Marvin J. Bittner

Limited impact of sustained simple feedback based on soap and paper towel consumption on the frequency of hand washing in an adult intensive care unit

OBJECTIVE To determine whether hand washing would increase with sustained feedback based on measurements of soap and paper towel consumption. DESIGN Prospective trial with a nonequivalent control group. SETTING Open multibed rooms in the Omaha Veterans Affairs Medical Centers Surgical Intensive Care Unit (SICU) and Medical Intensive Care Unit (MICU). SUBJECTS Unit staff. INTERVENTION Every weekday from May 26 through December 8, 1998, we recorded daytime soap and paper towel consumption, nurse staffing, and occupied beds in the SICU (intervention unit) and the MICU (control unit) and used these data to calculate estimated hand washing episodes (EHWEs), EHWEs per occupied bed per hour, and patient-to-nurse ratios. In addition, from May 26 through June 26 (baseline period) and from November 2 through December 8 (follow-up period), live observers stationed daily for random 4-hour intervals in the MICU and the SICU counted actual hand washing episodes (CHWEs). The intervention consisted of posting in the SICU, but not in the MICU, a graph showing the weekly EHWEs per occupied bed per hour for the preceding 5 weeks. RESULTS Directly counted hand washing fell in the SICU from a baseline of 2.68+/-0.72 (mean +/- standard deviation) episodes per occupied bed per hour to 1.92+/-1.35 in the follow-up period. In the MICU, episodes fell from 2.58+/-0.95 (baseline) to 1.74+/-0.69. In the MICU, the withdrawal of live observers was associated with a decrease in estimated episodes from 1.36+/-0.49 at baseline to 1.01+/-0.36, with a return to 1.16+/-0.50 when the observers returned. In the SICU, a similar decrease did not persist throughout a period of feedback. Estimated hand washing correlated negatively with the patient-to-nurse ratio (r = -0.35 for the MICU, r = -0.46 for the SICU). CONCLUSIONS Sustained feedback on hand washing failed to produce a sustained improvement. Live observers were associated with increased hand washing, even when they did not offer feedback. Hand washing decreased when the patient-to-nurse ratio increased.

Impact of a clinical pharmacokinetic service on patients treated with aminoglycosides : a cost-benefit analysis

In a prospective, randomized study, 75 adults receiving aminogly-cosides were followed by a clinical pharmacokinetic service and 70 followed as controls. The two groups were similar in age, gender, height, and APACHE II score. A cost-to-charge ratio was used to derive direct costs of hospitalization and calculate cost-benefit. Excluded from this comparison were patients with incomplete acceptance of pharmacokinetic service recommendations and patients followed by other clinical pharmacists. Pharmacokinetic service patients had shorter hospitalizations (322.67 ± 270.28 h; controls 442.89 ± 536.81, p = 0.087) and febrile periods (50.05 ± 79.38 h; controls 92.23 ± 122.50, p < 0.05). More pharmacokinetic service patients had adequate peak levels. Pharmacokinetic service direct costs were lower (7,102.56 ± 9,898.19; controls 13,758.64 ± 22,874.31, p < 0.05). Calculated direct cost of the service was 85.00/patient. Annual savings for 500 patients is 2,220,540.00.

Methicillin-resistant Staphylococcus aureus in Veterans Administration Medical Centers.

To determine the frequency of isolation of methicillin-resistant Staphylococcus aureus (MRSA) at Veterans Administration Medical Centers, 163 hospitals were surveyed; 137 responded. Between 1975 and 1984, the number of Veterans Administration Medical Centers with known MRSA increased from 3 to 111. This increase was geographically widespread and occurred in hospitals of all sizes. In Veterans Administration Medical Centers, isolation policies for MRSA-infected patients were (% of hospitals using): strict (19%), contact (52%), site-related (28%), no isolation (1%). For patients colonized with MRSA policies were: strict (15%), contact (44%), site-related (35%), and no isolation (6%). Only 41% of Veterans Administration Medical Centers reported discharging known MRSA-colonized patients to nursing homes. Most attempts to eradicate MRSA carriage used trimethoprim-sulfamethoxazole plus rifampin with or without bacitracin ointment; success rates were low. MRSA incidence is increasing at Veterans Administration Medical Centers across the United States. Improved regimens to eliminate MRSA carriage are needed.

