frustrated doctor

They used to be called “hospital-acquired infections” (HAIs). Now the CDC has softened that terminology to “healthcare-associated infections” (also HAIs). Perhaps it seems a little less scary if life-threatening infections are “associated” with, rather than “acquired” through hospital stays. Whatever you call them, hospital germs can be deadly.

The CDC estimates that there are 722,000 HAIs in the United States each year. The Centers for Disease Control and Prevention calculates that 75,000 people die each year from such infections. Many of them could be prevented.

How Do People Catch Nasty Hospital Germs?

A study from Duke University Medical Center (presented at IDWeek, Oct. 27, 2016) suggests that dangerous bacteria may be spread by health care workers’ clothing. Researchers tracked bacteria in samples taken from 167 patients, patients’ rooms and the scrubs worn by 40 nurses.

Scrubs are the clothes nurses and other health care workers wear on duty. The term scrubs originated when this clothing was provided for surgeons scrubbing in for an operation.

What They Found:

The infectious disease experts at Duke found nasty bacteria such as Klebsiella and methicillin-resistant Staphylococcus aureus or MRSA. These bacteria leave fingerprints that allowed the researchers to determine where they came from.

The nurses were given clean scrubs at the beginning of each 12-hour shift in the intensive care unit (ICU). Bacteria showed up most frequently on pockets and sleeves. Nurses picked up these dangerous germs from patients or the rooms themselves, even though the rooms were cleaned every day.

The lead investigator, Dr. Deverick Anderson, associate professor of medicine in the Division of Infectious Diseases at Duke was quoted as saying:

“We know there are bad germs in hospitals, but we’re just beginning to understand how they spread…We think it’s more common than not that these bugs spread to patients in hospitals because of temporary contamination of health care workers.”

Dr. Anderson added:

“This study is a good wake-up call that health care personnel need to concentrate on the idea that the health care environment can be contaminated…

Any type of patient care, or even just entry into a room where care is provided, truly should be considered a chance for interacting with organisms that can cause disease.”

Why We Worry About Hospital Germs:

We have been concerned about hospital-acquired infections for a very long time. The idea that a perfectly healthy person could go into a hospital for “routine” surgery, catch MRSA or C. diff during the stay and then die has horrified us.

A good friend experienced just such a travesty. She was planning a vacation to visit family in Europe. A sore knee worried her because she did not want to be slowed down by arthritis. Well in advance of the trip she arranged for knee replacement surgery. She entered the hospital in excellent health, except for the arthritis in one knee. The surgery went very well and she was optimistic about her recovery until a C. diff infection took hold. Within a few weeks she was dead.

Doing Something About Hospital Germs:

In January, 2008, the National Health Service in England banned ties and white coats worn by physicians. The British health care authorities went even further. They issued a rule: “bare below the elbows.” In addition, health care workers were not supposed to wear watches or other jewelry that could harbor bad bugs.

The theory was that white coats and shirt sleeves could attract hospital germs and serve as a transport system to pass antibiotic-resistant bacteria from patient to patient. Keeping arms bare below the elbow makes it easier to wash hands and arms thoroughly.

Other Hiding Places for Hospital Germs:

There is a name for things that harbor bacteria, viruses, fungi and other infectious organisms. Doctors call them fomites. They include cell phones, pagers, watches, stethoscopes, pens, badges, blood pressure cuffs, computer keyboards, bed rails, TV remote controls, door knobs and portable hospital equipment.

A review of “mobile communication devices” (abbreviated MCDs) in The Journal of Hospital Infection revealed that 9 to 25 percent of mobile phones, pagers and “personal data assistants” were contaminated with nasty bacteria like MRSA that could cause human disease.

A review in the journal Infection Control & Hospital Epidemiology, (Nov. 2016) titled “Healthcare Personnel Attire and Devices as Fomites: A Systematic Review” noted:

“We found that stethoscopes, digital devices, white coats, and neckties are commonly contaminated with bacterial pathogens including S. aureus (including MRSA) and GNRs [gram-negative rods]…

“Our findings have implications for clinicians and infection preventionists. Once hand hygiene practices have been optimized, attention to reducing reservoirs of organisms that may exist in clothing and devices is a reasonable next step in infection control.”

What Hospitals and Clinics Should Do!

