The images above are from a piece in the New England Journal of Medicine.
The top one is the handprint of a health-care worker after examining a patient's stomach. The pink colonies are methicillin-resistant Staphylococcus aureus (MRSA), a virulent type of bacteria that doesn't respond to standard antibiotics. The bottom image is the worker's hand after washing.
MRSA bacteria can enter the body through a surgical wound, IV, catheter or breathing tube. MRSA infections in the bloodstream, heart, lungs and urine can be deadly. Those pretty-pink handprints can kill.
One in 10 hospital patients will develop a common or antibiotic-resistant infection after being admitted. In a small Canadian study of hospitalized children, 9 per cent developed an infection while in hospital.
When an IV, catheter or breathing tube isn't inserted and cared for properly, bacteria that normally resides on the skin without problems can gain entry and cause infection. You may also pick up a superbug like MRSA or C. difficile from the environment -- by touching a dirty bed rail, light switch or a person who hasn't washed their hands.
Health-care associated infections (HAI), as they're now called, are the fourth leading cause of death in Canada. Between 9,000 and 12,000 Canadians die each year as a result, says Dr. Michael Gardam, medical director of infection prevention and control at Toronto's University Health Network. I spoke to Dr. Gardam to learn more.
BLOOM: How many infections acquired in hospital are preventable?
Dr. Michael Gardam: Ten years ago we would have said at least a third of them, but now we would say the vast majority. We used to consider many of these infections as the cost of doing business but now realize they can be dramatically reduced.
BLOOM: Is lack of handwashing among professionals the main cause?
Dr. Michael Gardam: Handwashing has certainly gotten a lot of attention. The World Health Organization and others say poor hand hygiene is responsible for at least 50 per cent of these infections. But you can also catch an infection from the environment. For example, a health-care worker's hands may be pristine but a person could pick up C. difficile from the bed rails. Or a patient can develop C. difficile in a room where a previous patient had it, if the room isn't cleaned properly.
A lot of hospital infections happen because we're doing something to you -- inserting a catheter or IV. Did the worker properly wash your skin? Are they checking the IV site daily to see if it's red or sore, and are they discontinuing the IV if you don't need it? If the IV isn't cared for properly you can develop an infection from your own skin flora. That can cause a skin infection or get into your blood and cause life-threatening sepsis.
Surgery is an area that's well-studied on how to prevent infections. There are multiple things you can do to decrease the infection rate, but the system is still fairly slow to adopt all of them.
There are times when we can do everything perfectly and the person still might get an infection. But many times we are not doing things perfectly. With most patients who get an infection, we can identify things that weren't done properly.
BLOOM: How big a problem are these infections for preemies or for children with disabilities or chronic conditions who may be hospitalized frequently?
Dr. Michael Gardam: Infection is one of the main causes of death in preemies and there are multiple reports of child deaths from infection acquired in the NICU. They've linked these infections to handwashing and to the environment as well. For example, nurses wearing artificial nails have been linked to deadly outbreaks: fungal infections can get under the nail and then be passed on to these remarkably susceptible children. Their skin isn't normal, they have multiple IVs and are often intubated and once they're colonized with organisms it's easy for those organisms to walk right in.
Children with disabilities would be at the same risk as other children who are having IVs or catheters or breathing tubes put in. What increases the risk are pre-existing conditions that affect the immune system -- like diabetes. Of course the more you're in the hospital, the more likely you are to catch something.
BLOOM: What kind of disabilities can be caused by serious infections?
Dr. Michael Gardam: Brain infections can lead to permanent brain damage and lung infections can cause chronic lung problems.
BLOOM: Would a family be informed that the infection their child had was preventable?
Dr. Michael Gardam: Usually not. Not because the staff are lying, but because they see these infections as a cost of doing business, and it's not just health-care workers, it's all of society. Let's say a loved one is in the ICU and the doctor comes out and tells the family "We gave him the wrong dose of this drug and he went into cardiac arrest and died." I'm sure the family would think of this as a mistake, an error, and might talk about suing. But if the same doctor comes out and says "Your loved one caught an infection in the ICU and we gave him antitbiotics but they weren't strong enough and he died," people accept that kind of news. Infections are still seen as things that happen.
BLOOM: But you've just said that most are preventable?
Dr. Michael Gardam: It's a brand new world for us. We're waking up and realizing that these things are preventable. Twelve years ago when I trained in infection, doctors were saying there was no way of ever preventing central-line infections, they were simply the cost of doing business. And now we know they can be prevented. We'll never get to zero but we can bring them down remarkably.
BLOOM: So why would a health-care worker not do everything possible to eliminate them?
Dr. Michael Gardam: Let's say I'm a surgeon and my infection rate is 2 per cent. If I do your surgery I can say there's a 98 per cent chance that you'll be fine. If I do all of these infection practices I may be able to say there's a 99 per cent chance you'll be fine. Some surgeons are looking at probability and stats rather than individuals. They're not thinking about the one patient who gets an infection for whom it's 100 per cent. The surgeon will be upset if one of his patients gets an infection, but he won't put two and two together. We're changing, but at a snail's pace.
BLOOM: What would you recommend parents of preemies or children with disabilities who are hospitalized do to try to prevent their child from getting an infection?
