Bath Basins as a Source of Hospital-Associated Infections

Reprinted from ICT, 2007

Hospital-associated infections (HAIs) affect millions of patients in the United States annually, with treatment costs exceeding $6.5 billion. As mandates, legislation and changing payment structures increase pressure to eliminate HAIs, hospitals are looking more closely at possible sources of contamination. One area that hospitals are looking at is patient bath basins.

Increasing research indicates that patient bath basins are a source of bacteria and pose a threat of cross contamination. Bacteria exist in hospital water supplies and hospital staff can transmit bacteria both into and via water. In addition, reusable washcloths can spread harmful bacteria during bathing when bacteria are transferred to the basin and returned to the patient. Patients who have surgical wounds or skin breakdown are prone to acquire HAIs from bath water.

Justine O’Flynn, RN, infection control liaison at Kosair Children’s Hospital in Louisville, Ky., took some time via email to discuss research she has conducted with hospital bath basins and the steps her hospital has taken to reduce organism spread, cross contamination and HAI risk.

Q: Can you provide some background information on hospital-associated infections that can help readers understand the scope of the problem?

A: The vast majority of people go into a hospital with very little concept of how easy it can be to pick up a hospital-associated, or nosocomial, infection. In fact, estimates indicate that HAIs affect up to 3.5 million U.S. patients and cause about 90,000 deaths each year. They are the fifth leading cause of death in acute-care hospitals.1-3 Although hospitals and clinicians are becoming increasingly aware and the healthcare industry has made some progress toward addressing the problem, hospital-associated infections remain a growing concern.4-6 Hospitals and clinicians need to explore all possible contaminant sources if they are to get this major cause of morbidity and mortality under control.

Q: How much of a problem is basin bathing when it comes to HAIs?

A: In general, when a person is sick enough to stay in the hospital, they have an increased risk of infection. According to recent research, hospital water supplies are likely sources for many HAIs and can lead to infections like pneumonia, bacteremia and urinary tract infections.5,7,8 Contaminated water supplies can spread infection from patient to patient.4,9-12 Hospitals take precautions, such as chlorinating, filtering or disinfecting the water and these measures can decrease water microbial counts4,5,10,13,14 but do not eliminate bacteria completely. Hospital staff members can also transmit pathogens into the water with their hands and with washcloths.15,16 In reality, mechanical friction during bathing sloughs skin flora into water, so basins can become a source for cross-contamination and serve as a potential reservoir for pathogens that lead to infections.13,15,17 The drying effect of soaps and hot water, combined with the friction of harsh, rough washcloths on skin can leave skin dry and cracked and can provide entry points for bacteria.18 Reusable bath cloths can exacerbate the problem and provide an avenue of spread from a patient to the basin and back to the patient. Studies have shown up to 100 percent of bathwater samples to be positive for bacterial growth.19 Based on my own research, I would say it is very likely that bath basins increase the potential for HAIs.

Q: Can you give some examples of the types of bugs spread through basin bathing? Are there serious symptoms or outcomes?

A: In our study, more than half of the basins were positive for organism growth. Most often, we found coagulase-negative Staphylococcus species, Bacillus species and Micrococcus species on the cultures. These bugs can cause mild to major skin infections, and can lead to things like bacteremia, pneumonia and — in some cases — sepsis.

Q: What can hospital staffs do to reduce the risk of spreading infection via bath basins?

A: The most obvious and simple step hospitals could take to reduce a patient’s exposure to these pathogens would be to find ways to help patients bathe without using a basin, because the organisms are clearly there. Harsh soaps and rough, reusable towels exacerbate the problem by sloughing skin and organisms into the water and back onto the skin, as well as by drying out the skin which can lead to cracks. If there is no bath basin, there is no risk of contamination from bath basins.

Q: Basin baths have been standard in hospitals for years. For the patient who is not able or permitted to get up and shower, what are the alternatives?

A: You are correct. Most hospitalized patients do not have shower privileges and the bath basin has indeed been the standard. One viable option would be a pre-packaged bath product, such as a cloth with a solution already on it. Some hospitals use these already. For example, one product is a gentle cloth with USP purified water, surfactants, aloe and vitamin E. Naturally, that removes the risk of contamination from the basin and any waterborne contamination risk. It also reduces environmental cross contamination and the transfer of bugs. Moreover, the material is soft and the cleanser is mild so it does not strip away the skin’s natural protective barrier. I would strongly recommend using a product like this in place of basin baths.

Super Bowl 2009: NFL Players and Staph Infections

January 28, 2009
by Vicki Rackner MD, Seattle Doctor- Patient Examiner

Defense is a critical strategy for NFL players who got to Super Bowl 2009. That's defense against bacterial infections.

Peyton Manning and Tom Brady didn't perform this year as expected. Their major problem was not a weak offensive line, but rather failure of their defensive immune systems to protect them from infections. These two high-profile stars join the growing number of NFL players who fall victim to serious Staph aureus bacterial infections.

Every time NFL players take to the field, they risk infection. Staph aureus is a common bacteria. You may have some on your keyboard and your hands right now. Your skin is like your own personal border patrol that protects you against bacterial invaders; however, a break in your skin lets the bacteria slip in and set up an infection. NFL players often sustain cuts, abrasions and turf burns.

Usually your immune system, with some help from antibiotics can contain the infection. Sometimes, though, the bacteria spread beyond the local boil and infect the whole body. The bacteria's ability to do some genetic reshuffling makes local infections harder to treat. Who has not heard of the dangers of MRSA infections caused by staph that have acquired resistance to the best antibiotics we doctors have. Young, healthy people die of overwhelming bacterial infection., including a 20-year-old Brazilian model who made the news this week..