The Society for Healthcare Epidemiology of America published recommendations for hospitals and other healthcare facilities in 2014. Suggestions included:

  •  “Bare below the elbows” (BBE)
    • [This would presumably eliminate white coats]
  • If a hospital requires white coats “for professional appearance” it should require house staff and students to own two or more white coats and provide laundering on site at no or low cost.
  • If a doctor, nurse or student comes into contact with a patient “or patient environment” clothing “should be laundered after daily use.”
  • Hospitals should provide hooks where white coats or “long-sleeved outerwear” should be hung “prior to contact with patients or the patients’ immediate environment.”
  • “Shared equipment including stethoscopes should be cleaned between patients.”

Why Are Doctors, Hospitals and Clinics Slow to Change Practices?

Several years ago I served on a Patient Safety and Clinical Quality committee at one of the country’s most highly regarded hospitals. After the Brits initiated their ban on white coats, ties and jewelry and adopted the bare below the elbow policy, I asked the leadership of this hospital why they weren’t adopting a similar plan.

The answer I received from the infectious disease experts was that there was no evidence that fomites like white coats, ties, cell phones, stethoscopes or jewelry posed a problem for patients. I pointed out that “absence of evidence is not evidence of absence.” In other words, if no one does the research there will be no way to know whether there is a problem or not.

Although no one will admit this, providing changing rooms and lockers to healthcare workers and offering free laundry services costs money. Changing a culture that values white coats and ties is equally challenging. Asking physicians to give up watches and to scrupulously clean cell phones, stethoscopes and pagers could be tricky. Just consider what happened to Dr. Ignaz Semmelweis in the 19th century.

The Ruination of Dr. Semmelweis:

In the mid 1800s many women died during childbirth from puerperal fever, also known as childbed fever. In those days the germ theory had not yet been discovered. At a hospital in Vienna, Austria, Dr. Semmelweis noticed that medical students would go from dissecting cadavers in a laboratory next to the maternity ward to delivering babies without washing their hands.

He conducted an experiment in which medical students were required to disinfect their hands before touching patients or helping deliver babies. Childbed fever and deaths were radically reduced. Dr. Semmelweis did not know the reason why his recommendation was so successful, but he realized immediately that it could save lives.

Sadly, his colleagues found his hand-washing proposal offensive. They ridiculed him and made his life miserable because he could not explain why hand-washing was working to reduce illness. Despite his best efforts to educate the leading doctors of his day, his hand-washing idea was roundly rejected. The medical establishment was annoyed by the idea that doctors might have to take time to wash their hands before touching patients or delivering babies.

Dr. Semmelweis published his findings in 1861. Four years later he was confined to an insane asylum. Within two weeks of admittance he was dead from an infection brought on by a beating from hospital guards.

What Are We to Make of the New Duke Research?

There is still very little research to prove that white coats, scrubs, ties, jewelry, cell phones, or other fomites transmit infections to patients. That doesn’t mean they do not contribute to the spread of disease. Deverick Anderson, MD, of Duke said it elegantly in describing his research:

“This study is a good wake-up call that health care personnel need to concentrate on the idea that the health care environment can be contaminated. Any type of patient care, or even just entry into a room where care is provided, truly should be considered a chance for interacting with organisms that can cause disease.”

[Research presented at Infectious Disease (ID) Week, 2016, New Orleans, Oct. 27, 2016]

Do you care about hospital-acquired infections? Want to read more? Here is an article about one of our heroes, Peter Pronovost, MD, PhD, one of the country’s leading experts on patient safety. He suggested that perhaps it’s time for doctors to ditch the white coat.

What Do Patients Think?

Share your own thoughts below in the comment section. Here are just a few messages from visitors to this website:

Eugene in Tampa, Florida, mentions something many hospitals might not consider:

“The curtains dividing patients in a hospital room can also harbor germs. I asked the infection control person at a hospital how often the curtains were laundered. To my surprise she told me there was NO scheduled laundering. She added that only when a highly infectious patient was in the room would they be changed.

“With everyone touching the curtain and it being subjected to a concentrated germ environment, they should be changed like the bedding is – after every patient at a minimum and optimally daily!”

Mary in Abilene, Texas, offers a good idea:

“Why not have disposable lab coats? I love to wear lab coats. I feel I need all those pockets for pens and medical devices. I always have 2 clean lab coats besides the one I’m wearing in our office. I’m old school. White lab coats make people look clean and professional.

“We just have to get into the habit of cleaning our stethoscope, pens, and other equipment.”

Laurie in Maryland may have the best idea yet:

“I understand about long sleeves, but the whole white coat goes from patient room to patient room, carrying fomites on it. Seems like a better practice would be to wear a disposable gown over your clothing, using a fresh one for each patient.”

Share your own thoughts below.

