Friday, October 24, 2014
What I learned from Ebola
I’m sitting at my dining room table trying to reflect on and process the events of what, without a doubt, will go down in the annals of infection prevention as a pivotal point in time. Hospitals across the country furiously raced to prepare for Ebola, propelled by the unfortunate news of transmission of the virus to 2 nurses at Texas Presbyterian Hospital in Dallas. I’ll share with you what I think are the lessons of this incredibly interesting week:
Texas Presbyterian Hospital isn’t the exception, it’s the rule. It’s easy to be the Monday morning quarterback and criticize the emergency medicine providers for initially missing the diagnosis of Ebola, but given that this was the first case to ever present to an emergency department in the U.S., it should not be surprising. In the process of diagnosis physicians are trained to use probability in their reasoning. And Ebola simply wasn’t on their radar screens.
It’s also important to keep in mind that even today given everything we know, fever in a returning traveler from Liberia is most likely not caused by Ebola virus disease. Malaria remains a much more common diagnosis. For this reason, our Ebola plan reminds physicians to consider infectious diseases consultation in the setting of a person under investigation for Ebola, so as to avoid having a patient die of falciparum malaria while Ebola is being ruled out.
In addition, there may have been, and likely were, systems issues at play. There are many distractions in the hectic environment of an emergency department that may have had impact as the physician worked through Thomas Duncan’s case. Nosocomial transmission to healthcare workers would have also likely happened at almost any hospital with the exception of the four hospitals that have a biocontainment unit. While American hospitals have made great strides in reducing healthcare associated infections over the last decade, the challenges posed by Ebola virus in terms of the prevention of transmission are unparalleled.
The efficacy and effectiveness of personal protective equipment (PPE) need to be considered. By efficacy we mean how well PPE works in the ideal setting to protect the healthcare worker. Effectiveness is how well it works in the real world. For most pathogens, this difference is likely quite small. Not so for Ebola. Removing PPE in the Ebola setting without contaminating yourself is a Herculean effort, and we are dealing with what Dick Wenzel calls “an unforgiving virus.“ Before Ebola, the implications of minor errors in doffing were trivial. Now they’re life-threatening. An article in today’s New York Times sums it up beautifully:
Debra Sharpe, a Birmingham, Ala., biosafety expert, has overseen safety at a nonprofit laboratory that researches emerging diseases and bioweapons, and has run a company that trained workers to handle biological agents ... “It’s totally shocking ... It would take me anywhere from 4 to 6 weeks to train an employee to work in a high containment lab in a safe manner. It’s ludicrous to expect doctors and nurses to figure that out with a day’s worth of training.
To her comments I would add that the challenging setting of an ICU with an Ebola patient having 10 liters of vomiting and diarrhea per day is nothing like the controlled environment of a specialized laboratory dealing with contained aliquots of the virus. How well PPE works in the lab approximates efficacy. How well it works in the ICU is a measure of effectiveness.
The most advanced ICU in the best U.S. hospital is not a biocontainment unit. It’s absurd to think that the standards of a biocontainment unit can be met outside of that special setting. These units have special physical layouts with lab facilities, specimen dip tanks, employee showers, and autoclaves. They were created and supported with federal funding, and their providers have had ongoing training over years. So we need to realistically attempt to match the facility with the expected function: all hospitals should be proficient at rapidly identifying a potential Ebola patient, quickly isolating them and providing initial care, but once the diagnosis is confirmed, these patients should be transferred to a specialized biocontainment unit if a bed is available.
We need to think about exposures differently. In infection prevention, we tend to classify exposures to infectious agents on the basis of whether the exposure was protected: Did the nurse have on an N95 mask when she treated the patient with tuberculosis? Did the young man wear a condom when he had sex last night with an HIV-infected man? Typically, unprotected exposures pose greater risk of infection than protected exposures. In Dallas, the same paradigm was applied: the unprotected healthcare workers in the ER who evaluated Mr. Duncan before he was suspected to have Ebola were thought to be at higher risk than those who cared for him in the ICU will full PPE. This turned out to be wrong. Early in the course of Ebola the infectivity is low, as demonstrated by the fact that none of Mr. Duncan’s unprotected household contacts became infected. Late in disease, infectivity is very high and two nurses in gowns, gloves and face protection became infected.
