Hospital acquired infections are the fourth largest killer in Canada. Each year, 220,000-250,000 hospital acquired infections result in 8,000-12,000 deaths. Thirty to fifty per cent of these hospital-acquired infections are preventable.[1]
The danger is worsening, as many hospital infections can no longer be cured with common antibiotics.
Key hospital-acquired infections are:
MRSA: Short for methicillin-resistant Staphylococcus aureus. It lives harmlessly on the skin but causes havoc when it enters the body. Patients who survive MRSA, often spend months in the hospital and endure several operations to cut out infected tissue. The Canadian Nosocomial Infection Surveillance Program reports consistently rising MRSA rates at hospitals. Since its first report in 1995, MRSA rates have increased ten-fold. In 1974, 2 percent of US staph infections were from MRSA. By 1995, that number had soared to 22 percent. Today, experts estimate that more than 60 percent of staph infections are MRSA. MRSA can be found on everything from hospital cabinets to bedside tables. MRSA can live on surfaces for weeks. Once patients and caregivers touch these surfaces, their hands can spread the disease. Ordinary cleaning solutions can kill these bugs, but surfaces need to be drenched in disinfectant for several minutes, not just sprayed and wiped quickly.[2]
C. Difficile: C. Difficile is a bacterium spread by touching a surface or skin that is contaminated with fecal matter. A new strain, twenty times more virulent, has been going through
Today’s growing C. Difficile epidemic is characterized by the emergence of a highly virulent and resistant strain, increases in incidence and severity of infection, increases in failed responses to existing therapies, and a growing number of recurrences following treatment.
VRE: Of perhaps even more concern is vancomycin (or glycopeptide) -resistant enterococci (VRE or GRE). For the first time since the introduction of antibiotics, here is a strain of clinically important bacteria that is resistant to all available antimicrobials.
A variety of responses are needed to deal with these “Superbugs”. But clean hospitals are the backbone of infection control and hospital support workers keep our hospitals clean. Hospital support services have been cut back ruthlessly over the last 30 years. Further cuts should not be on the agenda – but unfortunately, they are.
Hospital Support Work Today: Approximately 50,000 support workers are employed in
Spending on hospital support services has fallen. The Canadian Institute for Health Information reported in 2002 that hospitals had actually cut the dollars spent on support services in the recent past: Housekeeping spending had been cut (on average) 1.8% per year; Material management cut 2.2% per year; Patient food services cut 3.1% per year; Plant administration and operation cut 1.1% per year.[4] Indeed, a 2005 CIHI study indicates that since the mid-1970s, hospital spending on support services has been squeezed– dropping from 26% to 16% of hospital spending.[5]
Hospital Support Services Under Attack: The Ontario Liberal government has made further cuts in spending on hospital administrative and support services a goal. But cleaning hospitals is labour intensive. Staff costs account for 93 per cent of the cost of cleaning. As a result, “efficiencies” are largely at the expense of staff. Health Minister George Smitherman has virtually suggested wage cuts for hospital support workers: “Just because it is a public health-care system doesn’t mean …. that we should expect to pay more to sweep the floor in a hospital.”[6]
So what has been the experience of jurisdictions that have attacked support services through cuts or privatization?
Britain
Britain experimented with compulsory contracting of hospital housekeeping services. The result? In the last 15 years, the number of hospital cleaning staff has dropped from nearly 100,000 to 55,000. The outbreak of infectious diseases in British hospitals and the filthy condition of British hospitals has become a major public policy issue.
Twenty out of 23 of the hospitals that had poor standards of cleanliness used contract cleaners. A National Audit Office report found that ‘Cleaning and portering service unit costs were higher at PFI (i.e. privatized) hospitals and were perceived as providing a lower quality of service.’
