Targeting zero credibility?

I have written before about the unintended adverse consequences of an inability to be honest about HAI prevention, and Mike recently blogged about “aspirational goals” and reality. At the end of his post, Mike linked to an inspiring news story about the success being achieved at the City of Hope, among the sickest of patients. A telling quote from this piece demonstrates how “zero talk” can not only motivate, but also demoralize those who are on the front lines of infection prevention:

"It's tough, especially when there is a lot of literature out there that talks about zero infections….I think there should be zero infections. But not all health care-associated infections are preventable.”

As if on cue, I got an e-mail today from Bard Access Systems APIC, announcing the roll-out of a new website entitled, “I Believe in Zero CLABSIs”. Zero is no longer an “aspirational goal” for Bard Access Systems APIC, but a very concrete one:

“We not only believe in Zero CLABSIs — we know it is possible, and we are confident that the tools and resources contained on this website will provide you with the framework you need to help your facility BELIEVE and ACHIEVE ZERO CLABSIs.”

If APIC is unwilling or unable to speak honestly about HAIs, they will eventually lose credibility with their members who fight daily to prevent them. Furthermore, insisting that zero is already achievable weakens the rationale to perform the kind of groundbreaking translational research that is needed to push CLABSI rates ever closer to an irreducible minimum. Why investigate novel approaches to prevention if we already know how to eliminate every CLABSI?

Aspirational goals

There's a paper in the February issue of Infection Control and Hospital Epidemiology by a group of investigators at the University of Pennsylvania. They set out to perform a systematic review of the literature to determine the proportion of healthcare associated infections that are reasonably preventable. Their determination was that 65-70% of central line associated bloodstream infections and catheter-associated urinary tract infections were reasonably preventable, and that 55% of ventilator-associated pneumonia cases and surgical site infections were reasonably preventable. Quick, someone call APIC--they're still targeting zero! I know, I know: zero is an aspirational goal. And I'm still aspiring to be a professional football player.

Addendum, 1/23, 9:55 AM:  I just ran across this article published yesterday in a California newspaper. Now here's a piece that's apropos, and one that tries to tell the other side of the story.

What's in a name? APIC Name Change 2010 Edition

O, be some other name!

What's in a name? that which we call a rose
By any other name would smell as sweet;

-Romeo and Juliet

This just in (to me at least)...for the second year running APIC members have cast ballots in favor of changing their name to "Association for the Prevention of Infections”, replacing the original “Association for Professionals in Infection Control and Epidemiology" yet they did not achieve the necessary two-thirds majority to change the name.  Thus, APIC will have the same meaning at least for another year. For some reason, I've always thought APIC stood for "Spreading knowledge Preventing infection TM," so I'm a bit relieved that it doesn't.

Despite being an APIC member, I don't have a strong opinion on the name change. However, I wonder what the reasons are behind the failure to obtain the necessary super majority?  Perhaps dropping the word "Professional" might upset members since it could suggest a movement away from career development activities towards a purely outcomes-based organization.  For me, I like that "Epidemiology" is in the current name even if it's not in the acronym - I guess it is an invisible "E" instead of the usual silent "e"

Deciding what to name your organization or meeting can be quite tricky. I've been recently involved in a similar process within our research group at the Iowa City VA and have found it interesting to see how some people really favor one name, others strongly favor a different name and all have legitimately good reasons that are hard to reconcile. 

Recently, I heard that there's been a debate as to what the 2012 combined SHEA-IDSA meeting should be called.  Someone told me that they wanted to name it "ID Week" not to be confused with "National Pet ID Week," or "Protect Your ID Week (October 17-23)" or even "ID Weak."  I suspect SHEA members will not like that name as it buries Hospital Epidemiology and not all people involved in SHEA activities see themselves as "Infectious Disease." One nice suggestion I heard was that the meeting name should incorporate SHEA, HIVMA, IDSA and the ASTMH, the tropical medicine society. Somehow that seems about right.

Is APIC leadership paying lawyers and consultants to read blog posts?

The back story is this: Over the weekend, Mike posted an item that was critical not of APIC members, but of APIC’s leadership. He was critical of the APIC CEO in particular, and the close relationship she fostered between APIC and Becton Dickinson (a company she is now joining as a Vice President). I can’t speak for Mike, but I assume he did this because he recognizes, as do I, that APIC is an essential and influential voice in infection prevention—it simply cannot allow its agenda and vision to be co-opted by an industry partner.

