Tuesday, May 12, 2015

Intensive care from afar: Caregiver versus patient watcher

File:US Navy 030423-N-6967M-090 A central computer system monitors the heart rates of each patient in the Intensive Care Unit (ICU) to ensure a quick.jpgA recent NPR story by Michael Tomsic recounted the remarkable story of how the Carolinas HealthCare System monitors ICU patients in 10 of its hospitals from a remote "command center"-like facility. Several critical care specialists staff the center; nurses are present around the clock and doctors work nights. Command center staff also spend time at the hospitals they monitor.

The system began doing this roughly two years ago and have since found that the quiet atmosphere of the command center ("none of the bells and whistles going off that most ICUs need to alert nurses and doctors down the hall that they're needed") allows medical staff in the center to maintain a constant focus on patients. The approach seems to be working for the system: They've observed a higher patient volume, lower mortality rate, and decreased length of stay since opening the center (though, as the article describes, such improvement likely isn't due solely to the remote monitoring program).

The issue of alarm fatigue is recognized as an important patient safety issue, so the idea of placing a group of specialists outside the immediate patient environment for monitoring purposes has a strong rationale. What I found most interesting about the article, however, was revealed in remarks from two nurses interviewed. One observed that "There are things that I'm able to view here [in the command center] — trends that I'm able to view here — that I'm not able to view at the bedside", while another noted that since the command center staff has easy access to patient data, handoffs are better and issues are less likely to be missed.

Assuming that these ICUs are not fundamentally different from ICUs in other facilities, the story highlights an issue that is endemic far beyond this particular set of hospitals: the frequent failure to bring data to the bedside in an effective way. This is ironic, as the big data and IT revolution brags -- incessantly, it sometimes seems -- about delivering data and analytics to the point where they can be most useful. That isn't consistent with the remarks from healthcare workers in this article.

Is caregiving versus patient monitoring an either-or proposition? I doubt it, as I've seen data-driven intensive care delivered reliably over long periods of time. Rather, I think the question is how to make data actionable through delivery to the right people without disrupting their workflow. It's a question for all clinical environments beyond the ICU. We need to make more effective use of routine clinical data.

(image source: Wikipedia)

Saturday, May 9, 2015

Microbial ecology: Keeping one step ahead of the bad bugs

File:Clostridium difficile 01.pngTwo papers were published recently that apply notions of bacterial interference and competition rather elegantly. The first was a study by Dale Gerding et al on administering nontoxigenic Clostridium difficile spores to prevent recurrent C. diff infection. The study aimed to determine the safety, fecal colonization, recurrence rate, and optimal dosing schedule of nontoxigenic C. difficile, and the authors found that
Among patients with CDI who clinically recovered following treatment with metronidazole or vancomycin, oral administration of spores of NTCD-M3 was well tolerated and appeared to be safe. Nontoxigenic C. difficile strain M3 colonized the gastrointestinal tract and significantly reduced CDI recurrence. 
It's a fascinating study and I recommend reading it. In addition to contemplating this as a potential future treatment for recurrent CDI, it's intriguing to wonder if patients could have their GI tracts colonized by nontoxigenic C. diff prophylactically before receiving antibiotics associated with CDI.

The other study, by Alice Deasy et al, demonstrates how nasal inoculation with the commensal Neisseria lactamica inhibits carriage of N. meningitidis in young adults. N. lactamica is a commensal occupying the same ecological niche (the nasopharynx) as the pathogenic organism N. meningitidis, which is associated with epidemic meningitis. They observed a significant inhibition of meningococcal carriage in carriers of N. lactamica, which was attributed to displacement of existing meningococci and to inhibition of new acquisition. Their findings suggest N. lactamica as a potential "novel bacterial medicine to suppress meningococcal outbreaks". Again, I recommend reading the complete study.

The notion of exploiting microbial ecology is appealing for many reasons, including that it doesn't require developing intrinsically new pharmacologic compounds and that it may have no significant side effects. At the same time, its important to remember previous trials employing bacterial interference, such as the deliberate colonization of newborn children with "low virulence" Staph. aureus, so that old missteps aren't repeated.

(image source: Wikipedia)