In 2002, the British National Health Service (NHS) began publishing the names of hospitals with high infection rates in newspapers and in July 2004, the NHS announced that every hospital will have to publicly display its infection rate.[7]Quebec
The Montreal Gazette has editorialized on the province’s C. Difficile outbreak:
A number of factors are believed to be contributing to this outbreak. An easily corrected one is the lack of proper hygienic cleaning in Quebec hospitals. Budget cutbacks that date from the mid-1990s have resulted in hospitals where patients’ toilets and sinks are too rarely disinfected or even cleaned…..In some Montreal hospitals, housekeeping staff is stretched so thinly that a cleaner is given exactly 36 seconds to clean a toilet. This is completely unacceptable.[8]
Dr. Mark Miller, head of infection control at Montreal’s Jewish General Hospital and a specialist in hospital-acquired infections told the Gazette that the hospitals just aren’t clean enough: “It’s the general sanitation in the hospitals that is under the microscopic eye right now…You’ve got fewer housekeepers. You’ve got less cleaning of patient rooms and less intensive (cleaning)”.[9]
Other researchers investigating the Quebec C. Difficile outbreak concluded:
The aging infrastructure of hospitals and our willingness to tolerate hospital rooms with 4 patients and a single bathroom, less than 3 feet between beds and progressively fewer resources assigned to housekeeping all facilitate the spread of this disease, as does our inability to achieve acceptable levels of hand hygiene among hospital staff. .…This strain, or others similar to it, will almost certainly be introduced into hospitals across the rest of
After a subsequent C. Difficile outbreak, a St. Hyacinthe hospital hired 10 additional housekeepers in December 2006 and began disinfecting rooms twice rather than once. But this was months after the start of the hospital’s outbreak. As the lawyer representing victims’ relatives noted, “Unfortunately, many health care facilities cut maintenance staff in health care facilities for budgetary reasons without realizing that such cuts have a major impact on the health of patients”.
The hospital’s microbiologist later testified that the hospital failed to meet its own sterilization and disinfection standards. A strict plan to increase disinfection procedures was never enacted because of staff shortages. Rooms were not disinfected often enough and toilets in the emergency room were cleaned just once a day.
Sixteen people died.
The head of housekeeping and maintenance services testified that, “No one mentioned that it was so serious. I never knew the problem was so bad.”
The Quebec coroner fingered poor hospital hygiene in the the deaths of these patients at Honoré-Mercier Hospital. Coroner, Catherine Rudel-Tessier, concluded the principal problem was management’s need to save money - and its decision to skimp on appropriate prevention measures.
The coroner’s inquest heard repeated accounts of poor hygiene at the hospital in Saint-Hyacinthe including bed railings and stethoscopes that weren’t properly disinfected before repeated use. Angry family members told the inquest they encountered stomach-churning conditions when they brought ailing loved ones to the hospital, including balls of dust, dried blood and pools of urine in the emergency room.
“Things have to change.” Ms. Rudel-Tessier said. ”We must put more resources into the prevention and control of these infections. One death is too many.”
The (new) interim director of the hospital insisted Honoré-Mercier has changed its ways : it now produces a daily report on infection rates, has hired new permanent cleaning staff, and has allocated more funds for disinfection procedures.
Manitoba: Dr. Michelle Alfa, an infectious disease expert, sampled more than 1,000 toilets in two Winnipeg hospitals and found that 47 per cent of toilets used by patients with C. Difficile in Winnipeg hospitals had toxic bacteria spores on them. One in 10 toilets had C. Difficile bacteria on them even if the patient using the washroom wasn’t infected with it.
“The reality is it may look clean but there may be a lot of spores there.” The researcher, Dr Michelle Alfa, added: “I think it’s time for us to look at the staffing and the compliance with housekeeping…We need to make sure we have adequate guidelines, adequate timelines and adequate staffing to get the cleaning done properly.”
British Columbia: The B.C. Liberal government privatized thousands of health care support service jobs. Wages and working conditions were pulverized. Researchers interviewed workers in the new system and here is what we found.[11]
Poor training and high turnover: “The contractors don’t care how we use chemicals. They don’t know how to clean… I opened clean linen and it was full of hair. Six or seven sheets a day like that. Nobody listens to us. It’s frustrating.” With poor working conditions, many of the staff plan to leave as soon as they can.
Breaking the connection with staff and patients: Housekeeping staff are now often told to avoid talking with patients – to save time. As one experienced cleaner said: “We feel awful because the residents know us. They call to us.” Similarly, hospital staff can’t deal directly with housekeeping staff if a problem arises. Instead they have to call headquarters, breaking the link between housekeeping and infection control staff.
Supplies: Staff are sometimes told to use only one pair of disposable gloves per shift. The gloves are flimsy and break after extended use, exposing the workers to hazardous bodily fluids and wastes. Moreover, using the same gloves all day could spread pathogens throughout the facility. /h1>Cleanliness: Many cleaners are concerned that inadequate staffing levels are exposing patients and workers to serious risks. “[The company] can do better but they don’t,” said a lead-hand housekeeper. A survey of a Vancouver hospital Emergency Room staff, found that 86% felt that overall cleanliness had declined since housekeeping services were privatized. As one B.C. Registered Nurse stated: “Ask any nurse and they will tell you how filthy the hospital is.”
