DenverCovid19HospRate

Valverde neighborhood has the highest rate of Covid-19 hospitalization in Denver. Image from Christie Mettenbrink for Denver Public Health

by George Taniwaki

Denver’s Valverde neighborhood is just a few miles from the Barnum West neighborhood where I grew up. The streets there are busier and noisier, with more industrial businesses lining Alameda Ave. and Federal Blvd. Studies show excessive car traffic can lead to stress and chronic respiratory ailments, especially when combined with smoking, which is more common among residents there.

The houses are smaller, with more families living in multigenerational arrangements. Residents are more likely to ride public transportation to get to work or school. They are also more likely to have jobs that are considered essential. Crowded living and working conditions increase the likelihood of contracting Covid-19.

Finally, adults in Valverde are less likely to speak English at home, meaning they have less access to healthcare information. They are less likely to have health insurance and less access to healthcare providers, even if they have insurance.

This isn’t an accident of history. Cities like Denver had long adopted policies (Colorado Trust, May 2018) that encouraged racial segregation and discrimination. From the 1920s until the 1970s, the city worked with banks, mortgage companies, and property insurers, to draw maps of neighborhoods that were safe, a practice called redlining. Similar maps were used by Denver Public Schools to plan the location of new buildings to ensure schools were kept racially segregated.

Even today, the impact of segregation is still visible. An excellent article in The Conversation (May 2020) looks at the distribution of Covid-19 hospitalization rates by neighborhood (see map at top). You can see more charts and an explanation at Denver Public Health (May 2020).

InfectionPreventionConversationCartoon

Staff need to encourage patients to speak up. Image from CDC

by George Taniwaki

While doing research on the role being played by the Center for Disease Control and Prevention (CDC) during the Covid-19 pandemic, I accidentally discovered a website full of information on infection prevention for dialysis patients.

The most effective way to prevent infection is for both the patients and staff to be trained on infection prevention and best practices. Further, they should both actively monitor the dialysis procedure to be aware of opportunities for infection. Finally, patients should feel free to speak up if something looks amiss, and staff should welcome feedback.

The CDC website contains videos, posters, a cartoon (see screenshot above), and other resources for training staff and patients. It also contains information about the Making Dialysis Safer for Patients Coalition. Good stuff.

Making Dialysis Safer Coalition

TrackThis

Track this. Photo from Bloomberg BusinessWeek by Karen Ducey/Getty Images

by George Taniwaki

In a Bloomberg Businessweek editorial (Apr 2020), Cathy O’Neil (mathbabe) explains why a Covid-19 tracking app won’t work. It’s all about self-selection bias.

* * * *

Update: For a good non-technical description of how the Apple and Google contact tracing API works, including the encryption method, see Economist, Apr 2020. The article also suggests that even though using an app for contact tracing is imperfect, its low-cost and passive nature makes it worthwhile.

FlattenTheCurve

Can a partially effective vaccine flatten the curve?

by George Taniwaki

During this Covid-19 pandemic, we want to know when we can stop sheltering at home and go back into public spaces again. Further, we want to know which actions can speed up the time before that can happen.

One thing we do know is that when dealing with a novel disease (one that no human appears to have immunity for), the entire population cannot go back to pre-epidemic behavior at the same time before it is safe. Doing so will cause a spike in infections and deaths. This will terrorize the population leading to another round of isolation. If the public loses faith that the government knows when it is safe to change behavior, then when it finally is safe, people will still be afraid and time will be lost during the recovery, causing additional economic hardship.

So when can we go back to normal? I think that can happen only after herd immunity is achieved. This can take a very long time as a trickle of individuals become infected and recover with resistance or die, a process called flattening the curve. Or it can happen pretty quickly after the wide-spread inoculation of individuals with a safe and effective vaccine.

An effective vaccine may take 18 to 24 months to develop. Many people, including President Donald Trump, think staying home this long is unrealistic. Is it possible to shorten that time by releasing a partially effective vaccine sooner? Doing so may help flatten the curve without requiring social distancing.

Partially effective vaccines

An intriguing paper by Eduard Talamàs & Rakesh Vohra, entitled “Free and perfectly safe but only partially effective vaccines can harm everyone” pretty much contains the answer in its title.

