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Nosocomial Infections, Part 1

Nosocomial Infections, Part 1
©2010 Eric Rose 

In 2009, a manufacturer of baby furniture recalled 2.1 million cribs because 100 babies were injured and four babies died. These four deaths, though tragic, are small compared to the numbers of babies that die unnecessarily each year from nosocomial infections. 

Nosocomial infections occur in all types of healthcare settings and are caused by infection form germs apart from the original reason for treatment. Realistic estimates say that nosocomial infections kill about 100,000 patients of all ages per year in the United States. Some NICU and PICU (children’s ICU) wards can have nosocomial infections rates in the 20+% margin. 

This death rate from nosocomial infections equals a 9/11 every eleven days.  

An estimated two million cases of nosocomial infections occur each year in the US. Each case extends the patient’s stay by an average of five days. That’s ten million patient days per year. To crunch the numbers even further, the American Hospital Association (AHA) states there are about 5,800 registered hospitals in the US, with about 951,000 beds. On average, for each 100 beds that a hospital has:

  • it will see 210 cases of nosocomial infections a year.
  • This will create 1,050 additional patient days per year,
  • which will fill 2.89 patient beds year around
  • and will see 10.5 patients die each year. Some will be infants.

 An Early History of Nosocomial Infections

 Renaissance Europe had birthing centers, places where women went to deliver their babies under the guidance of people with medical training. Even as late as the 1840s, the birthing mortality rate (then called childbed fever) sometimes reached 40%. This was because some birthing centers were attached to medical schools, as many are today. Medical universities perform autopsies of cadavers as a part of medical training. The doctors and medical students would interrupt the dissecting of cadavers to deliver babies. While they might wash their hands between dissections and deliveries, they often didn’t change clothes, and disinfectants were unknown at the time. Tiny particles of decaying flesh and germs from the cadavers were taken to the delivery room with terrible results. Birthing centers that operated without research cadavers had lower mortality rates. Men like Semmelweis, Pasteur, and Lister did research in the 1800’s that linked poor medical hygiene to patient mortality rates. 

Let’s pause a moment for introductions. I worked for a time in a hospital in the Midwest as a contract manger for the Environmental Services Department (ES). The ES department is responsible for cleaning and disinfecting the hospital and making the rooms safe for patients. During my time there, I became aware of nosocomial infections, began to study them, and learned many things that helped me understand why imported germs have the opportunity to infect and kill patients. This article is the result of my observations, study, and questions. 

Note: I will generically use the term germ to refer to any organism that can cause a nosocomial infection. My goal is to offer a perspective of nosocomial infections though the eyes of an Environmental Services Manager. I want to share things I’ve seen and studied concerning nosocomial infections; with the consuming public, healthcare leaders, healthcare funders, and policy-makers, to create more accountability between these four stakeholders in healthcare. All four parties have responsibilities, which properly fulfilled, will greatly reduce the spread of nosocomial infections in healthcare facilities. Every time we drop the rate of infection just 1%, we will save 1,000 lives, eliminate 20,000 nosocomial illnesses, and save $45 million in medical costs every year. 

Let’s approach the basic information with a Question and Answer format. 

Again, what is a nosocomial infection?
It is the infection of a patient’s body by germs that weren’t the original reason for medical treatment.

Do these germs attack any special groups of people?
These germs touch many people, but healthy people usually have the immune systems to resist them. These germs infect patients with weak immune systems; usually children under two years of age and seniors over 70 years old. Also, these germs invade patients with open pathways into their bodies, such as burns, wounds and surgical openings; or through the use of catheters, IVs and respiratory devices.

Are all nosocomial infections the fault of the hospital?
No reasonable person that understands how germs originate and travel would claim that all nosocomial infections are the hospitals’ fault. Hospitals are clean when they are brand new. Patients bring in the germs. I don’t believe in strict liability in all cases of nosocomial infections, because the visiting public and even the patients themselves often spread nosocomial infections in healthcare facilities through their ignorance or indifference. With that said, there are many things that hospitals can do to reduce nosocomial infections.