MRSA infections are newsworthy. You might remember the MRSA infections in 5 of 58 St Louis Rams players in 2003. A staph infection ended Jack Snow's career and ultimately took his life.

The athletes who avoid steroid use give themselves a leg up in protecting their health. Steroids impair the ability of the immune system to fight off infection.

Brazilian Model Who Lost Hands and Feet Dies from Infection

By BRADLEY BROOKS Associated Press Writer
Jan. 26, 2009

RIO DE JANEIRO, Brazil (AP) — One month ago, 20-year-old beauty queen Mariana Bridi was living the dream of many young Brazilian women, trading her striking good looks for a modeling career that promised to lift her family out of poverty.

Then she contracted a seemingly ordinary urinary tract infection. The bacteria spread quickly and inexorably through her body, proving to be extremely drug resistant. In a desperate bid to save her life, doctors amputated her hands and feet. But by Saturday she was dead.

“God is comforting our hearts because he wanted her to be with him now,“ her father Agnaldo Costa told reporters outside the hospital where his daughter died. “I can’t accept that my daughter left us so soon.“

Bridi’s Web site says she began modeling at age 14 with the hope of giving “a dignified life to her parents.“ Her father is a taxi driver and her mother a house cleaner. By the age of 18, she was well on her way: In 2007 and 2008, she was a finalist in the Brazilian stage of the Miss World pageant. Her Web site said next month she was to participate in the second stage of a modeling competition held in Sao Paulo by Dilson Stein, the Brazilian model scout who discovered supermodel Gisele Bundchen. Last year, she took fourth in the Face of the Universe competition in South Africa and she had won bikini competitions across the globe. The Miss World Brazil organization said she was an example of someone “who knew how to intensely live her life.“

Half a dozen memorial groups on Facebook had already sprung up just hours after her death. On Bridi’s own page on Orkut — the most popular Web social networking site in Brazil — dozens of memorial messages were left.

The course of her illness was swift. In late December, she fell ill and doctors in her native state of Espirito Santo — northeast of Rio de Janeiro — initially diagnosed as having kidney stones. She returned to a hospital on Jan. 3 in septic shock — life-threatening low blood pressure — from the infection that would force doctors to amputate first her feet, then her hands. Doctors said there was little they could do but pump drugs into her and hope for the best.

It was a nightmare scenario for anyone with an infection: Her body did not react to the latest and most potent drugs while the bacteria in her veins spread from head to toe. In Bridi’s case, the culprit was the bacteria Pseudomonas aeruginosa, which is known to be drug resistant. According to the January 2008 book “Pseudomonas: Genomics and Molecular Biology,“ edited by Pierre Cornelis, a researcher at the Flanders Institute for Biotechnology in Brussels, the bacteria has the “worrisome characteristic” of “low antibiotic susceptibility.“ It also easily mutates to develop resistance to new drugs.

Death from infections caused by the bacteria are relatively rare, but not unheard of: In late 2006, an outbreak of the bacteria at White Memorial Medical Center in Los Angeles sickened five infants — leading to the deaths of two of them. The bacteria causes about 10 percent of the roughly two million hospital-acquired infections each year in the U.S., according to health officials.

A short statement from the Espirito Santo State Health Secretariat announced her death on Saturday “despite all the commitment of the hospital team.“ Her aunt said the hundreds of messages left on her Web site had lifted Bridi’s spirit in the past weeks. “I believe that the serenity on her face came from this spiritual comfort,“ Oriendina Pereira Wasen said outside the hospital.

Bridi’s funeral was planned for Saturday afternoon in the town of Marechal Floriano.

Children’s Staph Infections Increasingly Resistant to Drugs

Published: January 20, 2009

Children are picking up more stubborn staph infections that don’t respond to common antibiotics, and the proportion of ear, nose and throat infections resistant to standard drug treatment increased dramatically over a six-year period, a new study has found.

Methicillin-resistant Staphylococcus aureus infections, known as MRSA, accounted for 28.1 percent of children’s head and neck staph infections in 2006, up from just 11.8 percent in 2001, according to researchers at Emory University in Atlanta. It once was rare for an ear, nose and throat doctor to see MRSA infections, noted Dr. Steven E. Sobol, the paper’s senior author and director of pediatric otolaryngology at Emory University School of Medicine. “That was the impetus for the study,” he said.

The report was published in this week’s issue of Archives of Otolaryngology - Head and Neck Surgery.

“Over the past four or five years, we’ve seen an increased prevalence of these infections that used to be caused by other organisms that are now being caused by MRSA,” said Dr. Sobol. The researchers excluded from their analysis skin infections not caused by staph.

Though the study captured information from only a limited number of laboratories, the report’s authors said the overall trend is clear, concluding that there is “an alarming nationwide increase” in the prevalence of MRSA infections in children. The change parallels an increase in so-called community-acquired cases of MRSA among relatively healthy people who aren’t hospitalized or infirm.

The scientists analyzed 21,009 head and neck staph infections occurring among children from January 2001 to December 2006. The data came from a national electronic microbiology database that collects strain-specific drug resistance test results from labs affiliated with 300 hospitals around the country. The average age of the patients was 6.7 years old.

The proportion of drug resistant head and neck staph infections increased dramatically over the six-year period, the researchers found. Overall, 21.6 percent, or 4,534 samples, were methicillin-resistant, the greatest proportion of them involving the ear, nose and sinus and pharynx.