Dr. Michael Gardam: Well, when I was hospitalized in my own hospital a year ago, I washed my hands multiple times a day with alcohol gel, which is generally better than soap. I did this because many of the things you can contract in hospital you pick up because you're touching stuff. So as a parent, encourage your kid to clean their hands frequently and clean your own hands. I also used a container of disinfectant wipes to clean my room. I would wipe down my IV pole and the bed rails and the reason I did that is because no one else was doing it. Most hospitals have these wipes available. Clearly some people might take exception to a family cleaning up the room, but that's what I did.
You can let the health-care worker know that you understand most hospital infections can be prevented and you'd like to work with them to protect your child. The trick is to get the point across without directly challenging the health-care worker.
You can ask health-care workers to clean their hands, but the power differential there is absolutely unequal and to some extent you're at their mercy. When I'm rounding with residents, I tell them to always wash their hands in front of the patient, even if they've just washed their hands.
BLOOM: Do you get pushback on that?
Dr. Michael Gardam: Yes, I do. But I tell the residents that it doesn't matter whether you just did it, the patient cares about seeing it done and it's not about you. A woman was telling me about her son who was hospitalized for Crohn's disease and the IV team came in to start the IV and she knew they hadn't cleaned their hands. And she was struggling over how she could bring it up in a way that they wouldn't be offended and potentially not start her son's IV. What do you do? You don't want to be perceived as a difficult person. In the end you don't say anything because you're afraid.
BLOOM: I'm having a hard time wrapping my head around the idea that doctors and nurses know what to do to prevent these infections and they're not doing them.
Dr. Michael Gardam: There are major cultural impediments. If you ask health-care workers why they don't follow these known practices you'll hear "I don't have time" or "I'm too busy" or "I wasn't educated properly" or "Frankly, no one else is doing it that way." But it doesn't take long to do these things. There's a disconnect between their actions and what happens to their patients.
When a patient has been in hospital for days and gets an infection, you can't really pinpoint one person who's responsible. It's systemic. Multiple people occasionally don't follow all of the practices, which leads to multiple circumstances when a person could develop an infection. So while the health-care worker feels sad that a person got sick or may have even died, they don't know it was a result of their action.
BLOOM: What are other barriers to getting compliance with infection control?
Dr. Michael Gardam: A prevalent behaviour in doctors in general is that they have their one piece of the puzzle -- like surgery -- and others can deal with the rest. So as a doctor, I kind of understand how a surgeon would say: "I'm going to do the best operation possible," but not look at it holistically, in terms of feeling responsible for the entire care the patient receives in the hospital before and afterwards.
For example, if the room isn't cleaned properly the patient may become ill but a surgeon may not see that as part of the patient's care. There's a sense of "The operation went fine, our job is done." One thing we're doing now to close the loop at UHN is to treat all serious infections as adverse events, where an incident report is filled out and the people responsible have to report back on what things were not in place to prevent that infection.
BLOOM: Why doesn't a teaching hospital commit to a policy of zero tolerance for staff who don't follow all prevention practices?
Dr. Michael Gardam: Doctors wield enormous power and are typically not hospital employees. You might be able to do that to a hospital employee, but not a doctor who works "at" the hospital but not "for" the hospital. Let's says there's a surgeon at a teaching hospital who's a brilliant researcher and she's getting the hospital's name out there. Are you going to take away the hospital privileges of someone like that because she doesn't buy the corporate values about infection prevention? Not following these practices shouldn't be tolerated, but it's difficult for hospitals (to enforce). The tide is starting to turn, however, and more and more physicians are getting called on such behaviours.
BLOOM: I'm astounded that people wouldn't willingly follow these practices?
Dr. Michael Gardam: People get stuck in certain types of behaviours. They may do things that they know aren't good, but education may not motivate them to stop.
One doctor who's become a 'born-again' patient safety guy told me he resisted the whole central line practice bundle. "I refused to do it because I felt my patients weren't getting infected," he said. "Then they started sending out infection rates by the doctor's name and I was a negative outlier. Everyone else was doing it and I felt like an idiot." In this case no amount of book evidence had an effect because the surgeon needed real-life evidence in front of his face. He knew he should be putting in a line in a different way but it didn't seem relevant to him.
BLOOM: What can we do to change the culture?
Dr. Michael Gardam: We're not perfect, but in the last six years we've seen significant organizational change at UHN. The way we've done it is to engage frontline staff and have them own quality improvement initiatives. We don't lead these initiatives ourselves. Hand hygiene improved when infection control got out of the hand hygiene business.
We tell stories of patients and we ask staff to tell their own stories about patient infections. Sometimes we ask a group of staff to design a system to do the opposite of what we want it to do: How would you ensure that every child on this unit got a urinary tract infection and it would be severe? List all the ways that would happen. Are there any things on the list that you're currently doing? Is there something you'd like to see change? Usually there are a few people who want to make a change and they'll lead these changes.
BLOOM: I'm still astounded that you need to be a 'psychologist' to get these changes made when we know they can save lives.
Dr. Michael Gardam: Health-care workers are people and they have the same issues as everyone else. A lot of this is deeply-ingrained behaviour. To help us along, we need the public to say "We're not taking this anymore" and it's a tricky line to walk. If you push too hard health-care workers may shut you out and feel offended. By the same token, we need to hear the message.
It's not about the health-care provider, it's about you, the patient.
If you'd like to ask Dr. Gardam a question about infection prevention, post it here and we'll do a follow-up blog with answers.