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  1. Bob
    Ohio
    Reply

    Think about the one surface which patients come in contact with nearly 24 hours per day. That’s right…the hospital bed. Hospital mattresses have proven to not only harbor pathogens but also cause infections such as c.difficile. The mattresses can not be disinfected due to being a porous surface.

  2. Rick
    Reply

    They should worry far more about the antibiotics being passed around by the Doctors (like Cipro) and less about the bacteria, as many of those can be good for you!

  3. Martha P
    South Carolina
    Reply

    Within 8 or so years ago when family members had been in hospitals I sent a letter to the nurse staff to the local community hospital mentioning that “fashion of today” have visitors and all staff who are wearing slacks or trousers MOSTLY have them dragging along the floor. Today the hems on them are not adjusted to have the slacks and trousers to end up just to the top of shoes, sneakers, thongs. Sadly I did not have an acknowledge of receiving the letter trying to make hospitals more healthy. I wonder what would happen if I am a patient and if I request that no one can enter my room as a professional, visitor or anyone if their pants are dragging along the floor. I can see hospitals would have to have a rule to work, visit or whatever, when wearing slacks they must not drag on the ground.
    Hospitals were more cleanliness when I was young. Children about 12 years younger for themselves and the patients were not able to be a visitor even when a new baby was born. Limits per room were there also. Sad now we are rushed out of a hospital to avoid getting other health challenges. Thanks for the opportunity to share my thoughts.

  4. Judith
    FL
    Reply

    A while back I went with a friend of mine for a routine visit to his cardiologist. The cardiologist seems to be very competent and good with my friend but I was appalled by the cleanliness of the white coat he was wearing. The cuffs of the coat were dirty and the body of the coat definitely looked like it need washed badly. If I happen to go with my friend again and the condition of his cardiologist’s white coat is still the same, after reading the above comments, I will certainly speak up with as much discretion as I can muster.

  5. Dr. Richard
    Florida
    Reply

    If it is not about money or fear people do not care. the doctors have known about the simple task of hand washing and they do not do it. This would change from fear, if they children got MRSA. The prestige of long sleeve coats, scrubs, formited watches and dirty stethoscopes and cell phones are all examples of poor insight, lack of training, bad choices, and just plain laziness. Clearly the most dangerous place to work in medicine is a hospital. this is not new information. We killed a President James Garfield with our medical care.
    Our medical Herald, Dr. Semmelweis published his findings in 1861. Four years later he was confined to an insane asylum. Within two weeks of admittance he was dead from an infection brought on by a beating from hospital guards. This is how we treat our medical messengers, we martyr them.
    I see doctors who do not wash hands and nurses who cross contaminate clean surfaces with gloves from one setting to another . And the idea of wearing a tie or lab coats is dated and wearing scrubs in the street is ultimate stupidity. Clear medical research, training, accountability and common sense should interact come together, I hope before the next pandemic

  6. Carol
    UTAH
    Reply

    I always wonder about the finger monitor that is used to measure our oxygen percentage. Don’t germs get passed from sick patient to other patients even is the drs office?

  7. Gussie
    Denver
    Reply

    Out of surgery two weeks ago directly to rehab — complex hip replacement.

    Yes, good hygiene is missing. More to the point, critical thinking is missing.

    How often can a patient affect change during a four or five day hospital stay? Three shifts of nurses per day/3 shifts of CNA’s/one physician hi&bye visit per day. Two shifts of OT’s, PT’s each day. Two shifts cleaners, missing most surfaces each shift. So much more. It’s chaos.

    Patients cannot train 30 caregivers in five days to “pay attention to the most basic of all sterilization skills.”

    Bring: 10, 10 packs of antiseptic wipes; several 8 ounce bottles of liquid antiseptic gel; box of 100 plastic or latex germ free disposable gloves; a small to medium size inexpensive “covered” waste container. Offer wipes to staff who aren’t paying attention. Self-cleanse any place they touch you within a minute.

    Wipe off bed rails, bed tray, room phone, cell phone, laptop, pens, bathroom sink, toilet seat, toilet flush device — twice a day. Do all while wearing fresh plastic glove, disposing of it in self closing waste container. Line waste container with plastic liners for germ free disposal.

    Moved to rehab center, considered best in small high-rent city. Had to supply own table to place paperwork upon, sort mail, & provide a writing space. One overhead light in room, leaving rest of room dark at 7 pm — ordered clip up lamp.
    Room does not have a chair to sit up in — important to sit up straight with flat back and seat just above knee level. I sit in a wheelchair instead — I brought my own 4″ cushion knowing most rehab centers are designed for another generation of 4″ shorter people. I use it wherever I wish to sit — I am 5’8″.

