infectionNet - for people who manage infections

Ambiguity is the root of all evil when you’re collecting data. Although the differences between '07 July 2007', 'July 07, 2007' and '07/07/2010' are insignificant when writing a letter, they are very significant when importing into a database. If some of your data collectors write '07 July' while others write 'July 07', you’re going to end up spending time rewriting it. Same goes for names, identification numbers, nursing units, facilities, and almost any other field you can think of.

For example

Mary Smith | 111222333444 | July 7, 2010 | Unit 5 | General Hospital
Smith Mary | 111222333444 | 07/07/2010 | 5th Floor | General

Are completely different records to a database. This is an easy fix for a programmer, but what are the odds you have one of those on hand? Luckily, there's a few simple things you can do to get rid of bad data like this.

Simple steps

1. Tell them what you want
   If you want someone to fill in a date, tell them how you want it written. On all my data collection forms, I always write 'DD-MMM-YYYY', so for my example above, I’ll always get 07-Jul-2010. When I want a name, I tell people I want ‘Lname’ and ‘Fname’, in that order. I get the same result every time.

2. Ask only one question per field
   I saw a field on a collection form last week that asked: “Were antibiotics given? Were they appropriate? Logically, in your head, this is one field. For data collection purposes, however, these represent two distinct fields. Even if you end up having 100s of fields, you need to make sure that each field addresses only one question.

3. Take out all the guesswork
   This one sounds obvious, but gets overlooked all the time, and will save you major headaches down the road. Putting a simple (Y/N) after your questions will clean up a lot of your data issues. For example, questions like ‘Were antibiotics given? (Y/N) Were the antibiotics appropriate? (Y/N), will yield useful answers. If these questions aren’t black and white, leave room for a ‘Comments’ field.

Get it right the first time

This sounds like absolutely basic information that anyone would know, but yet I see reams of poorly constructed forms and piles of unusable data every day. Imagine if you had records of 400 MRSA cases, all with different date formats, all with little notes in Y/N fields, some with full patient names, some with just patient initials, etc. It’s a nightmare that’s going to cost you time to fix.

The difference between this:

Mary Smith | 111222333444 | July 7, 2010 | Unit 5 | General Hospital | Antibiotics were given, but they were not appropriate

and this

Smith | Mary | 111222333444 | 07/07/2010 | 5th Floor | General | Y | Not appropriate

is huge. Especially when there are 400+ Mary Smiths.

At our hospital, we get Pharmalerts in our email about once a week. These emails aren't applicable to what I do, so I don't read them, but every week I wonder just how many people actually do read them.

After just a few short weeks of seeing these alerts stream into my inbox, I started to mentally filter them out. I was immune to their effect. I associated the word "Pharmalert" at the top with a message that was going to be poorly designed and onerous to read. So I didn't read them. While this has much to do with inapplicable content, it also has to do with design:

The original

Lots of fonts, bolds, italics, underlines, different colours, different list styles, some parts are centred some are left-aligned, etc. There's a lot going on here.

A few minor adjustments

Nothing drastic here. Instead of using a lot of font weights, sizes and colours, I stuck with the least I could get away with. In my version there's just two colours and one font family (Times New Roman) with bold accents.

Lessons

1. Use as few 'extras' as possible. Try using just one font and add contrast by increasing size or adding a bold highlight.
2. An accent colour should only be used to accent. It should not be used throughout the whole body of text.
3. Whitespace, whitespace, whitespace. You can never have enough whitespace in documents like this. Divide your content into major chunks and give the chunks room to breathe.

Separate content from structure

When we put the two together and put them under a layer of blur, we can really see the design at work. Adding the blur forces you to think beyond content and narrow-in on structure. The original has lots of noise throughout the entire piece, while the second one is cleaner, has less distractions, and has way more whitespace.

Whether you're making policy documents, precaution signs, or Pharmalerts, you should think critically about structure and design. Keeping things simple and free from clutter gives you a much better chance of getting read.

An excellent paper and accompanying editorial in today's Canadian Medical Association Journal describes huge increases in fluoroquinolone antibiotic resistance in Ontario from 2002 to 2006. Similar changes have been described in many other parts of the world.

Fluoroquinolones have only been in existence since the 1980s and first licensed for sale in Canada in 1988. They were the first new class of antibiotic introduced for many years and were received with extreme expectations. They were widely touted as the solution to antibiotic resistance to penicillins, tetracyclines, sulfa antibiotics and others. Ciprofloxacin, the most successful of the class was brilliantly marketed to community-based physicians as having "IV power in an oral formulation".

In 20 short years one might say "the arse has well and truly fallen out of 'er". Fluoroquinolones are all but useless for many clinical indications. 20 years! All over the world!

Another good reason to increase attention to antibiotic misuse and develop the regulatory structures needed to tackle this urgent and relentless problem.

Influenza epidemics occur every year, most commonly in January-February in Newfoundland and last about 8 weeks with a very noticeable peak for about 2-3 weeks starting about the 3rd or 4th week. The current H1N1 influenza pandemic has markedly focused attention on the spectrum of illness associated with influenza. While it is true that this epidemic is relatively large and associated with relatively more illness requiring hospitalization than recent seasonal epidemics, it has not been catastrophic and is comparable to other bad seasonal influenza epidemics in many respects.

Influenza is certainly associated with deterioration of respiratory function in people with underlying respiratory disease and consultations and admissions for COPD, asthma and pneumonia markedly rise during epidemic peaks. Oseltamivir is a generally non-toxic, effective therapy for influenza. This gives rise to obvious primary care provider questions.

Should patients that do not need hospital referral be tested and/or treated for influenza during influenza epidemics?

Tested - No in general. Testing is not timely enough to help with treatment decisions. Improvements in point-of-care tests may change this in future.

Treated - Yes in general. Especially if the illness has been present for less than 2 days as neuraminidase inhibitor effect is greatest if initiated early. Oseltamivir 75 mg BID x 5 days is the standard course with some advocating a 10 day course for overtly immunocompromised patients.

Should COPD and Asthma patients receive antibacterial antibiotics as well?
This is a harder question. I am generally in favour of a conservative approach to antibiotics and most exacerbations of COPD and virtually all exacerbations of asthma are appropriately treated without antibacterial antibiotics. I definitely advise a higher threshold for antibacterials than for antivirals during peak influenza season. Patients who are felt to have pneumonia should, of course, be treated.

If I do treat with an antibacterial, which one?
Doxycycline is an underused, effective, inexpensive option. Perhaps because it has fallen out of favour for many years, resistance among respiratory pathogens is very low in contrast to the macrolides (erythromycin, clarithromycin and azithromycin) where Streptococcus pneumoniae resistance is above 25% in Newfoundland. Amoxicillin/clavulanate is a good second-line choice while I would reserve fluoroquinolones (moxifloxacin, levofloxacin) for failures.

I gave a talk at the Canadian Society for Laboratory Science annual general meeting today concerning antibiotic resistance. In it I suggested that everyone has a role in the solution to the problem. Afterward someone asked me if they should question their physician more thoroughly when they are given a prescription. It is something I have been asked before and have generally been reluctant to suggest that questioning their doctor's prescription decision was appropriate. I have been very conscious of the need for a cooperative, blameless approach.

I have changed my mind.

Everyone should demand very specific information about all antibiotic prescriptions. You should be aware of the exact diagnosis, the expected course of illness and symptoms that would suggest need for further medical assessment. Discussions of alternatives are completely appropriate. If your doctor can't or won't give you the information you want consider another opinion.

Taking antibiotics is serious business and deserves serious personal consideration. The more questions asked the better.