CDC

flying cadeuciiSome years ago I was in Australia’s Northern Territory. The intrepid explorer that I was, I was croc-spotting from the comfortable heights of a bridge over the East Alligator River. The river derives its name because it is east of something. And because it’s croc-infested.

I was reading a story about a German tourist (it’s usually a German) who was attacked by a saltwater crocodile in the vicinity (1). The story concluded to reassure that one is more likely to be killed by a vending machine than a saltwater crocodile.

I imagined what the apotheosis of a left brain thinker, the data-driven Renaissance man, might have done with that statistic. Might he have peeked in to the East Alligator River looking for a vending machine and seeing none, jumped right in?

This empirical fact is useful if you suffer from croc-phobia and live in the Upper East Side of Manhattan, and the biggest voyage you ever plan to undertake is to the Hamptons. But it’s not terribly useful, and marginally harmful, if you’re deciding whether to kayak rivers in Northern Australia.

The vending machine has reared its deadly head again. It seems that more Americans have been killed by vending machines than have died from Ebola. Well let’s head to Liberia for the winter, because there are fewer vending machines there.

Sorry, I jest. But this is not a joke. Some actually think this is a relevant statistic to put Ebola in perspective. And some are actually reassured by it!

Continue reading “The Antifragile CDC”

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When Thomas Eric Duncan first came into the hospital, he arrived with an elevated temperature, but was sent home.

On his return visit to the hospital, he was brought in by ambulance under the suspicion from him and family members that he may have Ebola.

Mr. Duncan was left for several hours, not in isolation, in an area where other patients were present.

No one knew what the protocols were or were able to verify what kind of personal protective equipment should be worn and there was no training.

Subsequently a nurse supervisor arrived and demanded that he be moved to an isolation unit– yet faced resistance from other hospital authorities.

Lab specimens from Mr. Duncan were sent through the hospital tube system without being specially sealed and hand delivered. The result is that the entire tube system by which all lab specimens are sent was potentially contaminated. Continue reading “Statement from the Dallas Nurses”

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Texas Health Presbyterian

A group of nurses at Texas Health Presbyterian has come forward with a very different picture of what happened when Liberian Ebola patient Thomas Duncan arrived at the hospital with Ebola-like symptoms on September 28th.  If true, the allegations are certainly unsettling.

In an unusual move, the nurses spoke anonymously to the media, conducting a blind conference call in which none of the participants were identified.

After arriving at the emergency room with a high fever and other symptoms of the disease , the nurses said the patient was kept in a public area, despite the fact that he and a relative informed staff that he had been instructed to go to the hospital after contacting the Centers for Disease Control in Atlanta to report a possible case of Ebola.

Continue reading “Angry Nurses Tell of Ebola Patient’s arrival at Texas Hospital”

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The Dallas hospital at the center of the Texas Ebola outbreak has changed its story.

Last Thursday, the hospital blamed a poorly designed electronic medical record for the failure to diagnose Duncan when he arrived at the hospital’s emergency room with symptoms consistent with Ebola, including a fever, stomach cramps and headache. According to the initial story, a badly designed electronic health record workflow made it difficult for doctors to see details of Duncan’s West African travel.  Duncan was sent home.  Very bad things happened as a result, as we all know by now.

On Friday, the hospital reversed itself without explanation.

The new statement:

Clarification: We would like to clarify a point made in the statement released earlier in the week. As a standard part of the nursing process, the patient’s travel history was documented and available to the full care team in the electronic health record (EHR), including within the physician’s workflow. There was no flaw in the EHR in the way the physician and nursing portions interacted related to this event. [ Full text ]

In other words: The EMR didn’t do it.

When the EMR story came out Thursday, critics jumped all over it. It did sort of make sense to some people, especially people who aren’t  fans of electronic medical records. The idea that a piece of key information could get lost in the maze of screens and pop ups and clicks in a complex medical record sounded plausible.

A lot of other people weren’t buying it:

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The swiftness of the hasty retreat led some critics to speculate that Texas Health’s statement Thursday provoked the wrath of EPIC, the hospital’s EMR vendor.  Industry critics pointed out that many major EMR vendors, EPIC among them, often include strongly worded clauses in contracts that forbids customers from talking publicly about their products.

After this story was posted, EPIC contacted THCB with a response via email. Company spokesman Shawn Kieseau wrote:

We have no gag clauses in our contracts.  We had no legal input or participation in our root cause analysis discussions with Texas Health staff on this issue.  Texas Health’s correction is appropriate given the facts in this situation.

Continue reading “Hospital at Center of Ebola Outbreak Reverses Its Story”

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Tom Frieden optimized

There has been a lot of fear about Ebola. The health care workers who care for Ebola patients are right to be concerned – and they should use that concern to increase their awareness and motivation to practice meticulous infection control measures.