Occasionally I check up on visits to our blog, just to see what the general trends are, where our visitors are from, and what posts interest them most. When I last checked, I was surprised to see that one blog post in particular was getting a fair bit of attention from two unusual visitors: a law firm, and a firm that specializes in shaping public opinion and handling crisis management. Both have visited this particular blog post multiple times over several hours. The law firm happens to be the contact for the APIC research foundation, so I assume they do APIC’s legal work.

APIC members have been toiling for years to prevent infections and improve patient safety. Most are literally on the front lines of infection prevention—overworked, underpaid, and underappreciated. So I sincerely hope that APIC leadership isn’t squandering its members’ hard-earned dues on lawyer and consultant fees in response to a blog post.

That’s such a ridiculous thought, in fact, that I’m sure it isn’t true. There must be people in these firms who are just interested in infection prevention—if so, I’d encourage them to look at all of our posts, not just that one. There’s a lot of other great stuff on this blog!

What's the next step for APIC?

Last week, the Association for Professionals in Infection Control and Epidemiology (APIC) announced that Kathy Warye was leaving her position as APIC’s CEO to become Vice President for Infection Prevention at Becton Dickinson. Warye joined APIC in 2004 and according to the organization’s 2008 Form 990, her total annual compensation was $360,000.

Warye’s transfer to BD shouldn’t come as a surprise when one considers the two organizations’ close relationship and intertwining interests over the past several years, as shown in the timeline below:

 2004:  GeneOhm MRSA screening test is approved by FDA
 2006:  BD acquires GeneOhm
 2006:  APIC holds a conference on Managing MRSA and launches a nationwide MRSA prevalence survey
2006:  APIC holds a summit on the Economics of Infection Prevention, co-sponsored by BD
 2006-07:  APIC develops and presents MRSA Grand Rounds, which is held in cities across the US, sponsored by BD
 2007:  APIC holds an Infection Prevention Summit, co-sponsored by BD
2008:  APIC launches a nationwide C. difficile prevalence survey (Principal Investigator Dr. Bill Jarvis, a consultant for BD)
2009:  BD’s rapid test for C. difficile is approved by the FDA
2009:  At APIC’s national meeting, BD sponsors the session where results of the C. difficile prevalence survey were presented by Dr. Bill Jarvis, as well as sessions on the MRSA Elimination Guide, the VA MRSA Prevention Initiative, C. difficile in the UK, and Managing MRSA in Long-term Care Facilities
2009:  APIC Anywhere, an online education center, goes live, co-sponsored by BD

In addition, the BD logo appears on APIC’s website where BD is described as “a strategic partner since 2006,” and APIC’s logo appears on BD’s website. BD contributes to the APIC research foundation, which funds projects such as the prevalence studies. BD also provides funding for APIC chapters. All of this raises the question of how much impact BD has had on APIC’s policy agenda.

An interesting aspect of Warye’s role at APIC was as the CEO she appeared to be driving the organization’s policy agenda and was highly visible. In contrast, in many professional organizations, the CEO is charged with operationalizing the board’s agenda and plays more of a behind-the-scenes role. When the person setting the agenda has come from outside the profession, there exists the potential for problems, as these leaders have not been socialized via their training to have a full understanding of the profession’s ethos. Perhaps this explains APIC’s numerous industry relationships and its strategy to commodify infection prevention. You name it, they’ve tried to sell it. They have priced many of their own members out of their annual meetings, and sell their infection prevention textbook for a whopping $625 (members get a reduced price of $475). They have also developed a consulting service.

Warye’s departure creates a good opportunity for APIC to step back and assess its mission, vision and values. Maybe the organization can get back to doing what it is supposed to do by representing its members' interest. Maybe it can now act like a non-profit organization instead of a business that is focused on selling products (theirs and industry's). And maybe it can re-evaluate its relationships with industry. Going forward, it will be interesting to see how APIC’s relationship with BD changes given Warye’s high-ranking position in the company. Any financial support of APIC by BD now will only heighten concerns regarding conflict of interest.

To be certain, Warye has had an impact on APIC. She effectively used the media to spread the organization’s message, developed partnerships with industry, and enriched APIC’s coffers. But in the process, she also sold the organization’s soul.

The CDC has a brand new blog

And I like it! I especially enjoyed the post by our own Phil Polgreen, which features his iScrub application. Alex Kallen also has a nice recent post on prevention of CLABSI outside the ICU, which is a topic overdue for attention.

However, I did wince when I read about this event:

“I believe in zero CLABSIs!” shouted a group of 3,400 APIC Annual Conference attendees at the conclusion of patient-safety leader Dr. Peter Pronovost’s opening session.

