Quality

NEW DEPARTMENT: Innovations


 

Washed white coats & bacteria

Washed white coats & bacteria

No one becomes a doctor to make a fashion statement, but a new study (http://onlinelibrary.wiley.com/doi/10.1002/jhm.864/abstract) in the Journal of Hospital Medicine reports that the choice between long-sleeved white coats and freshly laundered scrubs might be a question of taste, not safety.

The report, “Newly Cleaned Physician Uniforms and Infrequently Washed White Coats Have Similar Rates of Bacterial Contamination After an 8-Hour Workday: A Randomized Controlled Trial,” found no statistically significant differences in bacterial or methicillin-resistant Staphylococcus aureus (MRSA) contamination of physicians’ white coats compared with scrubs or in contamination of the skin at the wrists of physicians wearing either garment.

In an email interview, Marisha Burden, MD, interim chief of hospital medicine at the Denver Health and Hospital Authority, says that the topic area came up during a review of research regarding MRSA and infection-control policies. Dr. Burden found references to the so-called “bare below the elbows” policy in the United Kingdom, a reference to 2007 rules from the British Department of Health banning long-sleeved coats in an attempt to stop nosocomial bacterial transmission.

“This policy was interesting to us secondary to the fact that there was no literature to support the measures being implemented,” Dr. Burden says. “ … Our data show that bacterial contamination of work clothes occurs within hours of putting them on, as well that at the end of an eight-hour workday, there is no difference in bacterial or MRSA contamination of either dress.”

Dr. Burden says the data do not support discarding white coats for uniforms that are changed on a daily basis, or for “requiring healthcare workers to avoid long-sleeved garments.” She also says that white coats have traditional lures as well as practical ones: Most of the physicians who declined to participate in the study did so because they refused to work without the pockets that came with their lab coats.

“I think we also have to consider the professional image that our physicians portray,” she adds. “Our patients expect their physicians to appear professional with clean, white coats.”—RQ


Technology

App Allows CT, MRI, PET Diagnoses Via iPhone, iPad

What can a hospitalist do the next time someone in the group has no immediate access to a work station but needs to make a medical diagnoses based on computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET)?

Grab the nearest iPhone.

The FDA recently approved an application from MIM Software Inc. of Cleveland to let doctors review medical images on the iPhone and iPad via a secure network transfer. The application, Mobile MIM, is the first with the FDA’s imprimatur. It allows hospitalists and other physicians to measure distance on the image and image intensity values and display measurement lines, annotations, and regions of interest, according to the FDA.

Download Mobile MIM to your iPhone, iPad

“Think of how cell phones were perceived a few decades ago; many dismissed ‘anytime access’ as not necessary,” MIM chief technology officer Mark Cain says in an email. “Yet now we know myriad of cases where the cell phone has proven immensely valuable. The same can be said of diagnostic medical image access. How many ways can this improve healthcare? More ways than I can predict.”—RQ


Quality Research

Research Confirms Benefits of ICU Safety Checklists

The value of checklists containing evidence-supported QI interventions to improve ICU outcomes, pioneered at Johns Hopkins in Baltimore, has been confirmed by several recent studies. The Keystone ICU Project, which sought to replicate the Hopkins experience in hospitals across Michigan, succeeded in nearly eliminating bloodstream infections and reducing mortality.1

Based on Medicare claims from 95 study hospitals and comparison data from 11 surrounding states, patients in hospitals using the checklist were significantly more likely to survive a hospital stay. The project was not, however, sufficiently powered to show a significant difference in length of stay.

A second Keystone Project study showed that five simple therapies aimed at lessening the time spent on ventilators, including elevating the head of the bed 30 degrees, giving anticoagulants, and lessening sedation, combined with education and a hospital culture supporting patient safety, reduced cases of ventilator-associated pneumonia by more than 70%.2

A comprehensive, video-conference-based intervention to support implementing six evidence-based quality practices in 15 community hospital ICUs in Canada improved the adoption of these practices. Expert-led forums and educational sessions promoted the sequential dissemination of treatment algorhythms, with a new practice targeted every four months.3—LB

References

  1. Lipitz-Snyderman A, Steinwachs D, Needham DM, Colantuoni E, Morlock LL, Pronovost PJ. Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay: retrospective comparative analysis. BMJ. 2011;342:d219.
  2. Berenholtz SM, Pham JC, Thompson DA, Needhamm et al. Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit. Infect Control Hosp Epidemiol. 2011;(4):305-314.
  3. Scales DC, Dainty K, Hales B. A multifaceted intervention for quality improvement in a network of intensive care units: a cluster randomized trial. JAMA. 2011;305:363-372.

HM-Based Quality Research

Homeless Respite Helps Avoid Rehospitalizations

Some readmissions come about because things fall apart when patients are discharged with a follow-up plan that is not realistic to their circumstances. This is especially true for homeless patients, says Audrey Kuang, MD, a hospitalist at Santa Clara Valley Medical Center (SCVMC) in San Jose, Calif., and medical director of the Santa Clara County Medical Respite Program, a shelter for homeless patients following discharge from seven San Jose area hospitals.

Dr. Kuang described the collaborative program in a plenary presentation for the Research, Innovations, and Clinical Vignettes competition at HM10.

SCVMC is a county safety net hospital, and Dr. Kuang says the hospitalists “see a fair amount of homeless patients with recurrent exacerbations.” Patients given prescriptions for medications they can’t afford, special diets, or instructions for bed rest are then discharged to the street; inevitably, they are readmitted.

Dr. Kuang began tracking patients who had prolonged hospital stays because of homelessness or unsafe social situations. Her presentation to administrators led to participating hospitals contributing $25,000 each to launch the program with a multidisciplinary team, which included Dr. Kuang.

In its first year, 200 referrals were made to the respite program; 60% were accepted. The most common diagnoses were foot fractures, foot infections, and cancer. Quantified clinical outcomes are still being compiled, Dr. Kuang said, although the participating hospitals have reported decreased rehospitalizations and bed days—results documented in other studies of respite programs.1

“The main idea is post-acute medical care and support for homeless patients in need,” she explained. “Hospitalists may feel this is beyond our scope of practice, but it is our responsibility to know what’s going on out there.”—LB

Reference

  1. Buchanan D, Doblin B, Sai T, Garcia P. The effects of respite care for homeless patients: a cohort study. Am J Public Health. 2006;96:1278-1281.

By The Numbers

$44,000, $46,659, $120,000: EHR Implementation Costs Higher than Medicare Reimbursement

A new study in Health Affairs on the first-year costs of implementing electronic health records (EHR) in a 450-physician North Texas primary-care network doesn’t translate directly to HM, but figures showing that the installation cost is more for an average five-physician practice than Medicare is offering in incentive pay might serve as a warning sign for HM groups looking to build EHR into their practice:

  • EHR incentive payments from Medicare over five years: $44,000;
  • EHR implementation cost per doctor after first year: $46,659;
  • EHR adoption costs per physician, estimated: $120,000.—RQ TH

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