Ebola virus is transmitted through direct contact with bodily fluids of an infected person who is sick with Ebola, or exposure to objects, such as needles, that have been contaminated with infected secretions.

Travel from Affected Region

There is a risk for Ebola to be introduced to the United States via an infected traveler from Africa. If that were to happen, widespread transmission in the United States is highly unlikely due to our systematic use of strict and standard infection control precautions in health care settings, although a cluster of cases is possible if patients are not quickly isolated. Community spread is unlikely due to differences in cultural practices, such as in West Africa where community and family members handle their dead.

CDC has advised all travelers arriving from Guinea, Liberia, Nigeria, and Sierra Leone to monitor their health for 21 days and watch for fever or other symptoms consistent with Ebola. If they develop symptoms, they should call ahead to their hospital or health care provider and report their symptoms and recent travel to the affected areas so appropriate precautions can be taken.

Continue reading “The Ebola Outbreak: The CDC Director’s Guidance for Health care workers”

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Tom Frieden optimizedFor more than four decades, Ebola virus had only been diagnosed in central or eastern Africa.

Then late this past March, the first cases of Ebola began appearing in a surprising part of the continent. The Ministry of Health in Guinea notified WHO of a rapidly evolving outbreak of Ebola virus disease. The outbreak in Guinea was the first sign the virus had made the jump across the continent.

Ebola then spread quickly to Sierra Leone and Liberia, and then to Nigeria.

As the world learned of the cases, CDC began receiving questions from American hospital labs. They were looking for guidance on how to handle testing for patients who had recently returned to the U.S. from West Africa with potential Ebola symptoms.

If U.S. hospitals were to run laboratory tests on these patients, how could they be sure their staff could safely handle materials that might contain this dangerous virus? Did they need the kind of personal protective equipment they saw CDC scientists using when they were testing for Ebola?

Continue reading “CDC Laboratory Guidance on Ebola”

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Users and non-users of electronic cigarettes (e-cigarettes) have many legitimate questions about these nicotine-delivery devices. E-cigarettes represent a nearly $2-billion-a-year industry, and one that’s growing exponentially. The number of young people trying e-cigarettes doubled from 2011 to 2012, according to the Centers for Disease Control. So it is natural that so many people are interested in the health consequences of using e-cigarettes.

Research from the Department of Health Behavior at Roswell Park Cancer Institute has documented the impact of first-, second- and third-hand exposure to e-cigarette vapors. Our most recent research, done in collaboration with scientists from the Medical University of Silesia in Poland, offers insight into the user’s exposure to carcinogenic carbonyls.

The e-liquids used in e-cigarettes are primarily composed of glycerin and propylene glycol. We set out to find out what chemicals are generated during use of e-cigarettes, particularly at variable voltages. Some devices allow the user to adjust the voltage to increase vapor production and nicotine delivery.

We found that when e-cigarettes were operated at lower voltages, the vapors that were generated contained only traces of some toxic chemicals. These chemicals included the carbonyls formaldehyde, acetaldehyde, and acetone. However, when the voltage was increased, the levels of these toxicants also significantly increased.

The novel finding of our study is that the higher the voltage, the higher the levels of carbonyls. Increasing battery output voltage leads to higher temperature of the heating element inside the e-cigarette. Increasing the voltage from 3.2 to 4.8 volts resulted in increases of anywhere from 4 times to more than 200 times the exposure to formaldehyde, acetaldehyde and acetone. The levels of formaldehyde in vapors from high-voltage devices were similar to those found in tobacco smoke.

Continue reading “Electronic Cigarettes: What’s in the Vapors?”

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Tom Frieden CDCIn July, CDC will roll out a new way every hospital in the country can track and control drug resistant bacteria.CDC already operates the National Healthcare Safety Network (NHSN), with more than 12,000 health care facilities participating.  Now we are implementing a breakthrough program that will take control of drug resistance to the next level – the Antibiotic Use and Resistance (AUR) reporting module.  The module is fully automated, capturing antibiotic prescriptions and drug susceptibility test results electronically.

With this module, we’ll be able to create the first antibiotic prescribing index. This index will help benchmark antibiotic use across health care facilities for the first time, allowing facilities to compare their data with similar facilities. It will help facilities and local and state health departments as well as CDC to  identify hot spots within a city or a region.

We’ll be able to answer the questions: Which facilities are prescribing more antibiotics? How many types of resistant bacteria and fungi are they seeing? Do prescribing practices predict the number of resistant infections and outbreaks a facility will face?  Ultimately with this information, we’ll be able to both improve prescribing practices and identify and stop outbreaks in a way we have never done before.