Why does this make me uncomfortable? It isn’t because I haven’t bought into the power of CLABSI prevention efforts—we have units whose efforts have pushed CLABSI rates to zero for months at a time, and we celebrate that. I also think that most infection preventionists (IPs) understand the difference between a rah-rah, go-get-‘em, “aspirational” BHAG on one hand, and a realistic assessment of what is preventable on the other.

The problem is that many people don’t understand this difference. Among them are fellow healthcare workers, hospital administrators, reporters, the general public, third-party payers, and malpractice attorneys. To them, 3400 infection control experts witnessing to their belief in zero CLABSIs means that every CLABSI must be preventable, and therefore that every CLABSI represents an unconscionable breach of practice. We’ve blogged before about some of the potential unintended consequences of the “zero” paradigm. Fudged definitions, antibiotic overuse, pitched battles between unit personnel and IPs over every device-associated infection, and an atmosphere of blame and punishment, just to name a few.

The fact is that not every CLABSI is preventable. Most are, but not all. Even Peter Pronovost’s hospital's ICUs, though they have wonderfully low rates, still experience CLABSIs. If we follow perfect processes of care, we should be able to prevent those infections that arise from around the catheter insertion site, and those that are introduced exogenously. But what about those arising from gut translocation of bacteria in a critically ill patient? Even the most aggressive gut decontamination regimen (which will inevitably accelerate antimicrobial resistance rates) won’t be able to prevent organisms from gaining access to the catheter in this way.

We should be able to mobilize the troops to drive CLABSI rates to their irreducible minimum without setting unachievable goals. I do admit that “getting to zero” is a catchy phrase, though, and very well-suited to campaigning for lower infection rates. The theme I proposed for our latest CLABSI prevention campaign was roundly rejected….and I still don’t understand what was so wrong with: “Zero Is Great, But One Every Few Months Is Pretty Darn Good, Too”.

Confirmation Bias and Science as a Contact Sport

Just getting back from APIC - New Orleans. I've included this photo from Cafe Du Monde, where I broke "bread" with Titus Daniels, Tom Talbot and Keith Kaye. Thought I should avoid photos of people ingesting the beignets, especially those three guys.

While trapped in the Detroit airport (a freak storm flooded the gates and shut down the airport for a couple hours), I came across an interesting article in Ars Technica; a site normally associated with reviews of iPhones and Windows 7. The author Chris Lee discusses confirmation bias, a tendency for people to only look for data that confirms their prior beliefs, which permeates all of science and pseudo-science. He provides a number of nice historical examples of confirmation bias. I particularly enjoyed the end of the article where he describes what steps scientists can take to avoid confirmation bias including subjecting their work to as much internal and external criticism as possible. The "denier" section was good too. Can any of you think of examples of confirmation bias in infection prevention? Me neither.

Ars Technica article: (link)

Being Deb Yokoe - Atul Gawande's APIC keynote

I just sat through Atul Gawande's APIC keynote speech. I was expecting to be inspired and amazed. What I wasn't expecting was Deb Yokoe. Dr Gawande spent the first 30 minutes pacing the stage and discussing the day he followed Dr. Yokoe and her team around the Brigham. He described her as a smiling, occasionally giggling with dimples and tennis shoe wearing hospital epidemiologist. It must have been a very busy day as I think he mentioned 7-8 outbreaks she was dealing with at the time including tularemia and a frozen strawberry foodborne outbreak. Having worked with Dr Yokoe as a fellow in a research capacity, I have always appreciated her work and felt she never got enough credit for her contributions. It is very nice to see that changing.

A particularly touching part of the hospital tour with Dr Yokoe was when Gawande described the staff flowing in and out of the ICU rooms and realizing that this was far different than the controlled OR environment and then he realized one of the MRSA isolated patients was his own and that he might have given MRSA to the patient. He got his biggest applause when he quoted Deb as saying "I don't want to be an infection control cop.". Gawande agreed with her and spent some time discussing the importance of team work and getting infection control out of the police business. Well, he has every right to be hopeful. An important effort made at the Brigham that others should consider copying is that infection control is now a rotation for medical students. I suspect it isn't mandatory, but it is a start.

My favorite part of the talk, apart from his discussions of the surgical checklists that were highlighted in his latest book, was when he was asked a question about mandates. He described that in any advance there are early adopters, medium adopters and late adopters. He then added in a class of people called exceptionalists, people who say they are different or their hospitals are too different to do things like clabsi checklists. His point was that there is a time when mandates are needed but the key variable is the timing. One must wait to mandate until after the early adopters are on board and worked out all of the implementation details. Any mandate that comes too early, alienates these early adopters and hurts implementation. Food for thought.

Should a hospital epidemiologist buy an iPad?