The Supreme Court ruled that the law the B.C. government passed to break the collective agreement, fire hospital support staff, and privatize their jobs was unconstitutional. Despite this, the BC government continues to privatize health care support jobs.
The United States:
Here’s the conclusions of Former New York State Lt. Governor Betsy McCaughey:
New data presented in April at the annual meeting of the Society for Healthcare Epidemiology of America documented the lack of hygiene in hospitals and its relationship to deadly infections. Boston University researchers who examined 49 operating rooms found that more than half of the objects that should have been disinfected were overlooked. A study of patient rooms in 20 hospitals in Connecticut, assachusetts, and Washington, D.C., found that more than half the surfaces that should have been cleaned for new patients were left dirty.
As long as hospitals are inadequately cleaned, doctors’ and nurses’ hands will be recontaminated seconds after they are washed—when they touch a keyboard, open a supply closet, pull open a privacy curtain, or contact other bacteria-laden surfaces. In a recent Johns Hopkins Hospital study, 26 percent of supply cabinets were contaminated with a dangerous bacterium, methicillin-resistant Staphylococcus aureus (MRSA) and 21 percent with another stubborn germ, vancomycin-resistant Enterococcus (VRE). Keyboards are such reservoirs of deadly bacteria that a few hospitals are installing washable keyboards, including one that sounds an alarm if it isn’t disinfected periodically.
Hand to mouth. Stethoscopes, blood pressure cuffs, and EKG wires are used on successive patients without being cleaned. Studies published as long ago as 1978 warn that blood pressure cuffs frequently carry live bacteria, including MRSA, and are a source of infection. In a newly released British report, one third of blood pressure cuffs were found to be contaminated with Clostridium difficile, a germ that can cause lethal diarrhea if it enters via the mouth. It’s a short trip from a cuff to a patient’s bare arm, then to the fingertips and into the mouth.
The good news is that a simple solution—thorough cleaning with ordinary detergents and water—curbs the spread of deadly bacteria….
Even the cash-strapped British National Health Service recognizes that intensive cleaning is a bargain compared with the cost of treating infections. By nearly doubling cleaning-staff hours on one ward, a hospital in Dorchester reduced the spread of MRSA by 90 percent, saving 312 times the added cleaning costs.
Hospitals once tested surfaces for bacteria, but in 1970, the CDC and the American Hospital Association advised them to stop, saying testing was unnecessary and not cost effective. MRSA infections since then have increased 32-fold, and numerous studies have linked unclean hospital equipment and rooms to infections. …
Testing is essential because bacteria are invisible. A study in the Journal of Hospital Infection showed that 76 percent of various hospital sites checked by researchers had unacceptably high levels of bacteria, although only 18 percent of them looked dirty. In another study, Boston University researchers found that cleaning improved significantly once they sampled surfaces for bacteria and showed cleaning personnel the areas they had missed.
In 2005, health officials in Ireland and Scotland began rating hospitals annually for cleanliness—red (the dirtiest), amber, or green—and publishing the ratings. The first-year results made headlines, putting pressure on the worst Irish hospitals to clean up and earn higher marks in 2006.
In England last month, Gregory Barker, a Member of Parliament, rolled up his sleeves and worked a shift with the cleaning staff at a hospital in his district. “Hospital cleaning is a vital part of patient care,” he said in a statement released by his office. Where are his counterparts in Washington, D.C.?[12]
Ontario: In the Sault Ste. Marie Hospital, an outbreak of C. Diffcile appeared in 2006 killing 10 patients directly and another 8 indirectly. The hospital, which had privatized housekeeping services, was forced to increase housekeeping staff by 40% and institute a range of other measures. The hospital fell into deficit. Outbreaks are now regularly reported around the province.
A key Ministry of Health and LTC advisor on this issue, Dr. Michael Baker, advocated public reporting of C. Difficile, MRSA, and VRE in early 2008. Reportedly, the Ontario Hospital Association and the Ontario Medical Association have been meeting with the Ministry to implement a reporting system for HAIs. This means looking at how infections will be measured, how the data will be collected, and to whom hospitals will report. A ministry official stated in April 2008 that “We are reviewing (Dr. Baker’s) recommendations and we’ll be making a decision. If we do go forward, it will be by the end of the calendar year (2008).”
