Hand cleaning is a start - but not enough

Doctors fail to clean their hands before treating patients more than half the time, and when they fail to clean their hands, caregivers working alongside them also fail to clean their hands. In the United States, the federal Centers for Disease Control and Prevention, many organizations that promote healthcare quality and patient safety, and individual hospitals emphasize hand cleaning, and even urge patients to speak up and request that anyone treating them have clean hands.[1]

Importance of cleaning hospital equipment, rooms, and textiles

That’s a start, but not enough to curb the problem of hospital infections. In fact, at the risk of sounding iconoclastic, there has been almost too much emphasis on hand hygiene and too little attention paid to the importance of cleaning hospital equipment, rooms, and textiles. As long as hospitals are inadequately cleaned, doctors’ and nurses’ hands will become re-contaminated seconds after they are washed, when they touch a computer keyboard, open a supply closet, reach up to pull open a privacy curtain to see the next patient, or come in contact with other bacteria-laden surfaces.  In a recent Johns Hopkins study, 26% of supply cabinets were contaminated with methicillin-resistant Staphylococcus aureus (MRSA) and 21% with another hard-to-cure bacteria, vancomycin-resistant Enterococcus (VRE).[2] In an effort to stop computers from being reservoirs of deadly germs, several hospitals have installed washable keyboards, including a model that shuts down if it isn’t disinfected every four hours.[3]

Contamination of stethoscopes, blood pressure cuffs, and pulse oximeters

In most hospitals, stethoscopes, blood pressure cuffs, and pulse oximeters are used on one patient after another without being cleaned. In a 2006 study, 77% of blood pressure cuffs rolled from hospital room to hospital room and wrapped around the bare arm of one patient after another carried a variety of live bacteria.  The study’s authors urged hospitals to clean cuffs several times a day to avoid spreading infections.[4]   In another study, one out of every three cuffs carried Staph. and about the same proportion carried an organism that sometimes causes lethal diarrhea if it invades a patient’s mouth, Clostridium difficile.[5]  It’s a short trip from a patient’s arm to their finger-tips and into their mouth.

 

 

Numerous studies show the role of contaminated equipment and furniture in spreading dangerous bacteria. Researchers investigating an outbreak of VRE at a burn unit in Galveston found that 19% of bed rails, 18% of over-the-bed tables, and many other surfaces were heavily contaminated with this single germ. Imagine how many surfaces would be found unclean if more types of bacteria were considered. To beat back the bugs, the hospital required caregivers to wear gowns and gloves when treating VRE-positive patients, and initiated an aggressive twice-daily cleaning routine of all equipment and rooms. The result? VRE was eradicated, largely by cleanliness. The method failed only once, when an EKG wire the cleaning staff had overlooked was draped over a patient.[6] When the patient became infected with VRE, molecular typing matched the bacteria to the VRE on the wire.   The previous patient with VRE on whom that EKG wire was used had been discharged 38 days earlier.[7]

 

 

 

In addition to medical equipment, over-the-bed tables, bed rails, and many other surfaces in hospitals are heavily contaminated with infection-causing pathogens.  Why? Largely because environmental services staff are inadequate in number and poorly trained and supervised.  New data presented in April, 2007 at the annual meeting of the Society for Healthcare Epidemiology of America provide shocking examples. Boston University researchers examining 49 operating rooms in four New England teaching hospitals found that more than half the objects that should be disinfected were overlooked by cleaning staff.[8] A similar study of patient rooms in 20 hospitals in Washington D.C., Connecticut, and Massachusetts found that more than half the surfaces that are supposed to be cleaned for a new patient were left dirty.[9]

Clothing is frequently a conveyor belt for infections

A University of Maryland study showed that 65% of doctors and other medical professionals admitted they had not washed their lab coat in at least a week, though they knew it was dirty.  Fifteen percent said they hadn’t put on a clean lab coat in at least a month.[10]  Lab coats become covered in bacteria when doctors lean over the bedside of a patient carrying these organisms[11] and the bacteria can live on fabric for many days, creating a biological chronicle of the patients the doctors have examined.  When doctors reach into their lab coat pockets, the lingering bacteria are transferred to their hands. Hospitals that are conquering infections require staff to put on fresh gowns or disposable aprons every time they approach the bedside of patients carrying MRSA, not just infected patients, but all patients carrying the bacteria. 