Perhaps some of you have already purchased an iPad. I suspect many of you think that getting another device is completely ridiculous since you already have a BlackBerry or iPhone, laptop and a desktop computer. If that is the case, you should check out Dropbox, which allows you to keep all of your documents synced across all devices and safely backed-up. If you are still on the fence, you may have been searching the interwebs for advice only to be faced with >1,000,000 google hits for "should I buy and iPad" with various humorously handy decision trees. None, I suspect, were actually helpful to you, the daring hospital epidemiologist or fearless infection preventionist. That's why CHIP exists, to serve our loyal readers.

First and foremost, I don't think you should purchase iPads for tracking hand hygiene compliance and various other in-hospital surveillance activities. There are several reasons for this including cost, size (Hawthorne effect people!) and you aren't supposed to clean the screen with solvents since they can damage the oleophobic-coated screen, oh, and the cost. As Dan has stated, there are Apps for that, but stick with an iPhone or iPod Touch.

Beyond that, I think there are 3 basic types of hospital epidemiologists and IPs, each with different needs and lives. I'm sure I will leave some or most of you out, but perhaps reading between the lines will get you the answers you need. If you still have questions, we offer open comment posting and we will try to answer your questions.

1) I attend SHEA/APIC: This one's the easiest. If you want to travel lightly, and as of now TSA allows iPads to be kept in your bag when passing through security, then the iPad is for you. The key benefits of the iPad are light weight, long battery life - I used it for 11 hours Sunday and still had 25% battery life left - and access to any content you want to read. That includes .doc, .ppt and .pdf files. There is a 99 cent app called GoodReader that will meet 99% of your needs. You can use it to read almost any document, download any file, grab any email attachment from the iPad Safari web browser, save most webpages for later viewing, AND wireless sync with your laptop even if wifi is not available. That last one is cool, and more information on how to do that is available (here) on the GoodReader site. If you get a 3G iPad, you can surf, check email and even control your home or work computer all without paying crazy hotel wifi fees. Apple charges $15 or $30/month but you can cancel anytime. Thus, only pay when you attend SHEA/APIC.

The iPad is the best email device I've used and will get better when the 4.0 OS comes out in the fall when it will allow a single in-box for your half-dozen email addresses. Even now it's fantastic and typing is more than adequate. Enter your passwords once and never have to log-in again. It works with gmail, yahoo, mobileme, aol and outlook along with others. You can also probably log into your VPN and check labs and other hospital-specific data unless you work at the VA. Either way, you should check with your IT support staff if your require that type of access.

2) I submit abstracts to SHEA/APIC: Above, I described some reasons why I think the iPad is the single best media consumption (documents, email) device there is. It is also wonderful for PubMed searches and other web-based searches including uploading your abstracts. Creating abstracts is a bit tougher. They can be started or edited using Apple's Pages (for .doc) and Keynote (for .ppt) but these applications have their limitations, which hopefully will be remedied in a future update. First, you must email the documents to yourself to get them on/off the device (or sync with iTunes). Second, track changes is not available and all previous changes are accepted once the document reaches the iPad. Third, some formatting is lost. It is likely that none of the abstract, poster or slide presentations will need to be completed while you're traveling, however. Hopefully.

3) I submit manuscripts to ICHE/AJIC. This is a bit more complicated. I would still say the iPad is for you, but the reasons are more subtle. You can create a draft document in Pages while you travel, but you can't really do track changes, insert endnotes etc. There is a PDF work-around since you can modify PDF documents using iAnnotate, but I suspect that is too much for most. However, the iPad is the single best PDF reader. Reading on a laptop or computer is sub-optimal since you can never get the screen set to the proper distance or are forced to read at a desk or table. With iPad, you can read PDFs as you would a book or magazine. No more printing and carrying PDFs! That will save your back and your eyes. This is why I purchased the iPad (the work reason, I also stream MLB games). It is fantastic to have all of your PDFs and MS Word files via Dropbox and GoodReader in one device that you can place next to your laptop when writing a paper or take to your reading chair when you finally make it home.

Final note: I also recommend Papers if you own a Mac/iPad/iPhone. This software is great for organizing the 1000's of PDFs you have scattered around devices. It pulls them all together and allows searching using metadata like you can in iTunes - search by author, title, date, journal. You can also dump PDFs in a folder and then create an Endnote library.

Final, final note: You don't need to get the expensive 64GB model if you have easy access to wifi, or get the 3G iPad, since you can always access your files in the cloud with services such as Dropbox and MobileMe. If you want to have 20 movies available as you fly back and forth from the WHO, then maybe you need the 64GB. Most of what I described, apart from iWork (Pages/Keynote) can also be done on the iPhone, but reading PDFs for long periods can be tough.