Subduing infection in American hospitals has become even more difficult. As if methicillin-resistant Staphylococcus and necrotizing fasciitis weren't formidable enough, epidemiologists and infection control managers now have a new foe: public perception.

The climate shifted when the Chicago Tribune ran a lengthy three-part series July 21-23, "Unhealthy Hospitals," written by reporter Michael Berens, who looked into nosocomial infection.

The Tribune's independent analysis, which "adopted methods commonly used by epidemiologists," estimated that the annual death rate resulting from hospital-acquired infections at 103,000 in 2000. About 75 percent of these deaths were preventable, the report said, often by a procedure as simple as proper handwashing.

These alarming numbers were augmented by chilling anecdotes from health care workers in New Hampshire who infected patients by failing to wash their hands after petting dogs, to reports of buzzing flies in an operating room in Connecticut.

Some health care workers were thankful that the series brought this issue into the public eye; others rolled their eyes at some of its implications.

"I do believe [the series] has helped focus attention," said Judene Bartley, MS, MPH, CIC, vice president of Epidemiology Consulting Services of Beverly Hills, Mich. "But it could have done a better job in not being so depressing. There are a lot of programs in hospitals across the country to improve the situation."

Patti Grant, MS, RN, CIC, director of infection control at Memorial Medical Center and Trinity Medical Center in Dallas, said, "What bothered me is that it seemed to imply that hospitals just don't care about infections. And nothing could be further from the truth."

Challenges ahead

There also is some question as to which direction the battle is headed. The Tribune stated that nosocomial infections are steadily increasing, but the CDC studied rates of what it considers the four hot spots-infections of surgical sites, the bloodstream and the urinary tract, and ventilator-associated pneumonia-in intensive care units during the 1990s and found each to be in decline.

Still, no one in the health care field is downplaying the challenges. With an ever-aging population, premature infants rescued at increasingly miraculous weights, drug-resistant bacteria and budget cuts throughout the industry, the risk of nosocomial infection remains high.

Larry Krebsbach, ME, CIC, a registered environmental health specialist, is well aware of the hurdles. As manager of epidemiology at Bryan LGH Medical Center in Lincoln, Neb., he's constantly reminding hospital employees to wash their hands properly, whether it's through attention-grabbing posters or hand-hygiene surveys.

"It boils down to getting people to be responsible in patient care and in equipment handling," Krebsbach said. "At the orientation I do, I tell them they're the ones doing infection control, not us."

Hospitals have long coached nurses and other caregivers on when and how to wash their hands. Many facilities provide specific instructions for routine hand cleansing, antiseptic washing (for working with isolated patients or contaminated items) and the surgical hand scrub.

Sometime between October and December, the CDC is expected to issue new evidence-based guidelines on hand hygiene in a health care setting, according to Michele Pearson, MD, chief of the Prevention and Evaluation branch of CDC's Division of Healthcare Quality Promotion. The standards will include not only the traditional soap-and-water treatment, but also alcohol-based, sinkless hand-degerming agents.
Every good nurse is aware of proper handwashing technique, but the problem isn't knowledge, it's execution. With overtaxed nurses racing to make their rounds, many argue that it's simply impossible to wash thoroughly between each patient visit.

One study suggested that such a regimen would result in 2½ hours of handwashing each day. Besides the time commitment, this would lead to many cases of dry, cracked hands-themselves a health risk.

One viable solution seems to be the waterless disinfectant that more and more hospitals are offering. By placing dispensers outside of each room, nurses can apply and rub while on the move. This disinfectant dries as the skin absorbs it. "It's like anything else," Grant said. "You make the environment as conducive to compliance as possible."

Under suspicion

Another increasingly common strategy is the banning of artificial or excessively long fingernails. CDC has long cast a suspicious eye on adornments, which include acrylic extensions, silk wraps and gels. Long nails (that is, extending beyond the fingertip) make it difficult to clean the subungual area-the crook where skin and nail meet-thoroughly, and increase the chances of tearing gloves.

Caregivers who wear artificial or long, natural nails have been blamed for several deadly outbreaks, including the pseudomonas outbreak that killed 16 babies in Oklahoma City in 1997-98.

