Transitions and the Curse of Knowledge

Don’t create yet another form! Make the discharge summary more functional. There’s a wide variation in the usefulness of the discharge summaries I read. Train your hospitalists to consider at least part of that dictation as their “sign out” to the primary doc.

Although the discussion is about communication problems between attendings at various points within the patient care stream, there is also a need for communication with those outside of this circle. I will attempt to explain. Part of this blog relates to Plavix and I will thus thread the discussion through that needle’s eye.

For those on Plavix who must undergo surgery, the issues are interestingly complex. I wish to discuss the problems with, and some of the drivers for pre-op prophylactic antibiotics. In our area, West Coast, there was a shift about four years ago to vancomycin, 1-gram, slow drip, about an hour prior to the procedure. Routine surgical prophylaxis with this drug may well see its loss as a tool. Here is where the communication starts to break down. Actually the eventual loss of vancomycin is being driven now by its own energy. In essence we have a tragedy of the commons revisited. It is almost unconscionable now not to give vancomycin as a routine pre-op

The other issue, but not to be discussed, is development of a histamine-mediated reaction or red man syndrome as well as phlebitis developing within the infusion vessel from the vancomycin, hence barrier breakdown.

The blog’s moderator and contributors discuss the issues of disjointed communication and transitions between physicians——-Transitions and the Curse of Knowledge. I would like to add to that thought string. In doing so, however, I will remove the reader far from the hospital, but at the same time show how a revolving door is created through the routine surgical prophylaxis with vancomycin. The illustrative case will be narrowed to the need for periodic battery replacement in an ICD or implantable cardiac defibrillator. Implant duration for some devices was calculated to be, on an average of 26 months. Note that 26 month time span as the discussion continues. Perhaps this battery defect has been corrected.

Vancomycin is mainly given to deal with the methicillin resistant Staph aureus (MRSA), a very serious professional pathogen. There are two brands of MRSA, hospital acquired (HA MRSA) and community acquired (CA MRSA). These are thought to be separately derived, i.e., originating from distinctly different sources. This thought, however, bears some reflection, as will become apparent momentarily.

Let us shift from the hospital to the community at large. The levels of CA MRSA and consequent number of cases are rising dramatically in a non-linear fashion. Infectious disease (ID) docs are now lecturing hospital nursing staff about the precautions of CA MRSA, least the nurses bring it back into the hospital. In the interim, vancomycin is given more frequently.

What is interesting about the topic— disjointed communication and transitions—is that many ID docs do not well understand the reservoirs of CA MRSA and thus deal with it mainly at the hospital level, some at the community level.

As antibiotics are given, many of these drugs transition through the body essentially intact and are eliminated either in the urine or feces—both discharged to the sewer. Along with this removed metabolic waste are myriad bacteria (the gut flora). Thus entering the local sewer plant are the exact ingredients to either initiate or maintain antibiotic resistance. There are numerous papers demonstrating that sewer plants actually generate antibiotic resistance and the genetic material from these bacteria leaves via wastewater to be later noted in the drinking water (see for example works by A. Pruden or E. McGowan). Hospitals are a major source of antibiotic resistant pathogens as well as discharged pharmaceuticals and other metabolic toxins, (see for example: B. Pauwels & W. Verstraete’s review paper at IWA Pub 2006, Jr Water & Health 04.4 200, p 405 et seq).

The genetic exchange between different bacteria and even different kingdoms occurs at impressive numbers within sewer plants—hence the above quip about the real origin of CA and HA MRSA. Additionally many cities are now using reclaimed wastewater for irrigation or recharging groundwater basins. The revolving door is now more apparent, is it not? By using, under current standards, this wastewater and the levels of pharmaceuticals and other metabolic toxins in the “treated” wastewater are sufficient to initiate resistance in soil bacteria. Now mix into this background the professional pathogens and the chance to transfer this to humans is vastly increased. Imagine playing on a ball field and dropping your mouth piece or licking your golf ball as so many do or holding the tee in your teeth?

Once inside the body’s gut bacterial community, these resistant pathogens or normal bacteria that have acquired some of that genetic information may multiply and share that information making later treatment with particular antibiotics ineffective. Also one must consider transfer of genetic information from these organisms to more robust organisms as highlighted by Sjolund et al (2005) indicating that resistance in the normal flora, which may last up to four-years, might contribute to increased resistance in higher-grade pathogens through interspecies transfer (remember the battery replacement interval noted above?)

These authors go on to note that since populations of the normal biota are large, this affords the chance for multiple and different resistant variants to develop. This thus enhances the risk for spread to populations of pathogens. Furthermore, there is crossed resistance. For example, vancomycin resistance may be maintained by using macrolides.

Christopher Walsh in his new text (ASM-2003) notes that resistance to antibiotics is not a matter of IF but one of WHEN.
Schentag, et al., as found in Walsh, followed surgical patients with the subsequent results. Pre-op nasal cultures found Staphylococcus aureus 100% antibiotic susceptible. Pre-op prophylactic antibiotics were administered. Following surgery, cephalosporin was administered. Ninety percent of the patients went home at post-op day 2 without infectious complications. Nasal bacteria counts on these patients had dropped from 105 to 103, but were now a mix of sensitive, borderline, and resistant Staphylococcus sp. By comparison, prior to surgery, all of the patients’ Staphylococcus samples had been susceptible to antibiotics. For the patients remaining in the hospital and who were switched on post-op day 5 to a second generation cephalosporin (ceftazidine), showed bacterial counts up 1000-fold when assayed on post-op day 7 and most of these were methicillin resistant Staphylococcus aureus (MRSA). These patients were switched to a 2-week course of vancomycin. Cultures from those remaining in the hospital on day 21, revealed vancomycin resistant enterococcus (VRE) and candida. Vancomycin resistant enterococci infections can produce mortality rates of 42%+.
Note in the above, that these patients had no resistance upon entering the hospital, but what would the results have been if they were colonized prior to entry?

Thus, to conclude, not only is one’s life complicated when one is facing surgery while on Plavix, but that surgical procedure may become yet more complicated because of the above. The lack of communication between the in-house medical profession and those dealing with the above merely extends the argument that there is a need for transition and the curse is the lack of communication between seemingly disparate groups that are in fact connected.

Cheers—————–Edo

As an inner city primary care doc in Vancouver BC this was an issue I constantly struggled with…the main inner-city hospital was 6 months behind on all discharge summaries, and had given up on discharge phone calls to family doctors, even for those family doctors who wanted to keep track of their patients in hospital, the hospital was no longer interested in priviliges for family docs.
I can’t tell you how many times I tried calling people in the hospital to find out what had happened to one of my patients only to be met with the angry “we are too busy to talk to you”.
So I’d ask my HIV positive patient “What do your new ARVs look like?”, and do the best I can….
To me this is an example of systems stress that leads to worker stress that has major impact on patient care.
It’s nice to be working in the arctic, where I see a patient in emerg, admit them to myself, then discharge them to follow-up with me in clinic. Of course the 3 hour plane ride to specialist help can be a bit daunting at times…