    Briefly, receiving the best care in hospital & rehab is a DIY project. These are businesses with bottom lines, relatively young and inexperienced staff, & short attention spans.

    P.S. What did I forget? Rehab center had no surgical dressings as used by my surgeon & refuse to change the two I have had for 3 weeks. Rehab had no compression binder for my leg when my first one became too large. I ordered one online from Amazon — arrived today — two weeks since request.

    If caregivers say “maybe or don’t answer with date of arrival & show you purchase order” — don’t wait. Assume it’s a NO, order yourself. You are more on your own than any of us wants to believe.

  8. Virginia
    Reply

    I am an RN, recently having been treated for an HAI. The 4 big-gun antibiotics were killers, as much as the possible infection. The scrub situation changed over the years because of the expense to the hospital- also whinny personnel about having to change clothes & not being able to “express their individuality” with their clothes. Seriously! The ubiquitous yellow cover gown is useless draped over your elbows like one sees all the time. No one gets an adequate education for actual bedside nursing these days so many of the old fashioned ideas are gone by the wayside. BUT,they can certainly use the computers, which are also a haven for microbes! Keep on telling people to never go to the hospital alone.

  9. Fred Overstreet
    Winston-Salem, NC
    Reply

    My wife was admitted to a hospital with a urinary tract infection. Approximately six months later (after six transfers between the hospital and skilled nursing facilities, a broken back from a fall from her bed, back surgery, and a punctured esophagus from a feeding tube insertion, she died from spinal meningitis. Since then I have been told that I should have surgery to correct my spinal problems. You can guess what my response was to that. I am 84 years old and I may be admitted to a medical facility some day but only if I am unconscious.

  10. JP Marx
    Washington
    Reply

    I lost my husband to “hospital associated infections,” specifically MRSA, C. difficile, and Acinetobacter.baumannii. Changing the terminology of how these infections killed him does not disguise the fact that it was an ugly and preventable death.

  11. Irene
    Connecticut
    Reply

    Something should be done about the LONG HAIR worn by some caregivers, which can get contaminated when the caregiver bends over a patient, and the hair touches the patient’s clothes. The hair then touches the next patient and can transfer germs.

    At times the long hair sweeps across a sterile field at the bedside.
    If wearing gloves, the caregiver keeps brushing long hair away from his or her face, contaminating the hair.

    At one time, hair was considered a fomite and had to be worn above the collar.
    Perhaps we should reconsider that rule.

  12. Irene
    Connecticut
    Reply

    Something should be done about the LONG HAIR worn by many women caregivers, which touches the patient when she bends over, and at time, sweeps across a sterile field at the bedside.
    Also, even if she is wearing gloves, she is constantly brushing her hair away from her face and transporting germs to her hair.
    At one time in the past, hair was considered a fomite , and had to be worn above the collar of the caregiver.

  13. Pam
    Reply

    Perhaps it all comes down to money – hospitals don’t want additional expenses – but they are not realizing that word of mouth is the best recommendation – if a patient does super at a
    particular hospital, maybe more people would patronize that hospital?

  14. LYNNE
    Florida
    Reply

    I see people from the Hospitals wear their scrubs everywhere outside all the time. This is WRONG!

    Scrubs can be used for Casual wear by many people who are very comfortable in them and not hospital personnel but NOT if you are getting off Duty or going on a Chore between cases as is now very common practice. Many even go out to restaurants for Lunch either to eat in or pick up in their scrubs. Again WRONG.

    As a Medical professional now retired I see this and know it was NEVER allowed when I worked.

  15. HelenM
    Modesto
    Reply

    In my area we have hospitalists, doctors who provide patient care and are employees of the hospital. Your personal doctor no longer visits you, which means s/he is no longer a carrier of germs from the hospital to the office. On the negative side: this means your care is in the hands of a doctor who is a stranger to you, and vice versa, and not someone you personally picked to have as your physician. Doctors who do not do surgery, under these hospitals, may lose the freedom to do rounds.

    It has always been so: more security equals less personal freedom. In our country, that won’t necessarily fly. However, when you are in the hospital, you are at their mercy and must accept what is offered, for the most part. OTOH, whenever I have had surgery, the surgeon does a follow-up in the hospital.

    My surgeon at UCSF sees patients in her office on Mondays only. Otherwise she is in the hospital, operating and making rounds. Hopefully that means she does not bring life threatening, or other, germs to her office patients. Unfortunately, that does not mean these germs are circulating round and round in the hospital.