Education and Communication in an Interprofessional Antimicrobial Stewardship Program

CONTEXT Interprofessional education/interprofessional practice (IPE/IPP) is an essential component in medical education and training. A collaborative interprofessional team environment ensures optimal patient-centered care. OBJECTIVE To describe the implementation of 2 interprofessional antimicrobial stewardship program (ASP) teams using IPE/IPP and to assess the acceptance rate by the primary medical and surgical teams of ASP recommendations for antimicrobial interventions. METHODS A business plan for the ASP was approved at 2 academic medical centers used for the present study. During a 3-year study period, 2 interprofessional ASP teams included an attending physician specializing in infectious disease (ID), an ID physician fellow, an ASP pharmacist, physician residents, medical students, pharmacy residents, and pharmacy students. Educational seminars were presented for all adult-admitting physicians to discuss the need for the ASP and the prospective audit and feedback process. Cases were presented for discussion during ASP/ID rounds and recommendations were agreed upon by the ASP team. A motivational interviewing face-to-face technique was frequently used to convey the ASP team recommendation to the primary medical or surgical team in a noncoercive and educational manner. The ASP team recommendations for ASP interventions were documented in the medical records. RESULTS The overall acceptance rate of recommendations by the primary medical and surgical teams were greater than 90% (2051 of 2266). The most frequent interventions provided were streamline therapy (601), route of administration change (452), bug-drug mismatch (190), and discontinuation of therapy (179). Route of administration change was also the most frequently accepted intervention (96%). CONCLUSIONS The motivational face-to-face communication technique was particularly useful in conveying ASP team member recommendations to the primary medical or surgical teams. Communicating recommendations as a multidisciplinary team in an educational manner seems to have resulted in to greater acceptance of recommendations.

Other Slow-Growing Nontuberculous Mycobacteria.

The list of clinically important slow-growing nontuberculous mycobacteria (NTM) continues to expand as new species are identified and older ones are found to be pathogenic. Based on pigment production, the strains may be classified as photochromogenic, scotochromogenic, or unpigmented. Some of these organisms are not newly discovered but have heretofore been considered virtually nonpathogenic. Previously, many were regarded as contaminants when isolated from clinical specimens. Ubiquitous in nature, many NTM have been isolated from groundwater or tap water, soil, house dust, domestic and wild animals, and birds. Most infections result from inhalation or direct inoculation from environmental sources. They are not spread from person to person. The infections may be localized or disseminated. In most cases, the optimal regimen or duration of therapy has not been firmly established. The results of in vitro susceptibility testing may be used to select a therapeutic regimen. Many experts recommend clarithromycin with companion drugs such as rifampin and ethambutol for most, but not all, slowly growing species. Aminoglycosides, clofazimine, fluoroquinolones, linezolid, pyrazinamide, or trimethoprim-sulfamethoxazole also may be effective against some strains. Immunocompetent patients with clinically significant infections with NTM usually should receive 18 to 24 months of therapy. Infected immunocompromised patients, particularly those with disseminated infection, probably should receive therapy as long as their immune systems remain impaired. Some of the species discussed include Mycobacterium alsiense, M. celatum, M. gordonae, M. haemophilum, M. kyorinense, M. malmoense, M. simiae complex, M. szulgai, M. terrae complex, M. ulcerans, and M. xenopi.

Health in the Batey Libertad: A Physician's Impressions

North American physicians and other health professionals, as well as those training for health care careers, are gaining unique experience in a remote comer of the Dominican Republic. At the same time, they are providing a wide range of services to people who are underserved or unserved by indigenous medical systems. Personal experiences—ome frustrating, some rewarding—re recounted.

K————x-Rated Therapy

Excerpt It started with as promising a pain as any that can wake you up at two in the morning. I woke up with a painful, red, swollen great toe. Podagra? With a uric acid maven like Kelley as chief...

