Does wearing jackets over scrub suits prevent infections?

I always enjoy papers that reinforce my biases. Here’s one called “The Impact of Perioperative Warm-up Jackets on Surgical Site Infection: Cost without Benefit?”

If you’re a regular reader of my blog, you undoubtedly know the answer. Wearing jackets over scrub suits doesn’t prevent infections and adds costs.

Investigators from the University of Minnesota looked at infection rates one year before the institution of a mandatory warm-up jacket over scrub suit policy and one year after.

The rate of surgical site infection for the 13,302 cases done in the year before jackets had to be worn was 2.42% compared to 2.67% for the 12,998 cases done during the year after. The difference was not statistically significant with a p value of 0.1998.

Operative risk and surgeon decision-making

Should it surprise you that surgeons might have differences of opinion about whether or not a patient should have an operation?

It doesn't surprise me, but apparently a lot of people were taken aback by an Annals of Surgery paper published online last week stating just that.

The authors gave 767 surgeons four brief complex clinical scenarios and asked whether they would operate on each patient. The vignettes were purposely designed to not have "correct" answers.

In response to the question would you recommend an operation, the surgeons could choose one of the following responses: very likely, unlikely, neutral, likely, or very likely.

If you were in the emergency department with mesenteric ischemia, would you want a surgeon who responded "neutral"?

Why the authors selected five possible choices is puzzling. In real life when you are faced with a difficult decision in the middle of the night, you don't have five options. You have only two—operation or no operation.

Deciding whether adverse events are preventable or not

Adverse events and poor outcomes are not always preventable. Deciding whether an adverse event is preventable or not can be difficult.

"To Err is Human: Building a Safer Health System," the original Institute of Medicine report in 1999, stated that  between 44,000 and 98,000 deaths each year were caused by preventable medical errors.

That report was widely cited and spawned a number of studies and reviews claiming that anywhere from 250,000 to 440,000 preventable deaths occur in the United States every year.

I was critical of the 440,000 deaths paper as well as the most recent of these estimates—the one claiming 250,000 deaths due to medical errors per year.

It's not widely known or perhaps simply forgotten, but the 1999 Institute of Medicine report also came under fire. In 2000, two researchers from Dartmouth, Drs. Harold C. Sox Jr, and Steven Woloshin, published a critique called "How many deaths are due to medical error? Getting the number right."

When bad research is not critically reported by journalists

Yesterday I posted a critical review of the study "Medical error—the third leading cause of death in the US."

I did not have time to address the media coverage of the paper, but fortunately the website HealthNewsReview did.

Their post started with "Seemingly all the major outlets carried the story, with headlines so alarming that they’d have any conscious hospital patient demanding an immediate discharge."

They called attention to headlines which included the word "now" such as these:

CBS: Medical errors now 3rd leading cause of death in U.S., study suggests
Washington Post: Researchers: Medical errors now third leading cause of death in United States
Nature World News: Medical Errors Now the Third Leading Cause of Mortality in U.S.

They pointed out that the headlines were similar to the title of a press release issued by the PR department at Johns Hopkins and that using "now" in the headline implies that the incidence of deaths caused by medical error has increased.

Hand hygiene follow-up: The CDC may be reading my posts

Two weeks ago I blogged about a hand hygiene study that showed a 6-step alcohol-based hand washing technique significantly reduced hand colony counts compared to a standard 3-step technique.

The 6-step process took about 45 seconds and when coupled with the amount of time a healthcare worker took to remove gloves, go to the dispenser, and let the hands dry, at least a minute will have elapsed.

In a busy emergency department with 10 or more hand hygiene events per hour, personnel might spend 80 to 120 minutes per shift on that activity alone.

Today is World Hand Hygiene Day and none other than the Centers for Disease Control has validated my hypothesis. Here is what the CDC tweeted today:

An anonymous commenter on my original post said, "Now imagine doing this [the 6-step technique] on rounds, with 40 patients to be seen, and a chief, pgy 3, and 2 interns who have to line up at the sink to do this."

Are there really 250,000 preventable deaths per year in US hospitals?

For the last couple of days, the Twitter medical community has been discussing the latest in a long line of papers attempting to estimate the role of medical error as a cause of death.

This week's entry appeared in the BMJ (full text available here) and was by a surgeon at Johns Hopkins, Dr. Martin Makary, who claims that 251,454 patients die from medical error every year.

Makary's review extrapolated that figure from three papers published before 2009 which had a combined 35 supposedly preventable deaths. That's not a typo—35 deaths in all. One of the papers stated that all 9 deaths in three tertiary care hospitals were preventable. In his BMJ paper, Makary says, "some argue that all iatrogenic deaths are preventable."

I disagree. I have analyzed other papers on this subject and pointed out that certain complications and deaths are not 100% preventable. For example, no study of deep venous thrombosis and pulmonary embolism shows total efficacy of any prevention strategy. And some patients will suffer myocardial infarctions and die even when they are properly treated.

In this month's BMJ Quality and Safety, Dr. Helen Hogan of the Department of Health Service Research and Policy at the London School of Hygiene and Tropical Medicine discusses the problems associated with using preventable deaths as a measure of quality.