therapy for common infections. In an editorial in the September 2015 issue of Antimicrobial Agents and Chemotherapy, Jesus Rodriguez-Bano points to an equally important priority for comparative effectiveness studies: assessment of existing antimicrobials for organisms that are currently not considered good targets for those drugs. The problem he discusses is the rising rate of carbapenem use that has followed the global spread of extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae

Carbapenems are the drugs of choice for serious infections due to ESBL-producers, but several narrower spectrum agents (e.g. piperacillin-tazobactam, cephamycins (e.g. cefoxitin, cefotetan)) have in vitro activity against many of these organisms. What’s lacking are well-designed comparative trials examining whether these older agents might be similarly effective for selected serious infections (e.g. bacteremia, sepsis) due to ESBL-producers. The study by Matsumura and colleagues that the editorial accompanies provides some support for the effectiveness of cephamycins in the setting of ESBL-E. coli bacteremia, but is limited by its retrospective cohort design and its power.

Given the urgent threat of carbapenemase-producing Enterobacteriaceae (CRE), it would be nice to have more non-carbapenem options to turn to when confronted with these “garden-variety” ESBL-producers.

Wednesday, August 5, 2015

Coordination of what?

I’m glad that the new CDC Vitals Signs report, based upon a modeling study of the impact of regionally-coordinated interventions to reduce healthcare associated infections (HAIs) due to selected multiple drug resistant organisms (MDROs) and C. difficile, is gaining some media attention. The investigators modeled three different scenarios for control: (1) status quo, (2) “augmented” efforts at selected individual facilities, and (3) augmented activities coordinated across a health care network. Using data from various sources to inform the model (Emerging Infections Program and National Healthcare Safety Network for disease burden; Orange County, California and the VA system for patient movement across healthcare facilities; and experience from the UK and Israel for reductions in MRSA, C. difficile, and carbapenem-resistant Enterobacteriaceae (CRE) after national interventions), the model suggests that prevention approaches coordinated by public health authorities could reduce HAIs due to CRE by 55-74%.

This analysis has several limitations, most of which are pointed out by the authors in their discussion—models are models. And I don’t think anyone disagrees that coordinating infection prevention activities across healthcare systems is a desirable goal. The sad fact, though, is that we are very far from achieving this goal. I think Judy Stone has a good take on this, here. Furthermore, even if public health funding were increased enough to provide resources for state and regional coordination of MDRO control, the impact would depend upon each facility’s capacity to implement basic infection control practices (as the authors point out, “Optimizing implementation of basic infection control practice within individual facilities will be of fundamental importance to this effort”).

So while we wait for the inevitable boost in public health funding that is sure to come from our current Congress, we should remain focused on improving the basic “horizontal” infection control practices of individual facilities. It is not possible to know in advance which patient harbors a life-threatening bacterial pathogen (resistant or not), so it is best to assume that everyone does.

Wednesday, July 29, 2015

Hand Hygiene Interventions: A Network Meta-Analysis

Summer is in full blaze (especially for those in Rome, France and the western US), so we don't have much time for long posts. However, I had to point you to an excellent study in the BMJ (open access) by Luangasanatip et al. that utilized a systematic review and network meta-analysis to determine the comparative effectiveness of the WHO 2005 hand hygiene campaign and other interventions. The WHO-5 Campaign (not to be confused with the WHO 5 Moments) recommended a multimodal strategy consisting of five components: system change, training and education, observation and feedback, reminders in the hospital and a hospital safety climate.

The authors completed a systematic review of interventions from 2009-2014 and used prior reviews to identify other studies. A strength of the analysis was that they looked beyond randomized trials and included high quality quasi-experimental studies including non-randomised trials, controlled before-after trials, and interrupted time series studies. They then completed a network meta-analysis which suggested that the WHO-2005 campaign was effective and compliance could be improved if other interventions were added including goal setting, reward incentives and accountability.

For those interested in reading more about network meta-analysis, I suggest you read John Cornell's editorial and the PRISMA Extension Statement in this past June's Annals. Briefly, it allows direct and indirect comparisons of interventions. For example, if two interventions are not directly compared they can still be compared if they were both directly compared to a third intervention (see Figure 1 above - Treatment D vs Treatment B or C through their direct comparison to Treatment A). Additionally if there is a closed-loop of studied interventions, additional information can be gained from indirect comparisons even if direct comparisons also exist. For example, in Figure 1 above, we can learn about Treatment A vs Treatment B from their direct comparison but also indirectly through Treatment C.

I encourage you to read the full study and the editorial by Matthew Muller. Very nice to see that the BMJ published this important study. And for those in the southern hemisphere, enjoy your cool weather...these summers seem to be getting worse and worse.

Saturday, July 25, 2015

Clothing and corporate culture

Anyone who is a regular reader of our blog knows that healthcare worker clothing is a favorite topic, from the viewpoints of both infection control and "professionalism." And as we've recently blogged, colleagues at the University of Michigan are trying to ramp up professional attire, calling for doctors to put their white coats back on. But they've been outdone by Summa Health System in Ohio. Summa has now mandated that all healthcare workers at their hospital must wear underwear. That's right, no more going commando at Summa! [I did not make this up--see here]. Now as a pragmatist I have to wonder who is in charge of inspection and enforcement of that policy and exactly how they will inspect and enforce.

All of this reminds me of that classic SNL skit where Will Ferrell does indeed wear underwear to work.

I guess it's all about corporate culture. One company well known to many healthcare personnel is the behemoth EMR vendor, Epic. Its corporate culture makes it a place that is well known for employee engagement and friendliness. Having visited the Epic campus recently, I can attest to the palpable enthusiasm of its workers. Epic's dress code? When there are visitors, you must wear clothes. No mention of underwear, though.