Only 11.8 percent of childhood head infections were resistant in 2001, but the figure jumped to 12.5 percent in 2002, 18.1 percent in 2003, and 27.2 percent in 2004.

The rate fell to 25.5 percent in 2005 and rose again to 28.1 percent in 2006, the researchers reported.

Almost 60 percent of the head and neck infections occurred among children who had not been in medical settings beforehand and were seeing doctors as outpatients, the researchers said, suggesting that children were exposed to resistant bacteria in the community.

HHS Action Plan to Prevent Healthcare-Associated Infections

Executive Summary
Background on Healthcare-Associated Infections

The Department of Health and Human Services (HHS) “Action Plan to Prevent Healthcare-Associated Infections” (Plan) represents a culmination of several months of research, deliberation, and public comment to identify the key actions needed to achieve and sustain progress in protecting patients from the transmission of serious, and in some cases, deadly infections.

Healthcare-associated infections are infections that patients acquire while receiving treatment for medical or surgical conditions.

HAIs occur in all settings of care, including acute care within hospitals and same day surgical centers, ambulatory outpatient care in healthcare clinics, and in long-term care facilities, such as nursing homes and rehabilitation facilities.

HAIs are associated with a variety of causes, including (but not limited to) the use of medical devices, such as catheters and ventilators, complications following a surgical procedure, transmission between patients and healthcare workers, or the result of antibiotic overuse.

Healthcare-associated infections exact a significant toll on human life. They are among the top ten leading causes of death in the United States, accounting for an estimated 1.7 million infections and 99,000 associated deaths in 2002. In hospitals, they are a significant cause of morbidity and mortality.1 Hospital stays for Methicillin-resistant Staphylococcus aureus (MRSA) infection have more than tripled since 2000 and have increased nearly ten-fold since 1995.2

Four categories of infections account for approximately three quarters of HAIs in the acute care hospital setting. These four categories are:

1) Surgical site infections;

2) Central line-associated bloodstream infections;

3) Ventilator-associated pneumonia, and;

4) Catheter-associated urinary tract infections.

In addition, infections associated with Clostridium difficile and MRSA also contribute significantly to the overall problem. The frequency of healthcare-associated infections varies by location. Currently, urinary tract infections comprise the highest percentage (34%) of HAIs followed by surgical site infections (17%), bloodstream infections (14%), and pneumonia (13%).3

In addition to the substantial human suffering exacted by HAIs, the financial burden attributable to these infections is staggering. It is estimated that HAIs incur nearly $20 billion in excess healthcare costs each year.4,5,6

Whereas not all Staphylococcus aureus infections are healthcare-associated, healthcare charges for Staphylococcus aureus bloodstream infections for Medicare patients exceeded $2.5 billion in 2005.7

The HHS Action Plan to Prevent Healthcare-Associated Infections

In response to the increasing threat of HAIs and national and international concern, the Department has composed a Steering Committee of senior-level representatives from the Offices and Operating Divisions of HHS and conducted a number of in-person meetings and conferences with Federal experts. HHS’ Plan toward the prevention and elimination of healthcare-associated infections includes goals toward which the healthcare and public health communities have been moving over the past several years. Despite uncertainty about whether there ultimately will be a limit on meeting this goal, the decision to move forward has been embraced by the Steering Committee.

A five-point draft strategy was developed by HHS for this Plan and included:

• Establishing an HHS Steering Committee for the Prevention of Healthcare-Associated Infections to develop an action plan.

• Beginning to prioritize, in partnership with the HHS Secretary’s Healthcare Infection Control Practices Advisory Committee (HICPAC), the significant scientific questions that need to be addressed to move the field forward rapidly and the current 1,200 recommended clinical practices to facilitate rapid implementation amongst healthcare organizations.

• Identifying and explore policy options for regulatory oversight of recommended practices and provide critical compliance assistance to select hospitals.

• Working to establish greater consistency and compatibility of HAI data through developing standardized definitions and measures for HAIs.

• Striving to build on the principles of transparency and consumer choice to create incentives and motivate healthcare organizations and providers to provide better, more efficient care.

Some of the most prominent clinicians, scientists, and other public health professionals within HHS in concert with key individuals from other federal Departments worked to develop a road-map for addressing this important public health and patient safety issue in the short- and long-term. Five working groups of the HHS Steering Committee met this past year, deliberated on known facts, research needs, and how to prevent HAIs. The primary topics of the five working groups with their respective agency leads were:

• The Prevention and Implementation working group led by the Centers for Disease Control and Prevention (CDC),

• The Research working group led by the Agency for Healthcare Research and Quality (AHRQ),

• The Information Systems and Technology working group co-chaired by the Office of the National Coordinator for Health Information Technology (ONC) and CDC,

• The Incentives and Oversight working group led by the Centers for Medicare and Medicaid Services (CMS), and,

• The Outreach and Messaging working group led by the Office of Public Health and Science (OPHS).

The HHS Steering Committee and its sub-groups, which composed the Action Plan to Prevent Healthcare-Associated Infections, accomplished the following:

• Identified seven metrics with corresponding national 5-year prevention targets

• Identified gaps in the current knowledge of HAIs and created an agenda for current and future research on HAIs

• Recommended standardization of data elements and adoption and use of data and technology standards to track HAIs

• Documented the current regulatory and administrative authority and initiatives/strategies of CMS (working with other HHS agencies and federal partners) used to prevent and combat HAIs

• Developed a progressive campaign to release and publicize the Plan in concert with a number of national partners in the federal, academic, non-profit, and private sectors. This messaging and communications strategy will target a number of audiences using the principles of social marketing and risk communication to also reach the public at large.
Top Ten Messages on HAIs and the Action Plan8

• Many healthcare-associated infections are preventable.