This will help deploy supportive and evidence-based interventions at each facility as well as at regional levels to help stop spread among various facilities.

The need for a comprehensive system to collect local, regional, and national data on antibiotic resistance is more critical than ever. The system now exists, and we need quick and widespread uptake.

Rapid and full implementation of this system is supported through the proposed increase of $14 million contained in CDC’s 2015 budget request to Congress.

With the requested funding increase in future years, CDC would look to develop web-based tools and provider apps so physicians will gain access to facility- and community-specific data via NHSN on the most effective empiric antibiotic for the patient in front of them. For example, a physician in a burn unit treating a patient with a possible staph infection will know what antibiotics that particular microbe is likely susceptible TO and which ones are likely to be most effective.

Instead of broad-spectrum antibiotics being the default choice, as is often the case now, doctors will see recommendations for targeted narrow-spectrum antibiotics that are more likely to be effective and less likely to lead to potentially deadly infections such as C. difficile.

Continue reading “Where Are The Hot Spots For Antibiotic Resistance?”

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Lately, stories about outbreaks seem to be spreading faster than the diseases themselves. An outbreak of measles in Ohio is just part of an 18-year high of U.S. cases. Meanwhile, polio continues to circulate in Pakistan, Afghanistan, and Nigeria, while spreading to other countries, like Cameroon, Equatorial Guinea, and Syria, leading the World Health Organization to declare a “Public Health Emergency of International Concern” last month.

The Role of Globalization

As recent threats of H5N1, H1N1, and MERS attest, the increasingly global nature of infectious diseases presents serious risks. Foreign tourists, Americans returning home from international travel, immigrants, and refugees can all expose countries to disease.

With modern transportation shuttling people and products to nearly any part of the world in a matter of hours, the volume of these comings and goings is unprecedented. In 2008, approximately 360 million travelers entered the United States, which also takes in about 50,000 refugees annually.

It should be unsurprising, then, that the Ohio measles outbreak started when unvaccinated Amish missionaries visited the Philippines, then returned home. Infected persons spread the disease to others within their largely unvaccinated communities. The last naturally occurring U.S. outbreak of polio occurred in similar fashion: An outbreak in the Netherlands spread to Canada in 1978, then to the United States the following year, all among unvaccinated Amish populations across four states.

Compared to the United States, nations experiencing social unrest and political conflict face even more serious obstacles to preventing infectious disease.

Strife can interrupt routine vaccination campaigns, as is largely happening with polio. For example, the largest numbers of polio cases last year were in Somalia and Pakistan. Refugees and other displaced populations without health care access can create fertile settings for disease spread, especially if they’re not protected by vaccination. Health workers involved in vaccination campaigns can become targets of violence. And in some areas—Nigeria, for example—religious leaders haveconvinced their followers that the polio vaccine is a biological weaponpromulgated by the West.

For the most part, the United States doesn’t face these barriers. In America, vaccination is more of a choice. Unfortunately, some Americans are putting themselves, their families, and their communities at risk by choosing not to get vaccinated. If those who opt out of vaccination travel to areas where diseases are more common or come in contact with individuals arriving from such areas, they’ll be at risk of becoming ill from otherwise preventable diseases. Continue reading “An Outbreak of Outbreaks”

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Tom Frieden CDCAntibiotic resistance — bacteria outsmarting the drugs designed to kill them — is already here, threatening to return us to the time when simple infections were often fatal. How long before we have no effective antibiotics left?

It’s painfully easy for me to imagine life in a post-antibiotic era. I trained as an internist and infectious disease physician before there was effective treatment for HIV, and I later cared for patients with tuberculosis resistant to virtually all antibiotics.

We improvised, hoped, and, all too often, were only able to help patients die more comfortably.

To quote Dr. Margaret Chan, Director General of the World Health Organization: “A post-antibiotic era means, in effect, an end to modern medicine as we know it.”

We’d have to rethink our approach to many advances in medical treatment such as joint replacements, organ transplants and cancer therapy, as well as improvements in treating chronic diseases such as diabetes, asthma, rheumatoid arthritis and other immunological disorders.

Treatments for these can increase the risk of infections, and we may no longer be able to assume that we will have effective antibiotics for these infections.

Last September, CDC published our first report on the current antibiotic resistance threat to the United States.

The report conservatively estimates that each year, at least 2 million Americans become infected with bacteria resistant to antibiotics, and at least 23,000 die.  Another 14,000 Americans die each year with the complications of C. difficile, a bacterial infection most often made possible by use of antibiotics. WHO has just issued their report  on the global impact of this health threat.

It’s a big problem, and one that’s getting worse. But it’s not too late. We can delay, and even in some cases reverse the spread of antibiotic resistance.

Continue reading “The End of Antibiotics. Can We Come Back from the Brink?”

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