Incorporating Interprofessional Practice Education and Motivational Interviewing Techniques in Antimicrobial Stewardship Programs at Two Academic Medical Centers

Background Interprofessional practice education (IPE) is an essential component in educating healthcare residents and students in providing optimal patient centered care in a team environment. Antimicrobial Stewardship Program (ASP) teams with similar approaches were implemented at the two academic medical centers associated with our medical school utilizing an IPE approach in 2012. We describe the implementation/process of the ASPs. Methods A business plan for an ASP was approved at each location. An interprofessional ASP team was identified and includes the ID attending physician, ID fellow physician, ASP pharmacist, medical resident physician (MRP), medical student (MS), pharmacy resident (PR) and pharmacy students (PS). ASP educational seminars were presented for all adult admitting physician groups (Surgery, Ob-Gyn, Internal Medicine, Family Medicine) to discuss the need for the ASP and the prospective audit/feedback process. An ASP patient monitoring form for collecting patient information was developed. ASP rounds occur weekdays during ID rounds. Results The ASP pharmacist, PR and/or PS identify patients receiving intravenous antimicrobials and completes the ASP patient monitoring form. Patients are screened for ASP interventions prior to ASP rounds. Patients requiring interventions are presented during ASP rounds for discussion. The ID fellow or ASP pharmacist intervenes with the primary medical team, frequently utilizing motivational interviewing techniques to convey the ASP team recommendation in a non-coercive and educational manner. Antimicrobial education in relationship to clinical problems in patients enhances the educational learning of healthcare providers. Documentation of the ASP team recommendations is completed in the electronic or paper medical record. ASP acceptance rates were > 88% for antimicrobial recommendations since 2012. In addition, 8 ID fellows (82 rotation months), 26 PR, 82 MRP, 64 PS and approximately 32 MS have gained IPE experience in the ASP team. Conclusions The interprofessional ASP team implementation/process has been successful at our institutions. Antimicrobial stewardship and education are emphasized in all interactions of the ASP team. Motivational interviewing may be a useful technique in conveying ASP recommendations.  Business plan presented and approved at each location  Interprofessional ASP Team  Medicine: ID attending physician, ID fellow physician, MRP, MS  Pharmacy: ASP pharmacist, PR, PS  Education seminars  Adult admitting physician groups  Importance of ASP  Prospective audit and feedback process  Documentation procedures  Combined ASP and ID rounds weekdays  ASP patient monitoring form developed BACKGROUND RESULTS Incorporating Interprofessional Practice Education and Motivational Interviewing Techniques In Antimicrobial Stewardship Programs at Two Academic Medical Centers Pamela Foral, Pharm.D., BCPS1-3; Jennifer Anthone, Pharm.D., BCPS4; John Horne, MD2-4; Leo Dobronski, MD2-4; Javaria Syed, M.D.2-4; Christopher Destache, Pharm.D.1,2,4; Renuga Vivekanandan, MD2-4; Laurel Preheim, MD, FIDSA2-4; Gary Gorby, MD, FIDSA2-4; Marvin Bittner, MD, FIDSA, FSHEA2-4 Creighton University School of Pharmacy & Health Professions1, Creighton University School of Medicine2, VA Nebraska Western Iowa Health Care System3, CHI Creighton University Medical Center4, Omaha, NE

Are we missing anaerobic infective endocarditis in some acute coronary syndromes

A 76-year-old man presented with a 3-week history of intermittent fevers and dyspnoea on exertion after a dental bridge placement 2 months ago. The patients medical history was significant for mild to moderate mitral valve prolapse. Initial evaluation was notable for a 3/6 systolic apical murmur. Laboratory investigations revealed leucocytosis and elevated erythrocyte sedimentation rate, C reactive protein and cardiac biomarkers. Patient was treated initially for non-ST elevation myocardial infarction. A 2-dimensional echocardiography was concerning for a new mitral regurgitation and a questionable vegetation adjacent to the mitral valve annulus. Transoesophageal echocardiography study confirmed the diagnosis. Subsequent microbial identification was notable for Peptostreptococci and he was started on intravenous penicillin therapy. The unexplained illness with underlying valve disease prompted consideration of infective endocarditis. This case describes a rare occurrence of anaerobic endocarditis imitating an acute coronary event.