The University of Michigan Medical School Web site names 25 hospitals or hospital groups that prohibit artificial nails, and the list is growing. Kaiser Permanente's California facilities banned them in early July, and Krebsbach's hospital did the same in early August.

Personal expression is a fundamental right of nurses and other hospital employees and most hospitals understand this. But in the face of mounting evidence, it has become difficult to justify artificial nails.

"We did a lot of work educating, notifying the staff," said Inez Tenzer, MA, MS, RN, director of patient care services for Kaiser Permanente's 11 Southern California hospitals. "We created a toolkit for managers-how to talk to employees, how to remove the nails appropriately, how to care for the nails once [the extensions] were off."

Kaiser Permanente operates under a labor-management partnership. The no-nails edict, which applies only to "direct caregivers" (receptionists, clerks and most volunteers are excluded), was outside the partnership; it came directly from management. But Kaiser's unionized nurses raised no objections. Tenzer stresses that all hospital managers have complied, although some do not provide direct care.

Easy and cost-effective

Much more can be done to improve infection control, from more effective isolation of patients to research into Staphylococcus vaccines. Pearson insists that many solutions are easy and cost-effective. She cites application of the correct prophylaxis, in the correct dosage, to incisions within an hour of operation, and making sure ventilator-assisted patients are propped in a semi-recumbent position, which CDC believes can lead to a marked reduction in pneumonia.

Another example relates to catheterization. "It sounds obvious," Pearson said, "but get the catheter out. Often, it's left in for a just-in-case scenario. But the single most important predisposer to bloodstream infection is having an IV catheter in. Again, it's a cheap strategy."

Technology can play a major role, too. Antimicrobial central lines and catheters should make a significant difference. Some cardiac surgeons are finding that film dressing impregnated with ionic silver presents a barrier to infection at incision sites.

Another example is aloe-coated exam gloves, which may encourage users to wash their hands and change gloves more frequently.

Preventive strategies are only part of the solution. Hospitals also must do a better job of locating and tracking infections within their walls, never an easy accomplishment.

"Each infection control program has to be customized, based on epidemiology and population," Grant said. "You look at your historical data. You look at high volume or high risk. You can't do it all. If you tried to look at everything, you'd need more infection-control workers than nurses. And it's unnecessary."

While Grant and others hunt for germs on-site, some of the most important work is being done on a national scale. The CDC's National Nosocomial Infections Surveillance System has been around since 1970, and is more vital than ever.

The system's database, drawing from about 315 participating hospitals, describes the epidemiology of hospital-acquired infections and computes the rates of various pathogens, giving infection-control practitioners a better idea of what they should be looking for. The database will become more comprehensive and accessible, probably sometime in 2003, when the CDC's promotion department unveils its new Internet-based system, the National Healthcare Safety Network.

Ideally, the updated network would include data from nonhospital settings and would allow subscribers to retrieve specific information online.

Cultural hurdles

Not every problem has a technological or educational solution, however. When it comes to infection control, some of the greatest barriers are cultural.

First is the prevailing attitude among nurses and other health care workers that you go to work under any circumstances-even if you happen to be incubating harmful germs.
Smaller cleaning crews mean incomplete disinfection. Equipment can be expensive, too.

The Tribune mentioned a Connecticut hospital that declined to spend $20,000 on a new air filtration system, creating an environment in which dust hovered above an OR table. The CDC recommends one infection-control practitioner per 250 beds, but these departments have suffered from cutbacks as well.

And, of course, fewer nurses translates to hurried handwashing.

The connection between nurses and patient health is more than hypothetical. In a 2001 study by the Harvard School of Public Health and Vanderbilt University's School of Nursing, researchers looked at hospital discharge data, financial reports and staffing surveys from 799 hospitals in 11 states. They found "consistent relationships between nurse staffing variables and five adverse patient outcomes," including urinary tract infections and pneumonia.

"I've been focused on this since 1990," Grant said. "If you have good infection control, you'll have better outcomes. We have to spend money on this."

It's a message as simple as "wash your hands."

Contact Phil Barber at barzell@napanet.net.