• A systemic approach to reducing the transmission of disease can be more effective than disease-specific approaches.

• Developing and supporting basic and translational studies to address the gaps in the science in this field will allow generation of additional strategies to reduce the risks of HAI transmission.

• It will take a strong partnership between federal and local/state governments and communities to truly help prevent HAIs. HHS is committed to this partnership and many of its agencies are and will be involved.

• The education of best practices for providers and other healthcare personnel is critical to prevent HAIs.

• Specific metrics and national targets have been developed by HHS in concert with national experts on controlling infections.
• Educating patients on HAIs and how to prevent them is a critical part of the national effort.

• An informed media can help promote the education of the American public about the need to prevent HAIs and what HHS and its partners are doing.

• Preventive steps to control and prevent HAIs are cost-effective, save lives, and reduce disability for Americans.

• The time to act on HAIs is now, and HHS and its partners are working closely with providers, health systems, community leaders, and governments to help prevent HAIs.

Priority Recommendations of the Prevention and Implementation Group

• Progress towards 5-year national prevention targets

• Use and improve the metrics and supporting systems needed to assess progress towards meeting the targets

• Consider recommendations, grouped by priority module, outlined for each of the guidelines addressed
Priority Recommendations of the Research Group

• Perform Research Projects to Address Specific Knowledge Gaps (Basic Science, Epidemiology, and Practices)

• Develop strategies for preventing and/or eliminating biofilms associated with medical devices

• Study the epidemiology of bloodstream infections that occur outside of the hospital

• Establish the preventability of Clostridium difficile infection (CDI) through a regional hospital collaborative intervention

• Establish the preventability of unnecessary antimicrobial use through a multi-center collaborative intervention

• Establish the preventability of surgical site infection (SSI) through a multi-center collaborative intervention

• Assess the effectiveness of the ICU-wide application of a MRSA decolonization strategy

• Perform Research Projects to Enhance the Implementation and Impact of Existing, Evidence-Based Infection Control Practices

o Investigate the human cultural and organizational barriers to successful implementation of practices at the unit and institutional levels

o Develop and evaluate novel and automatable strategies for measuring HAIs

o Evaluate and validate standardized post-discharge surveillance methodology

o Develop proxy measures for ventilator-associated pneumonia (VAP) (i.e., acute lung injury) for inter-facility comparisons

o Develop standardized methods for measuring and reporting compliance with broad-based prevention practices (e.g., hand hygiene)

• Form an Interagency Working Group to enhance the federal capacity to lead a national prevention strategy

• Conduct a comprehensive HAI database inventory to guide future plans for near-, mid-, and long-term integration and interoperability projects and to establish the extent of definitional alignment and data element standardization needed to link HAI data across the nation

• Enhance individual agency systems to extend their coverage or establish new interfaces with other systems

• Accelerate transition to electronic reporting by healthcare facilities to reduce their reporting burden and increase timeliness, efficiency, comprehensiveness, and reliability of the data

• Improve regulatory oversight of hospitals and CMS oversight of the hospital accreditation program by refining the current method of measuring Accreditation Organization performance, enhancing surveyor training and tools, and adding sources and uses of infection control data

• Continue to incorporate measures of infection prevention and outcomes into Hospital Value-Based Purchasing (VBP) Plan methodology through implementing performance-based payment for hospitals, including measures of infection prevention and outcomes as a basis for payment

• Expand measures in CMS Hospital Compare which improves the quality and transparency of hospital care by increasing public accountability and provides consumers access to important hospital quality of care measures

• Increase support for the HHS Action Plan to Prevent Healthcare-Associated Infections

• Increase knowledge and awareness of key messages and prevention practices among providers, consumers, the media, and general public
Healthcare-associated infections are one of the most preventable causes of leading mortality in the U.S. The infections also add a significant economic burden to the healthcare system. The Department, in conjunction with experts, has developed an action plan to help reduce, prevent, and eventually eliminate much of the significant burden to our nation, health systems, communities, and individuals of HAIs.

We strongly encourage you to read the HHS Action Plan to Prevent HAIs. For additional details on what is in the Plan or on what HHS is doing to address this critical public health issue, please contact the HHS Office of Public Health and Science.

1 Klevens RM, Edwards J, Richards C, Horan T, Gaynes R, Pollock D, Cardo D. Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002. Public Health Reports 2007; 122:160-166.
2 Elixhauser A and Steiner C. Infections with Methicillin-Resistant Staphylococcus Aureus (MRSA) in U.S. Hospitals, 1993–2005. AHRQ Healthcare Cost and Utilization Project Statistical Brief 2007; 35:1-10.
3 Klevens RM, Edwards J, Richards C, Horan T, Gaynes R, Pollock D, Cardo D. Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002. Public Health Reports 2007; 122:160-166.
4 Stone PW, Braccia D, Larson E. Systematic Review of Economic Analysis of Health Care-Associated Infections. American Journal of Infection Control 2005; 33:501-509.
5 Roberts RR, Scott RD, Cordell R, Solomon SL, Steele L, Kempe LM, Trick WE, Weinstein RA. The Use of Economic Modeling to Determine the Hospital Costs Associated with Nosocomial Infections. Clinical Infectious Diseases 2003; 36:1424-1432.
6 Stone P, Larson E, Kawar LN. A systematic audit of economic evidence linking Nosocomial infections and infection control interventions: 1990-2000. American Journal of Infection Control 2002; 30,3:145-152.
8 That HHS and Collaborators will communicate these to many stakeholders and the public – including healthcare organizations, professional provider organizations, governmental agencies, non-profit public health organizations, and the public.

