American College of Physicians: Internal Medicine — Doctors for Adults ®

Wednesday, May 6, 2015

Close proximity interaction and S. aureus spread in long-term care

There is little doubt that Staphylococcus aureus is transmitted between patients via contaminated hands, white coats or fomites carried by health care workers (HCW). Fortunately, that doesn't curb the enthusiasm of scientists seeking to understand the mechanisms of transmission in clinical settings. A case in point is a recent study in PLOS Computational Biology by Thomas Obadia and colleagues that HCW and patient close proximity interactions (CPI) via small wireless sensors and correlated the interactions to incident S. aureus colonization.

The study was conducted in a 200-bed long-term care facility (LTCF) in France and utilized data collected from 329 patients and 261 HCWs over a 4-month period. Using weekly nasal swabs from all patients and HCW, they spa-typed and determined the resistance profiles to antibiotics of each detected S. aureus. Isolates were considered identical if they shared the same spa type and resistance profile. Incident cases were only considered in patients since HCWs could have been transiently colonized and missed by the weekly swab interval. Each incident case was evaluated to confirm that at least 1 time-consistent CPI in the prior 3 weeks with the same strain was possible. The 3-week interval was chosen since all but 4 cases could be linked to another patient with the same strain during that time period.

Without going into all of the statistical modeling methods, major findings include:

(1) When limiting the analysis to the 201 patients not already colonized on admission, 73 acquired S. aureus. The 1-month acquisition rate was 33%.

(2) Time to acquisition among new admissions did not change based on the number of colonized neighbors in the preceding week using either raw number of CPIs nor cumulative duration of CPIs.

(3) There were 237 incident cases throughout the 4 months in 111 patients. Only 173 had candidate transmitters. The analysis was limited to 153 because sensors failed to record a CPI in the prior week in 20 cases.

(4) A CPI path existed for 149 of 153 episodes. As seen in the example figure above, P1 (patient) and H1 (HCW) were two-hops away from the incident case. P2 was three-hops away. In the same figure, distance between a transmitter and an incident case (black) was shorter than random simulations predicted (white). Additionally, a direct contact between candidate transmitter and incident case (i.e one hop away) occurred in 48% of cases vs. 30% expected by random chance. These findings supported that CPI predicts S. aureus incident colonization.

(5) HCWs spent about 20% of their shifts in direct contact with patients (110 minutes over 8 hours) and had CPIs with 15 unique individuals during their day (9 were patients, 6 other HCW) with 3.7 hours spent in contact with others. 36.3% of HCW were colonized with S. aureus.

(6) Interestingly, patients had CPIs with 12 unique individuals each day (half were other patients). Overall, patients spent half of their day (12.2 hours) in contact with another person.

A few thoughts. Studying social interactions and transmission in long-term care settings using these methods is quite brilliant. Given that LTCF cohorts are more stable with longer lengths of stay, it is easier to catch acquisition events through repeated screening. It is also important to note the huge amount of contact that LTCF residents have directly with each other, around 10 hours/day. This sort of social interaction among residents is not seen in acute care hospitals and goes a long way to explain why infection control in LTCF is so critical (and so extremely difficult). Given the richness of the CPI data, including frequency and duration of contacts, new mathematical models using these parameters could provide more accurate estimates of S. aureus transmission and effectiveness of candidate control strategies.

One issue that I think the authors might want to address in future studies is the use of spa typing to link transmission events. It is true that they also used susceptibility data, but it is my understanding (from another post) that the discriminatory power of spa typing may be suboptimal.

Additional reference: NPR Shots blog by Scott Hensley with comments from David Hartley on this study.

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.

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Tuesday, May 5, 2015

Indiana: 1 out of 2

Indiana passed a “Religious Freedom” law last week, signed by Governor Mike Pence.

Reaction to the law has been swift and furious. The law purports to enhance religious freedom by allowing business owners to cite their religious beliefs as a legitimate reason for discrimination. Many national organizations, both religious and commercial, have declared their intent to cease doing business in Indiana.

Judging by the news cycle and social media reactions to the law's passage, you could say Governor Pence has made a very poor choice.

Interestingly, the same week, he went against his own stated principles and made, from a public health viewpoint, a resoundingly good and evidence-based choice about another matter affecting his state.

Rural Scott County, in southeast Indiana, has reported more than six dozen new cases of HIV in 2015 alone. In public health terms, this is an epidemic spread, given the very low population density of the county. In a typical year, Scott County might see five new HIV cases. In just the first quarter of this year, the county's reported a nearly 16-fold increase over the annual rate, leading Governor Pence to acknowledge that Scott County is facing a “Public Health Emergency.”

To combat the spread of HIV, which is due to the sharing of needles for injection drug use, Governor Pence's emergency order permits public health officials to immediately begin a clean needle exchange as per CDC recommendations.

Pence has spoken out against a statewide or permanent needle exchange program, instead limiting the effort only to Scott County on a temporary basis. NPR quoted the governor as follows: “I don't believe that effective anti-drug policy involves handing out paraphernalia to drug users by government officials,” he says. “I reject that.”

It's easy to see why someone could reject clean needle programs on the basis of not wanting to subsidize or potentiate illicit drug use. Yet when faced with such an emergency, Governor Pence has yielded to experts wielding scientific evidence.

