My blog on the “disease called peer review” (Dec 12th) evoked many comments (including from some journal editors), and these directed me to the concept of preprint publishing. Physicists started this 25 years ago, and were followed by mathematicians, computer scientists, and more recently by biologists. It is not yet widely known or practiced in the medical sciences. At least I was barely familiar with it, but I can only admit that this may well help to cure the “disease called peer review“ and H-indexitis. Continue reading
Year: 2016
“Santa isn’t coming to town”
WARNING: This isn’t a heart-warming Christmas tale. It’s actually rather sad.
In Christmas BMJ classic, a team of US researchers have explored associations with Sanda Claus not visiting paediatric wards over Christmas 2015. Whilst I am pleased to report that Santa made an appearance on 90% of the wards overall, heart-wrenchingly, Santa was least likely to visit paediatric wards in the most deprived areas.
The day after the WIP died
Yesterday, Andreas Voss heartbreakingly described the end of the Workinggroup Infection Prevention (WIP) in the Netherlands. Yet, the end of the WIP is not the end of the Netherlands. The WIP enormously contributed to the success of Dutch infection control and then ran towards it’s own grave, where many now cry (some like a crocodile).
In the final moments before death, nobody was willing to rescue the patient. What went wrong? The government didn’t want to pay for infection prevention guidelines, as they may feared they would then need to pay for all guideline. More fascinating is that the beneficiaries of succesfull infection control, hospitals, didn’t want to pay either. Either they take infection control for granted or were no longer pleased with these guidelines.
Now, let’s look at the crime scene. The WIP created 136 guidelines! You name it, we have a guideline for it. Haircutters in the hospital? Hospital beds? We have it. All these guidelines were drafted by professionals with the best intentions, mostly for free and in absence of convincing scientific evidence for specific recommendations. No problem, as long as we can use them as “best practices” or recent updates for practitioners.
But the world changed. For every unexpected event in the healthcare system someone is to be blamed, for instance the Health Inspectorate, as they should reassure good care. So, they think: “I don’t wanna be blamed. How can we control that system? Wait a minute, they have guidelines and we just check whether they adhere to their own guidelines”. An understandable point of view.
So, we (as healthcare professionals) are now confronted with “sometimes-not-so-usefull-guidelines” to which we should adhere. As long as we can tick the box of adherence we’re safe. For instance, achieving adherence to the guideline of airway management in ORs has resulted in enormous financial investments for hospitals, without any evidence that it increased patient safety.
The death of the WIP can be used to break this chain. Let’s go back to a few multidisciplinary guidelines on things we really agree on: WIP2.0. Maintaining these guidelines will not be expensive (and can easily be covered by a professional society). And where evidence is lacking, professionals rely on their knowledge and experience, share on best practices and talk to each other when in doubt or need of support.
The day the WIP died
Today it became official that the Dutch Workingparty on Infection Prevention (WIP) will no longer be supported by funds from the Dutch Ministry of Health. Therefore, after 30-years of coordinated, voluntary work by infection control nurses, infectious diseases specialists, and clinical microbiologists (supported and strengthened by various, topic-specific healthcare professions) the number one IPC guideline organization found a sudden and in-part unexpected death. I am proud to have been part of the WIP, which was rightfully seen as one of the beacons of IPC, admired by many countries who had none or by far not as well organized guideline organization. The WIP was fundamental to the success of Infection Control in the Netherlands and even if some say that it wasn’t the only contributing factor, all those doing Infection Control know that the present state of AMR and HAI control could not have been achieved without the WIP. Was all the WIP produced “gold”? Certainly not. Despite best intentions some recent guidelines went over the top, but overall the set of guidelines produced by the WIP are of high quality and an enormous treasure, that might now be lost for the future.
Rumor has it that Dutch Public Health Services, the Professional Society for Elderly Care Specialists (Verenso) and other professional medical societies will take it on them to issue infection control guidelines (in part for their own specialty). If that is truly the case, why stop at killing coordinated and independent Infection Control guidelines, why not take over Infection Control at whole, starting with surveillance. I can ensure (by the lessons of the past) that HAI rate will immediately drop by up to 50%. The Dutch have a nice saying about situations that are wrong by default and don’t leave you with a lot of trust or hope: “The butcher who checks the quality and safety of his own meat”.
I believe that only an independent, integrated and coordinated approach (= by one organizational structure) can ensure the basics of effective and sound infection control. If the Dutch Ministry of Health and the medical professional societies are serious about their engagement to control AMR and HAI, in my opinion, a future solution can only be the formation of a WIP 2.0.
Disclaimer. The opinion in this post is a personal and does not reflect the opinion of the national professional boards I am a member of.
KPC Casanova carbapenemase
The risk of interspecies transmission of carbapenemase genes is a real concern. We can barely get our heads around many different types of carbapenemase in a whole host of Gram-negative bacteria (compare the relative simplicity of methicillin resistance in S. aureus: a single gene, in a single species). Throw in interspecies horizontal transmission of carbapenemases and things get really tricky! Do we implement different control strategies to try to interrupt the transmission of carbapenemases (in contrast to the organisms themselves)? Could you have a multispecies outbreak of a carbapenemase on your hands and not even realise it?
What do you do to prevent VRE transmission?
What do you do to prevent VRE transmission?
…you are not alone, if the answer to this question is ‘nothing special’, based on survey published in ARIC! Dale Fisher’s team in Singapore put together a simple survey, asking the global IPC community what measures they have in place to prevent the transmission of VRE. There was a huge degree of variability, ranging from ‘nothing special’ to ‘the kitchen sink’!
A disease called “peer review”
One of our newpapers addressed the peer review practice in science. Based on a flawed but sexy paper in Nature, where review obviously failed, the system was diagnosed as sick, and cure is needed. Here is my solution. Continue reading
Do single rooms reduce HCAI?
An interesting review article examines the relationship between three related variables: the proportion of single rooms, the size of the patient room and patient proximity, and the availability of antiseptic hand rub, with various HCAI indicators. The bottom line is that both a move towards a higher proportion of single rooms and larger patient rooms are associated with reduced HCAI, and making hand gels more available improves compliance with their use (unsurprisingly).
ESPAUR 2016: an early Christmas present
I am just getting around to reading (well detail-scanning the exec summary) of the ESPAUR report. My main reflection is what a fantastic resource this reporting stream offers us: to have freely accessible, regular, accurate, national data on antimicrobial resistance and usage, and other related indicators is pretty unique!
The art of predicting “broad brush estimates” of people dying from AMR
Sometimes you read something you wished you had authored. For me, that is the essay “Will 10 Million People Die a Year due to Antimicrobial Resistance by 2050?” published yesterday in PLoS Medicine. At last, a scientific response to the highly praised AMR review from Jim O’Neill. Summarized in a few words: scrutinized to the bone, hardly anything remains. Continue reading
Reflections on Infection Prevention and Control 