APIC Statement on Need for Increased Infection Prevention Measures

Washington, DC, January 6, 2009 -- The following statement is attributable to Kathy Warye, CEO of the Association for Professionals in Infection Control and Epidemiology (APIC):

“A review article appearing in this month’s issue of the Annals of Internal Medicine identified 33 outbreaks of hepatitis B or C virus infection in U.S. outpatient healthcare settings during the past 10 years caused by unsafe injection practices. This comes on the heels of a highly publicized outbreak in Nevada in which 40,000 people were notified of their possible risk of hepatitis C due to improper use of syringes at a Las Vegas endoscopy clinic. Unsafe injection practices have also been cited at free-standing centers in Nebraska, New York, Michigan and North Carolina, needlessly exposing hundreds of thousands of patients to life-threatening infections.

“As the nation’s largest infection prevention organization, APIC is very concerned by the mounting number of cases in which clinicians in ambulatory care settings failed to follow safe injection practices, causing outbreaks of serious infections and endangering the lives of patients. These outbreaks were preventable and should never have occurred. Consumers seek healthcare services to get better and should not be exposed to
unnecessary risk.

“To raise awareness of the risks and ensure that clinicians understand the basics of safe injection practice, APIC is participating in HONOReform, a national coalition formed to bring a halt to unsafe needle practices in outpatient centers. HONOReform was founded by Evelyn McNight, a breast cancer survivor who received chemotherapy at a Freemont, Nebraska ambulatory care clinic and was infected with hepatitis C because the clinic reused syringes. APIC is providing educational resources and expertise.

“With an increasing amount of care being delivered in outpatient settings, more patients will be put at risk unless clinicians are adequately educated and consistently adhere to infection prevention measures. Clinics should also be concerned about new and more virulent pathogens, such as MRSA, which can be transmitted in outpatient settings and take a hard look at how they are addressing infection prevention overall.

“APIC offers a host of resources including Webinars, newsletters and a Guide to Infection Control in Ambulatory Care. APIC’s evidence-based elimination guides translate CDC guidelines into practice.”

APIC’s mission is to improve health and patient safety by reducing risks of infection and other adverse outcomes. The association’s 12,000 members direct infection prevention programs that save lives and improve the bottom line for hospitals and other healthcare facilities around the globe. To promote a culture within healthcare where targeting zero healthcare-associated infections is fully embraced, APIC has created the “Targeting Zero” initiative to accelerate both learning and delivery of practical tools for infection preventionists. APIC advances its mission through education, research, collaboration, practice guidance, public policy and credentialing.

Visit APIC online at

More Than 60,000 Patients at Risk

January, 2009 (HealthDay News) -- Failure to follow basic infection practices placed more than 60,000 U.S. patients at risk for hepatitis B and C, a new U.S. government review reported Tuesday.

The review, published in the Jan. 6 issue of the journal Annals of Internal Medicine, concluded that health care personnel in settings outside hospitals failed to follow basic infection control practices. Reuse of syringes and blood-contamination of medications, equipment and devices were identified as common factors, the study found.

Transmission of HBV and HCV while receiving health care had been considered uncommon in the United States, but the study revealed 33 identified outbreaks outside of hospitals in 15 states, during the past 10 years: 12 in outpatient clinics, six in hemodialysis centers, and 15 in long-term care facilities, resulting in 450 people acquiring hepatitis infections.

"This report is a wake-up call," Dr. John Ward, director of the U.S. Centers for Disease Control and Prevention's division of viral hepatitis, said in an agency news release. "Thousands of patients are needlessly exposed to viral hepatitis and other preventable diseases in the very places where they should feel protected. No patient should go to their doctor for health care only to leave with a life-threatening disease."

CDC officials said the findings showed the need for ongoing professional education and oversight for health care providers, as well as:

- Improving viral hepatitis surveillance, case investigation andoutbreak response.

- Strengthening state and local viral hepatitis prevention programs.

- Augmenting the CDC's National Healthcare Safety Network, the national surveillance system for tracking health care-associated infections, to collect outpatient setting information.

- Partnering with the Hepatitis Outbreaks' National Organization forReform (HONOReform), a patient advocacy foundation, to create patient and provider education materials.

- Working with partners in the dialysis, diabetes and long-term care communities to promote safe practices, and with regulators and professional societies to strengthen licensure and accreditation processes.

Learn more about preventing viral hepatitis in health caresettings at the U.S. Centers for Disease Control and Prevention.

3 Out of 4 Canadian Doctors Skip Hand Washing

by Aaron Derfel, The Gazette, Montreal
January, 2009

Only one in four doctors wash their hands between patients on some wards within the McGill University Health Centre, an internal audit has found.

Nurses do a better job, but their rate of compliance is still 40 to 50 per cent - a factor that's blamed for the spread of germs and deadly infections in hospitals. What's more, results from the audit taken last year show little progress since a study was conducted at the MUHC in 2001. That study found that fewer than one in four doctors and less than 40 per cent of nurses took hand-hygiene precautions.

Charles Frenette, medical director of infection control at the MUHC, acknowledged yesterday that his department has had a difficult time persuading health professionals to take handwashing seriously. "It's something that's hard to change," he said. "It's like stopping smoking. It takes a lot of time. It's a long-term process and we're just beginning to have the tools with those audits to try and change people's behaviour." Research has shown that 30 per cent of hospital- acquired infections can be prevented through handwashing.