That's what public health is all about. We may not like people's behavior or habits, but in truth, preaching or punishing has shown to be of limited (if any) value. Acknowledging that there's a problem without resorting to judgment, and designing programs to protect the public's health, is sound medicine and policy.

This post by John H. Schumann, MD, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.

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Health and health care

It has been known for a long time that “health care,” all the stuff that we do, prescribe, and provide, is a minor determinant of how “healthy” any of us is. Overall health, or more technically, the variability in health outcomes, is much more dependent on the combination of genetics, personal behavior (think smoking and seat belts), environmental factors, and socioeconomic status than it is on health care.

I was thinking about that when I read in the New York Times about how some health care provider systems, driven by the need to cut costs, are starting to address some of the non-medical social needs of their patients. These kinds of innovative community-based interventions started to get traction after they were highlighted by an influential profile by Atul Gawande in the The New Yorker. Their diffusion has been driven by the expansion of novel payment models that have started to reward providers for reducing utilization of services like ER visits and hospitalizations, the very services that they have traditionally been paid for.

From a society-wide perspective, all this makes perfect sense and is long overdue. No rational person would want to preserve the situation described the county health official quoted in the Times: “We'd pay to amputate a diabetic's foot, but not for a warm pair of winter boots.” That said, I see at least 2 big challenges to straightening this all out.

The first problem in ridding “the system” of the perversion of paying for amputations but not boots is that we don't really have a health care “system.” We have an unholy mess of independent actors and government agencies without any ability to make it rational from a society-wide perspective. Sure, there are pockets of integration and global oversight, like the Veterans Administration, or state governments, which are responsible for an array of social welfare and health benefits. But even within these bureaucracies, it is a real challenge even for well-meaning individuals to work across the barriers of separate budget lines and programmatic responsibility. It is not a simple matter (and may even be illegal) to transfer funds from, say, a diabetes clinic to a homeless shelter, even if more services at the latter would improve the health of diabetics.

The action lately has largely been to start to hold health care providers accountable for health outcomes instead of compensating them for the provision of services. In general, I think that is a good thing, but it raises the second challenge: health care providers may not be any good at providing the non-healthcare services that people need to be healthy. Why should we expect physician practices and hospitals, which have evolved over decades to become what they are now, to be able to morph into effective social welfare agencies?

Frankly, if I were paying the bills (and let's not forget that as taxpayers, we are all paying part of it) I'd be inclined to pay us less for care and pay others more to improve the social determinants of health.

What do you think?

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. He then held a number of senior positions at Mount Sinai Medical Center prior to joining North Shore-LIJ. He is married with two daughters and enjoys cars, reading biographies and histories, and following his favorite baseball team, the New York Yankees, when not practicing medicine. This post originally appeared at his blog, Ausculation.

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Monday, May 4, 2015

Should hospitals ban workers from smoking at home?

I practice gastroenterology in Cleveland in the dark shadow of a large medical institution whose name contains the name of our city. They are a world class medical institution whose reputation is largely derived from its cardiovascular department. Presumably, these practitioners, like all doctors, advise patients who smoke that cigarettes have deleterious health effects. The entire campus is smoke-free, as are all hospitals today. This is a relatively new development. A few years ago, nurses and other hospital staff would huddle at the entrance puffing away. No more. Now, there is no smoking anywhere on the hospital property. Hospital puffers now have to wait until quitting time, when they are behind the wheel and leaving the grounds before they light up.

I'm okay with all this. The hospital should set an example to promote better health. Patients and families who enter the hospital who must pass through a smoky fog might wonder about the hospital's commitment to health and healing. Of course, one could make the same argument about overweight nurses and physicians, but obesity apparently cannot be legally outlawed on hospital wards.

The mega-medical-mall here in Cleveland has put in place a no smoking policy on steroids. Not only can't you smoke on the job, but you can't smoke anywhere on this planet or any other extraterrestrial location. In fact, workers there will be tested periodically for nicotine to verify compliance with the edict.

I'm not okay with this policy. If medical personnel smoke on their own time, but refrain from doing so on the job, I do not believe this should disqualify them from their jobs. Folks are entitled to smoke, drink, curse, watch adult movies, gain weight, eat deep fried onion rings and forego aerobic exercise when they are on their own time. Of course, the hospital should encourage personnel to quit and offer treatment programs to assist them in doing so. But, mandating this as a job requirement is wrong.

We have staff in our office who smoke. I wish they didn't, and they know it. But, we're not about to fire them for this addiction which does not impact on their job performance.

While our office is smoke-free, we do permit staff smokers to take a break outside when they feel they need inhalation therapy. These sessions occur out of view of our patients. Some of our non-smoking staff have muttered that this is unfair as the puffers are in effect rewarded with a breaks during the day that they do not receive. While this argument is valid, we have left the status quo in effect. I'm not sure the greater good in our small practice would be served by enforcing a no smoking policy, although admittedly, this is arguable.

Outlawing Camels and Marlboros at both work and play is beyond Big Brother. It's an intrusive violation of personal freedom that should be extinguished.

To those who support it, why stop with cigarettes? What other activities and behaviors should be prohibited off the job? I have a personal interest here. If sarcasm were on the list, then I'd be fired.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

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.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
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).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
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.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

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.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
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.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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