The idea is that a partially effective vaccine will cause people to change their behavior too much, too soon, causing the spike we want to avoid. The conclusion is similar to the analysis popularized by Sam Peltzman of the Univ. Chicago (a microeconomics professor while I was a student there) who suggested that stricter automobile safety regulations could lead to increased deaths (of pedestrians) as drivers felt safer and became more reckless (J Polit Econ, Aug 1975).

The most important conclusion in Talamàs et al., is that with overlapping social networks, even those who do not increase the size of their networks after the introduction of the vaccine can be harmed by those who do. This conclusion is slightly different than those of most epidemiological models that assume random contact between individuals rather than strategic networks. A good description of the paper is given by one of the authors, Vohra, at The Leisure of the Theory Class (Apr 2020).

DoorLatch

Righty tighty, lefty loosy, when viewed using a mirror

by George Taniwaki

On a visit to the University of Washington Medical Center laboratory, I was asked to provide a urine specimen. As I approach the restroom, I notice the door is about 1m (40") wide to accommodate a wheelchair, which is good.

Both the outside and inside of the restroom door have solid metal lever handles. You push down to open the door. Levers are easier to grip than knobs and are now the preferred method to open and shut doors. Also good.

Once inside the restroom, there is an easy to grip lever above the handle that controls a lock for privacy. Good again.

As shown in the image above, the hinge for the lever is on top of a circular escutcheon and it flips left or right. But which way locks the door?

The rotation direction to lock the door is ambiguous. Apparently, there have been complaints, so someone printed a sign and taped it above the lever. But the sign is somewhat ambiguous as well since it is posted above the hinge, but the lever is below it.

Finally, it seems one of the lab techs used a grease pencil to indicate the direction to turn the lever to lock the door. But the grease is now smeared and illegible. The hand-drawn arrow points in the direction to lock the door, meaning the bottom toward the door edge or a counterclockwise turn. This is not standard in the U.S. and the likely source of confusion. Oh well, good thing I don’t have a shy bladder and don’t care if someone accidentally walks in on me.

Oddly, the convention to rotate a lock lever so that when the top points toward the door edge to mean the door is locked is not universal. In Japan, most locks are installed so that when the bottom points toward the door edge it is locked. You may notice this on some Japanese car doors.

* * * *

P.S. Ever have trouble knowing if a door opens toward you or away from you? To learn more about this design problem, read this blog post from 99% Invisible. Also watch the video. And read Don Norman’s book, The Design of Everyday Things.

[Update: Clarified the description of locks in Japan.]

by George Taniwaki

SEIU_775_purple FFlogo Wa2016Yes1501

I’m a libertarian by nature. (That’s libertarian with a small L, meaning I believe in government transparency and clarity. Please don’t confuse it with Libertarian with a capital L, which I associate with mindless anarchy.) Every two year, I dutifully check for my ballot and voter pamphlet (Washington has voter by mail). The number of items seems to be getting longer, especially voter initiatives.

Here is my method of deciding how to cast my ballot on voter initiatives. First, I start skeptically. Most voter initiatives are funded by political extremists who do not consider the consequences of adopting their pet idea. But I do my online research, checking analysis produced by hopefully reputable and unbiased sources. Ultimately though, I usually vote against them.

This year in Washington, there a really bizarre ballot issue. It is Initiative Measure No. 1501. “Increased Penalties for Crimes Against Vulnerable Individuals”

This measure would increase the penalties for criminal identity theft and civil consumer fraud targeted at seniors or vulnerable individuals; and exempt certain information of vulnerable individuals and in-home caregivers from public disclosure.

Should this measure be enacted into law? Yes [ ] No [ ]

How could anyone be against this? We want to help seniors, right? Well, it’s not that simple.

A convoluted story

There is a very complex story about this initiative. It involves a union, an antiunion think tank, and the U.S. Supreme Court. Initiative 1501 is sponsored by the Service Employees International Union (SEIU) that represents healthcare workers that work in nursing homes or provide in-home care. Washington, like most states, requires certain workers, such as nurses, to have a license in order to provide services to the public. About one-third of all service workers in the U.S. require licenses. In many cases, these workers are also unionized.

Enter the Freedom Foundation. This antiunion policy group is headquartered in Olympia, Washington. It was founded by Bob Williams, who was formerly with the American Legislative Exchange Council (ALEC). You may have heard of ALEC; it is a corporate funded lobbying group that writes model legislation (which obviously is designed to further the goals of its corporate clients) which it then provides to state legislators to review. The legislators can then submit the bills for approval into law. The Freedom Foundation provides very similar services.

