Economicks is hard!

I had the privilege of training in hospital epidemiology under Dr. Richard Wenzel, and alongside a number of really smart people (including fellow blogger Mike Edmond). We put a lot of time and energy into estimating the impact of HAIs on costs, lengths of hospital stay (LOS), and mortality…and our approach was simple and intuitive. If our HAI cases had a mean cost/LOS/mortality of x, and matched controls had mean cost/LOS/mortality of y, then the attributable cost/LOS/mortality must be x minus y. Right?



Yes, I’m oversimplifying, and I will give us credit for understanding that it was a little more complicated than that. However, at that time we were still trying to convince people that HAIs actually killed people, and that the damage they did was above and beyond that due to the patient’s underlying illness. So if our estimates were on the high side, it seemed OK (at least to me), since the main purpose was to jar people out of their complacency and increase resources for prevention.



The climate has changed. We know a lot more about the complexity of estimating the costs of HAIs (two excellent sources on this are here and here), and we’ve (at long last) succeeded in attracting needed attention to HAI prevention (from the public, from legislators, from the media, even from our hospital administrators!). So it now behooves us to “take it up a notch”, as advocated by Nicholas Graves and colleagues in a recent letter to the editor at ICHE (with response). You can read these at your leisure, but I want to highlight this section of their CID article, which I think is on target:

"The 'HAI costs a lot' approach to influencing decision making has served the infection control community well…..The time has arrived, however, for the methodological advances that have been achieved in this area to be implemented by researchers. Complete economic evaluations that include changes to all costs and health benefits should be performed...

The information used to update these studies should be of high quality and bias free. Inexorable growth in health care costs is forcing decision makers to respond to scarcity and work toward extracting greater value from health care resources….The time when reliable economic arguments will be paramount for obtaining extra resources—and even retaining existing ones—is close. Those working toward reducing the number of HAIs should craft valid economic arguments on the basis of sound methods and use them to build strong and cost-effective infection control programs"

ICHE Special Issue: Antimicrobial Stewardship

Infection Control and Hospital Epidemiology has just announced that it will publish a special issue devoted to antimicrobial stewardship in conjunction with the SHEA spring meeting in Jacksonville, Florida, April 13-16, 2012. 

Topics of interest include:

• Antimicrobial stewardship for special populations, including pediatrics, oncology, hemodialysis, and critical care
• Health outcome and cost effectiveness impact of antimicrobial stewardship
• Use of diagnostic tools and role of microbiology in antimicrobial stewardship
• Effective implementation of programs in community hospitals, long-term care acute care facilities, outpatient settings and non-acute healthcare settings (e.g., dialysis, ambulatory care and ambulatory surgery centers)

Due date: October 1, 2011.

Get writing and submit your paper here.

Call for manuscripts PDF available here.

Good luck!

The new ICHE is here, the new ICHE is here!!!

Congrats to all of the authors who had articles published in this August's ICHE. Now that ICHE has a massive new impact score, I suspect most of them now feel like Navin when he says, "Page 73 - Johnson, Navin R.!  - I'm somebody now! Millions of people look at this book everyday! This is the kind of spontaneous publicity - your name in print - that makes people. I'm in print! Things are going to start happening to me now."  Well, I hope all the things that happen to these fine authors are a little more positive.

Highlights:

Page 737, Boyce, John M et al. looked at the impact of an automated mobile UV-C light unit on environmental contamination in 25 rooms after patient discharge. They report the unit significantly reduced aerobic colony counts and C. difficile spores.

Page 743, Rutala, William A et al. wrote an accompanying editorial that concluded that "there is now ample evidence that no-touch systems such as UV-C light or hydrogen peroxide can reduce environmental contamination...(however) only a single study using a before-after design has been published that demonstrated that such a system can reduce healthcare-associated infections." There we go again, hospital infection prevention: the queen (or king) of intermediate outcomes. Would be pretty cool if there were more independent (federal or foundation) resources to study HAI prevention interventions, such as these.

Page 791, Gupta, Kalpana et al. report the results of a cohort of all patients at the VA Boston Health Care System that had clean or clean-contaminated in 2008-2009 and a nasal MRSA PCR test less than 31 days prior to surgery. 6.6% of the patients were MRSA+ and were at significantly higher risk for postoperative MRSA infections (RR, 8.46; 95% CI, 1.70–42.04). Interestingly, vancomycin prophylaxis was associated with higher SSI risk in those negative for nasal MRSA (RR, 4.34; 95% CI, 2.19–8.57) but not in MRSA+ patients.

Page 818, Tohme, Rania A et al. reviewed hepatitis B vaccination rates and immunity among healthcare students during a 10-year period at Emory University. They report that among 4,075 students, only 60% had documented vaccination and 84% had anti-HBs concentration greater than or equal to 10 mIU/mL. It is interesting that despite CDC and ACIP (1995) recommendations of routine vaccination of children aged 11-12 years, and for all less than 18yo in 1999, the majority of students were only recently vaccinated.

If I left you off this list, sorry! You are still awesome!

Infection Control Journals - Hooray!!!

Hanging out at the 1st ICPIC, yesterday.  Pretty exciting with ~1100 attendees from the whole world. Save the date for the next conference in Geneva - June 25-28, 2013.

While wandering about, I got a cool text message from Preeti Malani, an Associate Editor at ICHE, who informed me that the ICHE journal impact score is up to 3.751 - that's quite a huge jump in 1 year.  I suspect it will be even higher next year given the size of the 1-year jump.  Independent of how you feel about impact scores, it is still very good news for those of us that publish in this excellent and well-focused journal.  Given that promotion and tenure of medical school faculty often depend on publication in high impact journals, this is a big deal for academic types. Three cheers to the entire ICHE editorial board and especially Suzanne Bradley, whose tireless efforts should now be fully appreciated.

...and to emphasize that you can never rest on your laurels...Andreas Voss, the ICPIC co-chair, just announced a new BMC journal titled - Antimicrobial Resistance and Infection Control (ARIC).  The website for submissions is not yet active, but I will post the info when it becomes available.

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.