How do these germs get from one patient to another?
This transmission of germs is called the cycle of infection. The germs begin with the original host. To get to the next patient, they must have an escape route from the host, and an effective means of travel. This can be through the propulsion of a sneeze (which can stay airborne for three hours), the touch of a hand, or contact with an inanimate object. The next patient then receives the germs, and the opportunity for a nosocomial infection is born. (Realize that many germs can live on inanimate objects for months and use them as intermediary hosts). From there, the germs transfer to other humans. Bed rails, stairway handrails, water fountains, medicine carts, vending machines, stethoscopes, patient charts, and wheelchairs can all be intermediary hosts for germs that become deadly when they invade other, already weakened patients.

How can I learn more about nosocomial infections (n.i.)?
That’s a tough question. I searched the internet, as a layperson would, for information on nosocomial infections. I was looking for a chart that listed: 

  • The top infections, listing any n.i. that kills people,
  • what percent of n.i. cases each germ is responsible for,
  • what percent of n.i. deaths each germ is responsible for
  • how the germs are transferred,
  • how the germs damage people,
  • what type of objects each n.i. can live on,
  • the lifespan of each n.i. on room-temperature inanimate objects,
  • what type of patient is most likely to contract each type of germ,
  • how each of these germs are disinfected. 

I couldn’t find a remotely complete, accurate list. There is little lay-oriented material available.  

The two most lay-friendly sites I found for nosocomial infections were Web M.D. and CRID. (Committee to Rid Infection Deaths). Other websites, such as the Center for Disease Control have an abundance of articles and reports on nosocomial infections, but are written for professionals, not laypersons. I wish the CDC website had a section for lay people written  in common language. 

One of the best pieces I found is from Ohio State University; lecture notes by Stephen T. Abedon (http://www.mansfield.ohio.edu/~sabedon/bio12053.htm). Although over a decade old, it still gives a good outline. Bravo!

Update, March 2011: http://www.engenderhealth.org/ip/index.html  is a website that offers a tutorial for infection control. It's very interesting. 

Behaviors and practices in hospitals that can spread or reduce infections.

While I will highlight certain practices, only the microscope will tell if they are harmful. The germ count is what matters, not personal opinions. With that disclaimer, here is a list of practices that interest me. We’ll first discuss non-ES issues, and then in Part 2, target procedures in the ES department that can contribute to nosocomial infections. Remember; for every 1% we drop the infection rate, we will save 1,000 lives. Some of these observations include remedial suggestions; others are just observations of possible problems, left for others to solve. 

