Note: For additional information and footnotes, please see the 3nd edition of RID's popular publication,
Unnecessary Deaths: The Human and Financial Costs of Hospital Infections
Astoundingly, over half the time physicians and other caregivers break the most fundamental rule of hygiene by failing to clean their hands before treating patients. Programs to encourage better compliance have been disappointing. Brigham and Women's Hospital in Boston assessed the impact of installing dispensers for alcohol based hand cleaners in every patient's room and conveniently in the hallways, and conducting a year long campaign on hand hygiene. The results? Hand cleaning temporarily improved from 40% to 80%, but quickly dropped back to 60%.
Unfortunately, caregivers often think putting on gloveswithout cleaning their hands firstis sufficient, but pulling on gloves with unclean hands simply contaminates the gloves.
Cleaning hands is essential, but it's only the first step. Caregivers also need to learn how to prevent their hands or gloves from becoming recontaminated before touching the patient. Stand in the emergency room, and watch caregivers clean their hands, put on gloves, and then reach up and pull open the privacy curtain to see the next patient. That curtain is seldom changed, and it is frequently full of bacteria. The result? Caregivers' gloves are soiled again.
Research shows that nearly three quarters of patients' room are contaminated with MRSA and VRE. These bacteria are on cabinets, counter tops, bedrails, bedside tables, and other surfaces. Once patients and caregivers touch these surfaces, their hands become vectors for disease. One study showed that when a nurse walks into a room occupied by a patient with MRSA and has no patient contact, but touches objects in the room, the nurse's gloves are contaminated 42% of the time when leaving the room.
Environmental surfaces are vectors for drugresistant bacteria, but the most important sources of these bacteria are the patients coming into the hospital. Amazingly, most hospitals in the U.S. don't test incoming patients for MRSA. Seventy to ninety percent of patients carrying MRSA are unknown. They are the silent reservoir in the hospital. Knowing which patients are sources of bacteria is the key to stopping the spread.
Clothing is frequently a conveyor belt for infections. When doctors and nurses lean over a patient with MRSA, the white coats and uniforms pick up bacteria 65% of the time, allowing it to be carried on to other patients. Hospitals that are conquering infections require their 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. (The disposable aprons cost a nickel and are ripped off rolls like clear, plastic drycleaning bags.)
Stethoscopes, blood pressure cuffs, pulse oximeters, wheelchairs, and other equipment are frequently carrying live bacteria. Do doctors clean the stethoscope before listening to a patient's chest? Not usually, though the American Medical Association recommends it.
Recent research highlights the danger of MRSA lingering on surfaces long after the patient who carried it has been discharged. In one ninebed ICU, more than half the patients who picked up MRSA after entering the ICU acquired a strain of the bacteria not present on other patients in the ICU at the time. In other words, the bacteria had been left behind on floors, bedrails, tables, and other surfaces, by patients already discharged. These findings demonstrate 1) how essential it is to know which patients entering the ICU are carrying the bacteria and 2) the importance of housekeeping.
We have the knowledge to prevent infection. What has been lacking is the will. In 2003, a committee of the Society for Healthcare Epidemiologists of America codified the precautions that have worked well in Denmark, Holland, and Finland and in the hospitals here in the U.S. that have tried them. These SHEA guidelines work. One study shows that MRSA bacteria spread from patient to patient 15 times as fast under current Centers for Disease Control and Prevention (CDC) standard guidelines as under the more rigorous precautions advocated by SHEA. What a shame that most hospitals are not implementing these lifesaving precautions.