The MUHC, like other health centres across the country, has been hard hit with outbreaks of multi-drug-resistant bacteria. In 2003-2004, 780 patients at the MUHC contracted the C. difficile bacterium, 84 per cent of whom caught the infection in its hospitals. Of those patients, 36 died from C. difficile-related complications and another dozen required emergency colorectal surgery.

Accreditation Canada, the national council that certifies hospitals, is so concerned about the lack of routine handwashing by health professionals that it set tough new standards as of Jan. 1. Previously, hospitals were simply required to provide proof of educating staff and volunteers about the importance of handwashing. But now, they must carry out audits of hand-hygiene practices, share those results with staff and volunteers, and show measurable progress.

Hospitals that fail to improve within a couple of years will receive poor ratings by the council, and in the worst of cases, could risk losing their accreditation. The standards also apply to nursing homes and other health-care facilities. "Everyone would agree that handwashing is a no-brainer, but you and I both know that people do not wash their hands with the frequency required or do it properly," said Wendy Nicklin, CEO of Accreditation Canada.

"Whether it's the SARS outbreak in Ontario (in 2004) or the C. diff problem in Quebec, there's been a dramatic increasing awareness and concern for the need for health care professionals to take increasing diligent steps" with hand hygiene. The MUHC has installed alcohol-based hand-rinse dispensers throughout its hospitals. Staff and volunteers are required to wash their hands before and after every patient. In addition, people visiting patients who have been infected or colonized by a drug-resistant bacterium must wash their hands as well as wear a mask and gloves.

The MUHC's internal audit found that hand-hygiene compliance was only 50 per cent in the intensive-care wards. Full compliance is thought to be impossible, but some hospitals around the world have succeeded in reaching 70 per cent rates. And at the start of each of the shifts," CHUM spokesperson Lucie Dufresne said. Staff will be asked to wash their hands and then the inspectors will shine an infrared light on them to reveal any missed spots.

The CHUM has already carried out hand-hygiene audits in problem areas, but plans to expand them to all areas of care, Dufresne said.

Hospital Scrubs Are a Germy, Deadly Mess

You see them everywhere -- nurses, doctors and medical technicians in scrubs or lab coats. They shop in them, take buses and trains in them, go to restaurants in them, and wear them home. What you can't see on these garments are the bacteria that could kill you.

Dirty scrubs spread bacteria to patients in the hospital and allow hospital superbugs to escape into public places such as restaurants. Some hospitals now prohibit wearing scrubs outside the building, partly in response to the rapid increase in an infection called "C. diff." A national hospital survey released last November warns that Clostridium difficile (C. diff) infections are sickening nearly half a million people a year in the U.S., more than six times previous estimates.

The problem is that some medical personnel wear the same unlaundered uniforms to work day after day. They start their shift already carrying germs such as C.diff, drug-resistant enterococcus or staphylococcus. Doctors' lab coats are probably the dirtiest. At the University of Maryland, 65% of medical personnel confess they change their lab coat less than once a week, though they know it's contaminated. Fifteen percent admit they change it less than once a month. Superbugs such as staph can live on these polyester coats for up to 56 days.

Do unclean uniforms endanger patients? Absolutely. Health-care workers habitually touch their own uniforms. Studies confirm that the more bacteria found on surfaces touched often by doctors and nurses, the higher the risk that these bacteria will be carried to the patient and cause infection.

Until about 20 years ago, nearly all hospitals laundered scrubs for their staff. A few hospitals are returning to that policy. St. Mary's Health Center in St. Louis, Mo., reduced infections after cesarean births by more than 50% by giving all caregivers hospital-laundered scrubs, as well as requiring them to wear two layers of gloves. Monroe Hospital in Bloomington, Ind., which has a near-zero rate of hospital-acquired infections, provides laundered scrubs for all staff and prohibits them from wearing scrubs outside the building. Stamford Hospital in Connecticut recently banned wearing scrubs outside the hospital.

Across the pond, a British study found that one-third of medical personnel did not launder their uniforms before coming to work. One British surgeon who specializes in hip and knee replacements reduced postoperative infections by two-thirds at her hospital by protecting patients from contaminated uniforms. Before approaching any patient's bed, nurses put on disposable, clear plastic aprons that were pulled off rolls like dry cleaning bags. Each one costs a nickel.

In response to this evidence and public outrage over infections, the cash-strapped British National Health Service is providing nurses with hospital-laundered "smart scrubs." The smart design includes short sleeves, because long sleeves spread germs from patient to patient.

The new British policy will protect patients and prevent superbugs from being carried outside hospitals. In one study, more than 20% of nurses' uniforms had C. diff on them at the end of a shift. The germ can cause extreme diarrhea, dehydration, inflammation of the colon, and even death.

In a hospital, C. diff contaminates virtually every surface. It spreads when traces of an infected person's feces get in another person's mouth. Patients who touch objects in their room and then eat without washing their hands unknowingly swallow the germ. Many otherwise healthy patients who go into the hospital for elective surgery, such as hip replacement, have contracted C. diff and died.

Outside the hospital, C. diff is also difficult to control. It isn't killed by laundry detergents or most cleaners. Researchers at Case Western Reserve and the Cleveland Veterans Administration Medical Center found that even after routine cleaning, 78% of surfaces still had C. diff. Only scrubbing with bleach removed it. That's not the kind of cleaning restaurants are prepared to do after serving hospital workers.