  1. Housekeepers do their work with cloths that snag germs in their weave as they are pulled across dirty surfaces. This same type of weaving is used to make lanyards on employee badges, doctors’ neckties, and nurses’ stethoscope covers. If any of these materials contact a patient with germs, they can retain those germs, and then release them on the next patient.
  2. During times of patient overload, it is common to transfer nurses from one ward to another to meet nurse/patient ratio requirements. What if a nurse from a ward with many infections is transferred to a ward with practically no infections, such as the orthopedic ward, where people go for corrective surgery? My neighbor's son-in-law went in to have a knee replaced and died of a nosocomial infection. Do shift managers take this into account when arranging temporary transfers?
  3. Sex education informs us about condoms and disease control. First, it is stressed that condoms might reduce, but cannot completely eliminate the possibility of pregnancy or transmission of STDs. Likewise, rubber gloves cannot entirely protect the caregiver or the next patient from germs. Many caregivers with diamond rings pull rubber gloves over their rings. I wonder how often the prongs on the jewelry penetrate the gloves, not enough to split the glove open, but enough to allow transmission of germs. I also wonder just how colonized the average ring set is. Infected is the term used to describe the people that have germs inside them to the point of sickness. Colonized describes the infestation of a person or an object with germs, but without sickness.
  4. Speaking of latex protection, patients are advised to ask healthcare workers to clean the diaphragm of the stethoscope with alcohol before use. However, alcohol does not kill C. difficile germs. Latex covers for the diaphragms would protect ‘clean’ patients from C. difficile.
  5. Patients and their families often unreservedly trust healthcare workers to always know and always do what is best for the patient. This doesn’t always happen. Healthcare workers may take shortcuts to save time and money. While in the ES department, I suggested that each room have an ‘Expectation Card’ that would precisely list all the behaviors and procedures that each patient could expect during his or her hospital stay. A phone number would be on the card for instant feedback if these procedures are not followed. Patients and their families must be proactive in holding healthcare workers from all departments accountable for their activities Patients heal faster when proactive in their own medical care.
  6. Patients and their families should also have expectations placed on them as partners in healthcare. Visitors can bring in germs from contact with children and their friends that are deadly to patients. An infection may be considered nosocomial when the germs actually came from a school playground via the patient's grandchild. Perhaps one channel of the hospital TV system could show videos that teach patients and families how to protect patients and to help them heal faster.
  7. Isolation rooms holds patients with certain communicable diseases. The rooms are labeled with precautions necessary to protect visitors and healthcare workers. Nosocomial infections can occur when healthcare workers carry germs from an isolation room into a non-isolation room (Note: there are few dedicated isolation rooms, so ordinary patient rooms are deemed isolation rooms as needed). Isolation patients are placed into rooms according to room availability. Yet, when nurses, med-aids, food service workers, and housekeepers do their rounds, they do so in numerical sequence. Logic dictates there would be fewer nosocomial infections if these workers served the isolation rooms last on their rounds, then step into ‘spritzing booth’ that would help disinfect their uniforms before they started their rounds again.
  8. I once saw a Medication Aid pushing her med cart down the hall dispensing meds to the patients in the ward. She had an isolation gown thrown over the top of the med cart. The isolation gown is what workers put on, along with masks and gloves, to protect themselves and other patients from contracting infections. A gown is to be disposed of in the room in which it was worn. Because the isolation gown was on top of the med cart, I had to assume that she kept one gown for her entire rounds, and put it on for every isolation room she entered. I informed the Infection Control Director of this situation and never saw that behavior again.    Gloves, gowns, and masks are called PPEs (Personal Protective Equipment). They are designed to protect workers from unsafe elements in the workplace. These items are to healthcare workers what hard hats and steel-toed boots are to construction workers. However, in the hospital, PPEs don’t just protect the healthcare workers, they also protect other patients. I wonder if PPEs should instead be called ICEs (Infection Control Equipment). This would help workers remember they wear them as much for the next patient as for themselves. The term 'ICE' would also lend itself to clever ad campaigns aimed at healthcare workers.
  9. Every ward has a bio-waste room, a place where mop buckets are filled, trash is taken to, and where bio-waste is stored for pick up. Bio-waste is all disposable medical supplies used with patient body fluids. In some wards, the food racks are kept there, and the nurses put the empty trays in after the patient has eaten. This seems like a bad place to keep any reusable food service items, especially if the nurse doesn't wash after leaving the bio-waste room.
  10. While some medications are designed to kill bad germs, they may also kill good microbes in our bodies. The good microbes in our bodies help control the bad germs. No good microbes, less protection. This is one cause of C. difficile. We all have C. difficile germs in our bodies, but other microbes keep them under control. One product, lactobacillus planatarum 299v, is a beneficial microbe given to patients to restore their microbe balance, which helps restore the immune system.
  11. MRSA is an infection. Like most other life forms, it prospers according to the abundance of its food supply. MRSA lives on dead flesh. When someone is sick or wounded, parts of their flesh dies. MRSA lives on this dead flesh. Hospitals in Great Britain are experimenting with laboratory maggots to combat MRSA by removing its food supply. The maggots are secured to the wound area to eat the dead flesh, so the MRSA count decreases.
  12. Patients are less likely to contract nosocomial pneumonia when their beds are kept at a 30°-45°angle. Acid reflux and vomit contains gastric acid that destroys natural germ-killing systems in the upper respiratory tract. Patients’ families can help by not importing foods that promote acid reflux and by not letting patients lower their beds for comfort.