In 2014, the U.S. Supreme Court ruled 5-4 in Harris v. Quinn that an Illinois state law that allowed the SEIU to collect a representation fee (union dues) from in-home healthcare workers wages was unconstitutional. The reasoning was that the fee violated the First Amendment rights of the workers to not provide financial support for collective bargaining.

After the ruling, the Freedom Foundation complained that the SEIU was not doing enough to inform its members that they did not have to pay the representation fee in order to belong to the union. Though a public records act, it sued the union and the state, won, and started to send communications to members encouraging them to stop paying the fee.

Since a Supreme Court ruling covers the entire U.S., not just Illinois, the SEIU realized that it was very vulnerable to attack by the Freedom Foundation or other antiunion organizations.

Now the initiative makes sense

In Washington, the SEIU proactively sponsored Initiative 1501 as a direct attack against Freedom Foundation. The SEIU wants to avoid having to release the names, addresses, and phone numbers of its members (or having the state reveal these either). Initiative 1501 does this by saying that in-home caregivers are a protected class, like seniors or vulnerable individuals, that the state and the union cannot release personal information about.

After all that research, the story starts to make sense. This is a battle between two parties that a libertarian like me dislikes. But more transparency is better than less. So I will vote no. Sorry seniors and vulnerable individuals, you will have to rely on existing statutes to protect you.

by George Taniwaki

Patients are often frustrated and confused when navigating the healthcare system. Part of the problem is that if you are sick or hurt, it reduces your cognitive abilities. But it also because hospitals are busy places with little funding for improving the user experience. Often the layout of the rooms, the signage, the forms and instructions, and the language used by the staff are not tailored to the needs of patients who are unfamiliar with the system.

Design to reduce patient violence

A significant problem in hospital emergency medical departments (called A&E in Britain, ER in America) is abusive and violent patients. According to the National Audit Office, violence and aggression towards hospital staff costs the NHS at least £69 million a year in staff absence, loss of productivity and additional security.

Some other statistics from the Design Council report: More than 150 incidents of violence and aggression are reported each day within the NHS system. In 2010, the incidence rate of violence and aggression was about 1 per 1000 patients. In 2009, 21% of staff report bullying, harassment, and abuse by patients, 11% report physical attacks by patients.

Working with the National Health Service, a design firm called PearsonLloyd developed some low-cost methods to reduce the incidence of violence and aggression, increase patient satisfaction, improve staff morale, and reduce security costs. They call their program, A Better A&E. The program was pilot tested at St. George’s Hospital in London and Southampton General. For an introduction, see the video below.

BetterAE

Figure 1. Still from video “A Better A&E. Image from Vimeo

Signage and brochure

The program consisted of three parts. First, improved signage was installed that included an estimated wait times along with a brochure that explained why a patient who arrived after you could be seen a doctor before you.

BetterAEbusyBetterAEWait

Figures 2a and 2b. Large screen monitor alternately shows how busy the A&E is and then how long the wait time is for different categories of patients. Images from Design Council report

BetterAEbrochure

BetterAESignage

Figure 3a and 3b. A page from brochure explaining why wait times differ among patients and what to expect at each station. Signage posted at each patient area keyed to the brochure. Images from Dezeen.com

Root cause analysis

The second part of the redesign was the introduction of program to capture information from doctors, nurses, and other staff about factors that led to violent and abusive behavior. The program included root cause analysis and a prominently posted Incident Tally Chart to record the “variables within the system that might hinder the ability of staff to deliver high quality care.”

BetterAEIncidentTally

Figure 4. Incident tally posted where staff can record any events during their shift. Images from Design Council Report

Toolkit and patterns

The final part of the program was to design a toolkit that would take the lessons from the A&E departments of the two pilot hospitals and generalize them so that they could be adopted by any hospital within the NHS system. The toolkit is presented as an easy to use website, http://www.abetteraande.com

Results

Surveys of patients and staff taken after the redesign indicated that both groups saw benefits.

  • 88% of patients felt the guidance solution was clear
  • 75% of patients felt the signage reduced their frustration during waiting times
  • Staff reported a 50% drop in threatening body language and aggressive behavior
  • NHS calculated that each £1 spent on design solutions resulted in £3 in benefits