Imagine sliding into a restaurant booth after a nurse has left the germ on the table or seat. You could easily pick it up on your hands and then swallow it with your sandwich. Hospitals should provide workers with clean uniforms and prohibit wearing them in public.

January 8, 2009 By Betsy McCaughey

SUPERBUGS Among Seven Trends That Should Concern Us

by Richard Eskow

This country is in a healthcare crisis today — but we’re not thinking enough about tomorrow either. Here are seven trends to watch, starting with the short-term and ending with what may seem more like science-fiction.

The seven trends are: Doctors leaving the public system, a shortfall in primary care, underutilization of medical treatment, “superbugs,” virtual health care, climate change, and radical self-redesign and enhancement.

1. Doctors Leaving the Public System: Medicare dodged a bullet when Congress stopped a substantial pay cut for physicians this month. But doctors continue to leave the Medicare system - in Texas, in Washington State, in Tennessee, and elsewhere. And many doctors already limit the number of Medicaid patients they accept. Shortages will become more acute as SCHIP and other reforms (hopefully) increase the number of Medicare and Medicaid recipients, and they’ll hit lower-income and minority communities first and hardest.

2. Unavailability of Primary Care Doctors: Primary physicians (internists, family practitioners, gerontologists, etc. ) aren’t paid enough. It’s part of a general tendency to under-compensate for “cognitive services” - thinking, talking, and diagnosis. Doctors are economic actors like the rest of us. So the result of this payment bias is a critical lack of ‘cognitive’ physicians who should be the drivers of the medical process. Instead, young doctors are being lured into high-cost specialties. This increases the use of costly (and sometimes unnecessary procedures), according to studies conducted at Dartmouth and elsewhere.

This shortage is already crippling health reform in Massachusetts. The idea of increasing compensation for primary care keeps circling around in health circles, as it is now - along with the concept of a”medical home,” which is a re-articulation of health reform ideas that appear at regular intervals like comets. The thinking is probably correct, but the problem will persist - until there is fundamental reform in the way doctors are educated, compensated, and rewarded with social status. And meaningful reform will be difficult without adequate primary care.

3. Underutilization: Medical policy types are well-versed in the cost problems and health complications that stem from over-utilization of health services. Over-utilization is a central tenet of the McCain health proposals. But, while it occurs - especially in certain specialties - the reverse problem of underutilization is prevalent and growing.

As insurers and employers shift more and more costs to individuals’ pockets people are seeking less and less treatment, as this California survey (warning: pdf file) demonstrates. 38% of respondents said they avoided seeking medical care - either preventive or curative - because of health costs. That’s up from 34% three years ago, and it’s a problem. Failure to seek needed care increases health costs, adds to individual suffering, and can allow untreated contagious conditions to spread. Which gets us to …

4. Superbugs: A study of MRSA “superbug” infections published last year found a dramatic increase in occurrence among Chicago’s urban poor. Crowded living conditions in jails and public housing could be a factor, according to the study’s authors, and illegal tattoos may also be contributing to their spread. Now British hospitals are facing a new superbug called “Steno” that is at least as hard to treat as MRSA.

As new viruses mutate and spread, ready access to preventive and curative medicine becomes more critical. Superbugs would be a concern even if we had a fully functional health system. With the system we’ve got, the impact of new mutated viruses could be serious - and potentially catastrophic.

5. Virtual Health Care: Online healthcare holds great promise for the future - both as a way for people to manage their own health, and as a tool that links doctors and patients in a unified network. But even now, before “Health 2.0″ is a reality, we’re seeing a wave of health data losses and thefts. (They’ve become so common that I have a whole blog section devoted to privacy issues.)

The combination of electronic medical records, electronic prescriptions, and other online tools could result in new forms of crime - with scary enough potential results that I’d rather not describe them in public. (Why serve as a think tank for the bad guys?) Virtual health could also cause substantial shifts in the kind of medical care people demand. While that might actually be a thing, failure to plan for it could result in some temporary inconveniences.

6. Climate Change: Global warming could change the way we use medical care - and how much we need. As an Australian study found (and we summarized here), overall hospital admissions went up by 7% during heat waves, while mental health admissions went up by the same percentage - and kidney-related admissions increased 17%. That adds up to a snapshot of medical conditions on a globally-warmed planet. Other changes, like a dramatic increase in the occurrence of mosquito-borne diseases, could also take place.

7. Radical self-redesign: ‘Transhumanism’ - the movement to re-engineer the human body - isn’t a well-known term today. But the process is already underway, and it will gain momentum in the coming decades. Choosing our children’s genetic characteristics … building computer technologies into our bodies … extending our lifespans … all of these will come into being in the coming years. This will raise a series of questions in fields like medical ethics and health financing, as we’ve discussed before.

What should we be allowed to do to ourselves and our children? Which changes should be paid for as a social right, and which are a personal choice? Will we create a ‘two-tiered’ race of human beings? These science-fiction questions will become increasingly concrete as we consider the health care reform issues of the coming century.

A Hi-Tech Approach Helps to Track Infection

Pa. hospitals go high-tech on infection tracking
By MARTHA RAFFAELE – Dec 30, 2008

HERSHEY, Pa. (AP) — At Hershey Medical Center, a sophisticated computer program serves as a watchdog for infection outbreaks.

With a few mouse clicks on a Web browser, the hospital's infection-control staffers can quickly generate reports with charts and graphs illustrating how many patients within a particular unit are infected, and which lab specimen contained the germs. "It's more for us to look at the hospital as a whole and look for trends," said Dr. Kathleen Julian, an infection disease physician. "Is there a cluster of problems in this unit?"