  13. Urinary catheter tubes are a major source of infection. Catheters treated with silver alloys deter infections. Drains placed to prevent pooling discourage the travel of germs.
  14. Weak patients who are barely able to use the toilet may not wash properly afterwards. IV entry points can conduct germs into the body when fiddled with by these patients.
  15. Pre-operative shaving can contribute to infections. Since areas larger than the actual incisions are shaved, and antiseptic treatments are limited to the immediate cut area, perimeter cuts or abrasions would be a pathway for infections. I wonder if with planned surgeries, shaving could be done a week before the surgery at home or by a qualified barber, or the patient could even get the area waxed? This would give any cuts or abrasions time to heal before the surgery. This would apply to procedures where body hair could be 1/8th of an inch long for surgery. Perhaps a new line of business could grow out of this need for safe hair removal.
  16. Some patients bring germs with them on their skin, and then infect themselves during surgery. They can eliminate these germs by scrubbing with chlorhexidine soap for a week before their scheduled surgery. (CRID recommendation)
  17. Nosocomial germs can colonize the skin of healthcare workers without actually infecting them. Perhaps intermittent bathing with chlorhexidine soap would be helpful for healthcare workers too.  
  18. As of October, 2008, Medicare and Medicaid will not pay for expenses incurred for nosocomial infections, among other medical mistakes. I heard that some doctors, upon seeing symptoms of a nosocomial infection, will give that patient an accelerated dismissal. The doctor knows the patient will be readmitted shortly, but the nosocomial infection will then be chargeable because it will be diagnosed as an existing condition on the re-admit.
  19. Nursing shortages contribute to nosocomial infections. There is a shortage of nurses in the US. Labor shortages impose more work on fewer people. Nurses have to cover their own shifts and are then asked to stay late to help with the next shift, or come in on their days off. Remember that hospitals run 24/7/365. Tired, overworked mortals sometimes take shortcuts or simply forget things. That’s a part of being human. In the hospital, this can mean compromised safety practices. Is there a way to ease the current nursing shortage? First, we should ask, ‘What is the source of the problem?’ In part, the nursing shortage is due to a shortage of nursing college teachers. In 2005, 32,617 qualified students were turned away from nursing schools in the US, due to lack of teachers. I mention 2005 because these students would now be in the job market, and could have eliminated the nursing shortage in several states. Nursing college teachers make as little as half the wages they could as healthcare workers. This is especially true of community colleges where tuitions, teacher salaries, and student family incomes are all lower than average. Colleges with nursing programs could turn out more nurses if they had more teachers.                                                                                                                                                                             What if large hospitals gave teaching sabbaticals to qualified nursing staff?  A nursing director could teach for a year at a local nursing college. The hospital would continue to pay wages and benefits to the sabbatical nurse/teacher. In return, the college would forfeit to the hospital, the school’s costs of keeping a teacher. The sabbatical nurse/teacher would be able to wear her brand and recruit for her hospital from the nursing students. The opportunity to teach for a year might create opportunities for more innovations in healthcare. Selected nurses in the sponsoring hospital could cover for the sabbatical nurse/teacher and gain valuable management experience.
  20. Perhaps the most confounding statistic concerning nosocomial infections is that survey after survey states that only about 50% of doctors wash their hands between patients. Let’s not bother asking why. Instead, let’s look at the dynamics between hospitals and doctors that make this possible. Some people think that doctors work for hospitals and hospitals can control their behavior. Most doctors have independent practices and utilize hospitals as ‘healthcare hotels.’ Doctors use hospitals in their patient’s healthcare plan when doctor office visits or family cannot properly care for the patient. Doctors contract with hospitals to provide rooms, food service, nursing and diagnostic services to patients. This is like a business hiring a hotel to host a convention with rooms, foodservice, meeting rooms, etc. While hospitals can theoretically establish guidelines for patient care within the bounds of the hospital, there is more than one hospital in large cities. Hospitals need doctors to keep their rooms filled. It seems unrealistic to hope that hospitals will police doctors that are unwilling to police themselves. Additionally, many doctors work together in practices. This means that if a hospital bans one doctor for unsafe work habits, it is likely to lose an entire group of doctors. A solution?  The Joint Commission has an email address that patients and families can use when receiving non-compliant healthcare. (complaint@jointcommision.org). However, the Joint Commission is not government agency. It is a certification organization that hospitals subscribe to for triennial inspections to be eligible to collect Medicare and Medicaid funds. Keep this in mind when appraising the ability of the Joint Commission to effect changes in physician behavior. Patients should understand that a doctor refusing to wash hands between patients is grounds for changing doctors. Hospitals need to offer assistance to patients who need to change doctors in the middle of a hospital stay. Only then will proper accountability be in place to protect the patient. 
  21. Hospitals generally use two viscosities of hand soap; a foam, and a slick liquid. While both are anti-bacterial, the liquid soap clings to the hands and take more scrubbing to get off the hands. Since some germs can only be scrubbed off the hands, not sanitized, why not put only liquid antibacterial soaps where hand scrubbing is most important?

Please proceed to Part 2... 

Infection Control Today is an organization that offers HAI control from many perspective.  They have digital magazine. I have an article in their April 2011 edition.

digital.infectioncontroltoday.com/ I have an article in the April 2011 edition.

See what a  private Canadian organization  is doing about nosocomial infections control at  www.advin.org/en/contact/info/advin.org.html