Friday, September 5, 2014
Why are we dialing it up to 11?
We recently posted an excellent summary of what’s happening in U.S. hospitals as they scurry to plan for the public health issue du jour of Ebola. He astutely points out that there seems to be a disconnect between what we know about Ebola transmission and what we’re doing (or planning to do) with regard to safely caring for patients infected or suspected to be infected. I thought it would be interesting to examine what’s driving the disconnect. As I see it, a number of factors are at play here:
As noted by Dan, at a press conference prior to the transport of 2 Americans with Ebola infection to Emory University Hospital, Dr. Bruce Ribner stated: “Emory University Hospital has been asked to accept two patients who are currently in Africa infected with Ebola virus infection. Our facility was chosen for this because we are 1 of only 4 institutions in the United States capable of handling patients of this nature.” Not stated, but nonetheless presumed by the infection prevention community is that the agency doing the asking was CDC, given CDC’s physical proximity and given that quite a number of CDC physician-epidemiologists hold faculty appointments at Emory’s schools of medicine and public health. However, just a few days later, CDC’s primary message was that any hospital in the U.S. should be able to safely care for Ebola patients.
It’s also difficult to reconcile the CDC recommendation for contact and droplet precautions—highly familiar to all health care workers—with the images of health care workers on the ground in the outbreak epicenters and in Atlanta dressed in Tyvek spacesuits. And who hasn’t seen the video footage of the infected American doctor emerging from the ambulance in Atlanta also dressed in the same manner? However, it’s important to keep in mind that the exposure risk for healthcare workers in the outbreak setting, caring for multiple very ill, infected patients with scarce resources, is far different than the controlled setting of the average American ICU.
Fear and managing risk
Our greatest fears often revolve around areas where we lack experience, and very few health care workers in the U.S. have ever cared for a patient with viral hemorrhagic fever. Importantly, not only does Ebola fever not have any proven effective therapies, there is also no post-exposure prophylaxis. A simple lapse in infection control protocol cannot be undone with a pill or injection. One way we attempt to manage fear is to overprotect: if 1 barrier works, 2 must be better. In general, redundancies mitigate risk, but this isn’t absolute. As Dan pointed out in his post, we may inadvertently increase risk by complicating infection control protocols with gear that healthcare workers may find distracting, uncomfortable, and lack training to use. The litigious nature of American society also impacts our decisions regarding infection prevention strategies. And many health care workers, while willing to accept much greater health risks in their personal lives, demand zero occupational risk.
Non-epidemiologic decision making
In many hospitals today, health care epidemiology staff have become advisors to hospital administrators who ultimately make decisions regarding the logistics of infection prevention. And their decisions may not be purely based on science. They often have aversion to approaches that would appear to be out of the mainstream of what other hospitals are doing, even if that’s suboptimal. In addition, infection prevention seems to be increasingly used as a public relations tool. If you don’t believe that, do a simple Google search and you will find scores of press releases published in local newspapers from hospitals who have purchased germ-zapping robots.
By the way, I believe that one of the best uses for a hydrogen peroxide vapor robot would be terminal disinfection of the Ebola patient room. Perhaps those hospitals who have invested in this technology should be the first to receive Ebola patients.
Paramilitarization of public health
In the run-up to the Iraq War, the Bush administration sought to engage the public health and medical communities in the war on terror. Much effort was devoted to preparations for bioterrorism. Who can forget the smallpox vaccine debacle? Preparedness was all the rage, and the Joint Commission couldn’t resist jumping on that bandwagon.
Admittedly, some of the impacts of this were positive. For example, hospitals became more tightly linked to public health agencies and those agencies became much more engaged and proactive. But a new group of professionals emerged who are employed to make us prepared, and perhaps a little scared. A physician colleague who works in the IT world tells me that the constant fear mongering by IT security specialists is in part a job security tactic. So the folks who work in preparedness stand ready to help, perhaps in a more aggressive way than necessary this time.
Ok, anyone still surprised we’ve cranked it up to 11? I’m with Dan in hoping that we’ll be able to dial it down to 8 this week.
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. This post originally appeared at the blog Controversies in Hospital Infection Prevention.
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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:
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.
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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, 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
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 Iowa City, IA, 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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