Equipment and supplies for state-of-the-art care are inadequate. Several of us tried to find a stethoscope without ear tubes so that auscultation could be performed without bringing a device close to your face. We had no success. Much has been made of the fact that the Dallas nurses used PPE that didn’t cover their necks. This was even noted in an editorial in the New York Times. However, almost all (if not all) products that provide neck coverage, including bunny suits, are difficult to doff, making self contamination likely. Fortunately, our hospital has an in-house seamstress who rose to the occasion and rapidly began designing an item to cover the neck that is easy to remove. In addition, the supply chain for PPE is tenuous. Already, many items are on allocation and the national supply for some is not robust. Just-in-time manufacturing processes are not advantageous in the current situation.
Investment in infection prevention infrastructure and research is necessary. The health care system in the U.S. has talked a good game regarding the importance of infection prevention, but if budgets are statements of what we value, infection prevention has been a stepchild. Ebola should be our wake up call. Funding is needed to answer basic questions of infection control and to train hospital epidemiologists. Mandates for all hospitals to have infectious disease trained hospital epidemiologists should be considered. New models for compensation of infectious diseases physicians must be developed to encourage young physicians to pursue training in our field.
It was a truly challenging week. But from an infection prevention standpoint, it was challenging in a really good way. It allowed us to collaborate with experts across the health system and think creatively with them, while providing us an opportunity to demonstrate the value we add. I am very lucky to work with an amazing group of epidemiologists and a strong leadership team at the University of Iowa. And the Society for Healthcare Epidemiology of America (SHEA) staff did an outstanding job of promoting what we do in the mainstream media.
Lastly, we must keep all of this in perspective. Every issue I have talked about in this post is a first world problem. The tragedy of what is happening in West Africa remains incomprehensible.
Michael B. Edmond, MD, FACP, is the Chief Quality Officer at the University of Iowa Hospitals and Clinics. This post originally appeared at the blog Controversies in Hospital Infection Prevention.
Thursday, October 23, 2014
Ebola: The questions keep coming
The progression of the Ebola epidemic, particularly the recent episodes of transmission to health care workers who wore appropriate personal protective equipment, raises interesting questions. Certainly we need to continue to work on learning everything we can about the best approach to personal protective equipment and minimizing the risk of transmission during the process of care. But it’s also time to rethink some of the rituals surrounding care that have persisted in hospitals for decades.
Academic medical centers by their very nature increase the number of interactions with patients. Trainees at all levels need to interview and examine patients, and participate in their care to acquire necessary skills. While the benefits to the trainee are obvious, in some cases the patients benefit as well, via the therapeutic effects of another empathetic ear or the uncovering of a critical clue by the careful history of a novice interviewer. However, with a disease like Ebola, which can be transmitted in the health care setting, has no post-exposure prophylaxis, no effective treatment, and a high mortality rate, a strict approach to limiting the number of individuals in the physical proximity of the infected patient is appropriate as recommended by CDC.
Limiting contact typically means that in addition to students, other trainees such as residents and fellows also do not enter the room. But perhaps this needs to be taken a step further. Perhaps there should be one “examining” physician whose documented exam is used by consultants in their evaluations so as to limit room entry. In many cases, an additional exam probably doesn’t add much value, and is often performed because it’s expected or to maximize billing. Even before Ebola, as hospital epidemiologists we’ve asked ourselves the simple question: does every person on the care team need to examine every patient every day? Every encounter adds some level of risk for transmitting pathogens in the health care setting, but with Ebola the implications of transmission are taken to a whole new level. Fortunately, given technologies such as Skype, the ability to interview patients should not be impacted.
Ebola also pushes us to reconsider therapies that have a reasonably high probability of futility but increase risk to health care workers. In the case of the Dallas patient, who underwent endotracheal intubation and hemodialysis, we are left to question whether these procedures played some role in infection of the critical care nurse. Should CPR, which would seem to involve a very high degree of risk to bedside providers, not be performed? The ethical issues associated with withholding these procedures typically associated with “routine” critical care need to be explored since the risk-benefit calculus is markedly shifted by the level of risk to health care workers.