Pennsylvania health officials view the nascent technology as a critical tool for helping hospitals reduce health care costs by identifying potential systemic infection-control problems sooner than is possible by reviewing paper records by hand — an approach some health professionals call "shoe-leather epidemiology."

Using traditional investigation methods, infection-control professionals must spend hours poring over patient charts, but limit the scope of their inquiry to areas of the hospital where infection outbreaks are most likely to occur. With electronic monitoring, hospitals can cast a wider net, using software that employs algorithms to do the heavy lifting of sorting through every single laboratory, pharmacy and X-ray report that is entered into the hospital's computer network.

Gov. Ed Rendell's administration is expecting more hospitals to adopt the technology under a sweeping 2007 state law designed to reduce infections contracted by patients during their hospital stays.

"It frees up your infection-control people from trying to find infections ... so they can get out on the floor and put systems in place so they don't happen again," said Ann Torregrossa, policy director for the Governor's Office of Health Care Reform. Pennsylvania is the only state in the nation to include "electronic surveillance" — like the Hershey hospital's system — in its infection reporting laws, according to the Association of Professionals in Infection Control and Epidemiology.

Pennsylvania became one of the first states to mandate infection reporting by hospitals in 2003, and it was the first state to release public reports on infection rates in 2005.

Gov. Ed Rendell's administration championed the 2007 law as part of a broader health care reform agenda that includes reducing the cost of care. The administration has estimated that hospital-acquired infections add more than $3.5 billion annually to hospital bills in the state.

Monitoring infections has taken on greater urgency nationally with the emergence of antibiotic-resistant "superbugs" such as methicillin-resistant Staphylococcus aureas, or MRSA.

Also, in October, the federal government began withholding Medicare reimbursements to hospitals for preventable errors, including urinary tract and vascular infections stemming from the improper use of catheters, as well as certain surgical site infections.

Pennsylvania's law requires hospitals, outpatient surgery centers and nursing homes to develop state-approved infection control plans and report all infections to the Centers for Disease Control and Prevention. It also calls for the eventual awarding of bonuses to hospitals that reduce infections by at least 10 percent.

Rendell's administration originally sought a statewide mandate for the computerized infection tracking systems so that health officials could make uniform comparisons. But the state's hospitals fought back, arguing that the requirement was a costly mandate that would unfairly penalize small hospitals that have lower infection rates.

Under a compromise in the law, hospitals are allowed to opt out of the computerization requirement for now if they can demonstrate to the state Health Department that they lack the money or technological capability to do so.

Roughly one-fifth of the state's 163 general hospitals have told the department they will not install new monitoring systems, mainly due to budget constraints. The law requires each of those hospitals to have a written plan in place that explains how it will collect the data and a process for verifying its accuracy.

Other types of hospitals — such as psychiatric, long-term acute care and rehabilitation hospitals — are not being expected to install such systems because of their size or specialty, department spokeswoman Stacy Kriedeman said.

The hospitals that are proceeding are about evenly split between facilities that expect to meet the Dec. 31 deadline for implementing electronic monitoring and others that may need more time due to an overwhelming demand on the relatively small number of companies that provide the technology, said Stacy Mitchell, the health department's deputy secretary of quality assurance.

"We have to be flexible about that, because it's not the hospitals' fault," Mitchell said.
Electronic surveillance is a relatively new technology that has emerged over the past several years, and definitive studies on its cost-effectiveness are difficult to track down.

"It would be a complicated and expensive study to rigorously study whether there were cost savings," said Dr. William Trick, an internal medicine physician and researcher at John H. Stroger Jr. Hospital in Chicago. But Trick said his research has found that computerized monitoring can improve the efficiency and likely the reliability of infection tracking.

Trick and other researchers found that computer algorithms were more accurate than manual records reviews in detecting bloodstream infections associated with catheters inserted into a large vein, according to a 2004 study published in the CDC journal Emerging Infectious Diseases.

The algorithms were more likely to agree with a separate, independent review of the infection data than the determination of an infection-control professional who examined the records by hand, Trick said. But rather than rely solely on the computer to tell them something is wrong, there may be some advantages for hospitals to have their infection-control experts evaluate and interpret the data, he said.

"There might be benefits of a hybrid system in which both algorithmic and human interpretations are used," Trick said. The Joint Commission, a national nonprofit organization that accredits hospitals, has not taken a position on whether hospitals should adopt the technology, said Louise Kuhny, the commission's senior associate director for standards interpretation. "While good old infection-control data collection works, and what some people call 'shoe-leather epidemiology' has been used with success, there are some aids that can help infection-control practitioners," Kuhny said.

Computerized systems, she said, "should be considered a tool in data collection but they do not entirely replace (traditional) surveillance."

Hershey Medical Center has been using its computerized system, which cost about $268,000 to install and set up, for about 2 1/2 years, said Dr. Greg Caputo, the hospital's chief quality officer.

In the first year, the hospital saw the rate of reported infections increase dramatically because the system was capable of identifying "virtually all of the infections" in the hospital, Caputo said. Previously, the hospital's old system relied on samples of the patient population.

"Since that time, we've seen a gradual decrease in the overall rate of infection," Caputo said. Torregrossa is hopeful that hospitals that are reluctant to embrace the technology will eventually do so once they see the impact it has on reducing infection rates.

"We certainly are going to urge hospitals to use electronic surveillance systems," Torregrossa said. "We think their benefit has been proven."