Recent research highlights the danger of MRSA lingering on textiles and surfaces long after the patient who carried it has left the hospital. In one nine-bed British intensive care unit, more than half the patients who became colonized with MRSA after entering the ICU acquired a strain of the bacteria not present on other patients there at the time. In order words, the bacteria had been left behind on floors, bed rails, tables and other surfaces by patients already discharged. This finding demonstrates 1. how essential it is to know which patients entering the ICU are carrying the bacteria and 2. the importance of effective cleaning.[12]

The good news is that thorough cleaning with ordinary detergents and water curbs the spread of bacteria.  When researchers at Rush Medical College in Chicago trained cleaners to soak  surfaces with detergent, rather than merely  spraying and wiping, and to clean commonly overlooked objects, the spread of VRE to patients was reduced by two-thirds in nine months.  This significant reduction was due entirely to better cleaning.[13]

Can hospitals afford to improve cleanliness? 

They can’t afford not to.  Infections erode hospital profits.  When patients develop infections and have to spend extra weeks in the hospital and go through repeated operations, the hospital is often not paid for all the extra care.  These infections are adding an estimated $30.5 billion to America’s health tab in hospital costs alone.[14]

 

Even the cash-strapped British National Health service recognizes that improving cleaning is cost effective.  A hospital in Dorchester England added 57 hours a week of cleaning time  on one ward, nearly doubling it. The result?  Not one new MRSA infection in the next six months.  The savings from not having to treat those infections were three and half times the added cleaning costs.[15]

Clean hospitals are safer.[16] Astoundingly, the organization that inspects and accredits hospitals in the U.S., the Joint Commission,  doesn’t even measure cleanliness.  Neither do most state health departments or the federal Centers for Disease Control and Prevention.  Restaurants are inspected for cleanliness.  Food processing plants are routinely tested for bacterial content on cutting boards and equipment, but not hospitals, not even operating rooms.

At one time hospitals routinely tested air and surfaces such as floors and table tops for bacteria, but in 1970, the CDC and the American Hospital Association jointly announced that such testing was unnecessary.[17] The CDC has adhered to that position ever since, despite  a 32-fold increase in the incidence of methicillin resistant Staphylococcus aureus (MRSA),[18] and numerous studies linking unclean hospital equipment and rooms to infections. In the U. S., one out of every 20 patients contracts an infection in the hospital.[19] yet, the CDC’s latest guidelines for hospitals deem routine testing for bacteria “neither cost-effective nor warranted.”[20]

The truth is, these tests are so simple and inexpensive that they are used routinely in the food processing industry. Are we to believe that it is more important to test for bacteria in hot dog factories than in operating rooms?  The Boston University researchers mentioned earlier found that by sampling bacteria, then showing cleaning personnel what they were overlooking, cleaning improved substantially.[21]

Unfortunately, the Joint Commission gives little attention to cleanliness. Vice President of Standards and Survey Methods, Robert Wise, M.D., explains that if inspectors walk into a patient’s room and by chance find it noticeably messy and unclean, they will trace back to find out how that happened.  Otherwise, cleanliness is not assessed.  Joint Commission standards don’t specify how rooms should be cleaned, or what bacterial levels are unacceptable, and Joint Commission accreditation is no guarantee that a hospital is sanitary.[22]  In fact, California health inspectors, investigating complaints from the public, found that 25% of the hospitals where conditions were unsanitary had been inspected and accredited by the Joint Commission within the previous year.[23]

In Ireland and Scotland, hospitals are rated red, amber, or green (the cleanest), based on visual inspections, and the results are posted in newspapers.  The enormous publicity following the first year’s ratings motivated the worst Irish hospitals to clean up and earn higher marks the next year.[24]

Americans deserve similar information, and can improve on this system. How? By replacing visual assessments with objective sampling of bacteria levels.  Visual assessments can be misleading.  A study published in the Journal of Hospital Infection (2000) showed that only 18% of hospital sites looked dirty, but 76% of the same sites had unacceptably high levels of bacteria.[25] State health departments or the Joint Commission  should begin measuring  hospitals for cleanliness. Publishing the results would give hospital administrators a powerful incentive to clean up, and save lives.

When the public is asked what matters most in choosing a hospital, almost everyone says cleanliness (96% in a University of Pennsylvania survey.)[26] Obviously government isn’t listening.