Lastly, should health care workers be compelled to work with Ebola infected patients? Do they have the right to opt out? Should those who volunteer receive hazard duty pay? Should there be a compensation fund for families in the event a health care worker contracts Ebola disease occupationally and dies? How do we handle the issue of pregnant health care workers? In the long run, how do we design the hospital of the future to maximize safety of the patient and provider?
These initial questions demonstrate that the Ebola crisis is challenging us in many ways and will likely continue to do so for quite some time. But perhaps we’ll emerge from this with a more thoughtful approach to patient care that improves safety without sacrificing quality.
Michael B. Edmond, MD, FACP, is the Chief Quality Officer at the University of Iowa Hospitals and Clinics. This post originally appeared at the blog Controversies in Hospital Infection Prevention.
Monday, October 20, 2014
Donning and doffing
Many have spent the last month or so preparing for possible patients with Ebola (PPE). I had the opportunity to review the tremendous amount of work that the UIHC infection preventionists have completed towards our preparation. During this process, I watched these videos prepared by the Biocontainment Unit at the Nebraska Medical Center that demonstrate the proper use of Biological Level C PPE. My thoughts when viewing these are that without significant practice, it would be very difficult to prevent contaminating or breaking protocol when removing this level of PPE and that donning and doffing take almost 14 minutes. That’s a bit more time than hand hygiene, so no more complaints about that! And thanks to Nebraska for sharing these well-prepared videos.
Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands). This post originally appeared at the blog Controversies in Hospital Infection Prevention.
Saturday, October 18, 2014
Mayo conference: Killing the buzz some more
So earlier this week the Managing Complex Patients conference taught me that watching the sunset might kill a person. Today a lecture on hepatology by William Sanchez, MD, highlighted how the other popular vacation pastimes of gorging and boozing will kill you, too.
He offered a case study of a woman who had just recently started to feel sick and look jaundiced with a history of one drink each weekday and a couple on weekends. She would probably define herself as a social drinker ("Some of my patients are very, very social," noted Dr. Sanchez, also pointing out that a patient's definition of a drink might be different from medicine's), but any more than a drink a day is enough to put a woman at risk for alcoholic hepatitis. The patient needed a liver transplant, he said.
And not drinking won't save you from cirrhosis, if you're chowing down instead. A "tidal wave" of nonalcoholic steatohepatitis due to obesity is about to hit hepatology, just when the liver problems of the Hepatitis C epidemic are projected to slow down.
So as not to close out conference coverage on a down note, here's a fun fact about overeating. Amindra S. Arora, MB, explained the function and habits of the esophageal sphincter during his talk on esophageal diseases. Ever wonder why restaurants give after-dinner mints? It's because chocolate and peppermint relax the sphincter. "You need to vent so you don't feel so full," said Dr. Arora.
Friday, October 17, 2014
Mayo conference: It's all about the questions you ask.
Several experts speaking at the Managing Complex Patients conference today offered advice on specific questions to ask to elicit useful information.
In a lecture about dealing with and learning from medical errors, Kim Manning, MD, FACP, and Neil Winawer, MD, offered a checklist for helping yourself, your trainee, or your colleague respond to an error.
Roughly (because I can't get their slides to download right now), the questions to ask are:
What happened? What did I do that was good for this patient? (A question that most don't think to ask, they noted.) What could I have done differently? What did I learn? How can I avoid this happening again? How do I feel about what happened? How can honor my patient now? What advice would I give to another in this situation?
Going through this checklist can help convert errors into constructive changes and reduce burnout, Drs. Manning and Winawer said.
And, then, on a much weirder note, Lyell K. Jones, Jr., MD, offered neurology pearls, including some advice on dealing with idiopathic parkinsonian inpatients. It's common for these patients to have hallucinations, he noted, but they're unlikely to admit it, even when asked directly. The best way he's found to get the truth is a weirdly specific question: "Do you ever see small people or animals in your house in the evening?" And there is your bizarre pearl of the day.
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- What I learned from Ebola
- Ebola: The questions keep coming
- Donning and doffing
- Mayo conference: Killing the buzz some more
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- How can we make hand-offs a good thing?
- The very real-world limits of patient satisfaction...
- Mayo conference: Vacationing can be dangerous.
- Engaging patients
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Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
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Controversies in Hospital
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
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Suneel Dhand, MD, ACP Member
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Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
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Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
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Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
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