Quality Can Save Patients and Money: Hospital-acquired infections cost a lot of money to treat. Betsy McCaughey argued in a 6 June 2005 editorial in the New York Times that when hospitals invest in proven precautions “they are rewarded with as much as tenfold financial return. These infections add about $30 billion annually to the nation’s health costs. This tab will increase rapidly as more infections become drug-resistant.”[13]
Canadian researchers estimate that the total attributable cost to treat MRSA infections is $14,360 per patient.[14] Peter G. Davey, Professor from the Health Informatics Centre at the University of Dundee reports that patients in the intensive care unit (ICU) who contracted C. Difficile stayed in ICU for 6.1 days as compared to 3 days for patients with no C. Difficile. ICU costs increased to $11,353 versus $6,028 for patients with no C. Difficile.[15] The Sault hospital in Ontario was forced into deficit due to its C. Difficile outbreak.
Moving Forward: An important part of the solution lies in the meticulous cleaning of equipment and hospital rooms. As researcher Kris Owens – who recently demonstrated that MRSA can live on surfaces for weeks – told the media: “The results of this study clearly demonstrate the need for frequent hand washing and environmental disinfection in health care settings”.[16]
Hiring more cleaning staff after an outbreak is becoming a typical response. A better response would be to ensure – before the outbreak—high quality cleaning by adequate numbers of hospital staff who are part of a single, integrated health care team operating under the coordinated direction of the public hospital. Contracting out only breaks up the health care team.
Another part of the solution lies in public reporting of hospital infections. In Ontario, patients and their families may be the last to know. This may change. But without public numbers it is difficult to know what works best. Most importantly, public reporting will bring public pressure. And that will bring the care that hospital acquired infections deserve.[17]
[1] Zoutman et al, “The state of infection surveillance and control at Canadian acute care hospitals,” American Journal of Infection Control, 2003:31, 266-275. For comments from Zoutman regarding this study see also Medical Post, “Hospitals inadequate at infection control,” August 26, 2003, Page: 5. The Toronto Star, “Hospital infections blamed for deaths; Up to 12,000 die each year; Study National survey a ‘wake-up call’,” Wednesday, August 6, 2003, Page: A1.
[2] The New York Times, “Coming Clean,”Mon 06 Jun 2005,Page: 19,Section: Editorial Byline: Betsy McCaughey
[3] Laura Eggertson, “Hospital-Acquired Infection C. difficile: by the numbers,” Canadian Medical Association Journal, July 6, 2004; 171 (1). Laura Eggertson, “C. difficile strain 20 times more virulent,” Canadian Medical Association Journal, May 2005; 172: 1279; 10.1503/cmaj.050470.
[4] Canadian Institute for Health Information, National Health Expenditure Trends, 1975-2002, 2002.
[5] Canadian Institute for Health Information, Hospital Trends in Canada, 2005.
[6], “Hospital wages too high, minister warns; Latest salvo in battle over costs. CUPE braces for confrontation. Row brews over hospital wages,” The Toronto Star Thu 21 Oct 2004, p. A1.
[7] Committee to Reduce Infection Deaths web site, Hospital Infection Fact Sheet.
[8] Editorial, “How to better control C. difficile outbreak,” Montreal Gazette Saturday, October 23, 2004
[9] Debbie Parkes and Linda Slobodian, “Dirty hospitals lead to rise in deadly infections, says doctor,” Sat 5 Jun 2004, Montreal Gazette.
[10] L. Valiquette et al., “Clostridium difficile infection in hospitals: a brewing storm,” Canadian Medical Association Journal, July 6, 2004; 171 (1).
[11] Jane Stinson, Nancy Pollack, and Marcy Cohen, The Pains of Privatization, How Contracting Out Hurts Health Support Workers, Their Families, and Health Care, Canadian Centre for Policy Alternatives, 2005.
[12] Betsy McCaughey, “Why aren’t hospitals cleaner?” US News and World Report July 15, 2007
[13] The New York Times, “Coming Clean,” Mon 06 Jun 2005,Page: 19,Section: Editorial Byline: Betsy McCaughey
[14] Tony Kim, MA; Paul I. Oh, MD; Andrew E. Simor, MD, “The Economic Impact of Methicillin-Resistant Staphylococcus aureus in Canadian Hospitals,” Infect Control Hosp Epidemiol 2001; 22:99-104.
[15] Medical News Today April 2, 2007
[16] “’Super’ bacteria live on sheets, fingernails-study,” Reuters, Mon Jun 6, 2005 02:18 PM ET
[17] With rising public awareness, the Canadian Council on Health Services Accreditation will now require in January 2008 virtually all acute-care hospitals to provide the rates of MRSA and C. difficile. But this falls well short of mandatory public reporting.