  16. Alex
    Chicago
    Reply

    It all comes down to money. Hospitals used to use bleach to disinfect hospital rooms, equipment, etc. Now, taking the time to thoroughly clean the hospital environment is too costly and shortcuts are made all the time. Bleach is known for destroying various disease causing bacteria. The idea mentioned above of disposable gowns over hospital personnel clothing is an excellent idea.

  17. RG
    South Carolina
    Reply

    I have noticed registered nurses, licensed practical nurses and others wearing their scrubs in the supermarket and at meetings of a weight-loss group I attended. They have returned from clinical settings. They do this for their own convenience. This is most upsetting when you consider that they are exposing many others to pathogens (agents which cause disease) from their patients. I never did this when I worked as a registered nurse.

  18. Kassandra
    Arizona
    Reply

    My father died of MRSA which he contracted while in the hospital for something totally unrelated. One good step has been that many hospitals now have their orthopedic wings completely separate from hospital areas where the patients have contagious diseases. I have have two knee replacements, and no one on the wing was sick!

  19. Sabrina
    San Diego
    Reply

    I had colon cancer 4 years ago and went for a resection. I was in the hospital for 10 days. My 2nd biggest concern was getting MRSA. The bandage on my belly was never changed or touched my anyone except the doctor who did the surgery. He would come by, take a look and say “Looks good”. When I got home and looked at the 8″ incision I knew all was not good.

    Long story short, he refused to test me for MRSA so I went to my primary, got tested and treated. I don’t know if the OR was contaminated or the surgeon is a carrier. But I believe ALL healthcare practitioners who work in hospitals should be tested regularly. Especially surgeons who work medical emergencies.

  20. Eileen
    Illinois
    Reply

    Family members and visitors need to follow isolation protocols set by the hospital if needed for the patient they are visiting. The visitors take are also fomites when they fail to follow isolation procedures. Visitors fail to realize that they are posing a health risk to themselves as well as the community when the do follow isolation procedures. Every visitor should wash their hands or use hand sanitizer prior to visiting a patient and after visiting a patient.

  21. Paula
    Charlotte, NC
    Reply

    A disposable barrier (like a thin plastic bag) should be used on a blood-pressure cuff, since it touches the bare skin of many patients without being disinfected. A thin disposable plastic barrier might also be helpful on those computers that are wheeled from room to room (the nurse could type on the keyboard through the barrier).

  22. Jane
    Montana
    Reply

    This is so important! Thank you for the article and post. One of the things I worry about is the bedrail. I have never Seen someone disinfect any bed rails in the hospital. Perhaps they do and I just haven’t seen it? Last time I had an endoscopy I ended up contracting viral meningitis. I can’t say definitely that it was acquired there but am very suspicious. I really wonder if hospitals or clinics take this very important step to prevent infection.

  23. Andee
    Arizona
    Reply

    When I became a registered nurse in the 1960’s we were required to keep our hair above our collar, wear no jewelry except a watch and keep fingernails short and clean. Now I see long hair swinging well below the shoulders where it picks up dust and germs from surfaces. Furthermore long hair takes a long time to wash and dry so it isnt often. Fingernails are often long and not cleaned as often as they should be. My husband acquired MRSA in the puncture site for a chest tube for pleural effusion complication following heart bypass surgery. Treatment took a long time, and was difficult and expensive. We dont know the source of course. Later we learned that hospital had a high rate of infection. It has since been closed.

  24. george miller
    west virginia
    Reply

    Home-visiting nurses, hospice-type workers, and even home-makers who visit elderly infirm persons can also become transmission sources for germs especially if they visit more than one household each day. The standard use of gloves and a light gown-like covering seems to be very important.

    The problem arises after familiarity with the patient is established, and the friendship tends to drop the protective barriers since there is a relationship with the person. This is human nature but interferes with safety protocol. The human touch, skin to skin, is a powerful demonstration of closeness and trust. But that very act can spread an infectious disease between patient and caregiver and on to the next home visited.

  25. Bill H
    Maryville, Illinois
    Reply

    I received a small cut on my ankle in the early 80s and went to the local hospital emergency facility for treatment. After waiting in the treatment room for several hours, the physician finally cleaned my wound and stitched it up and surprisingly ordered me to check into the hospital for “observation.” Well, the next morning I had a full blown infection in my leg. Three days later I was diagnosed with staph infection, and I was one day from having my leg cut off at the knee or higher. Many years later I discovered that staph infections were HAIs, and I was furious that no one at the hospital had mentioned that to me at the time. I thank God that I had a good doctor who treated me and saved my leg from being amputated.

    Obviously, I support the recent studies on HAIs and strongly encourage all hospitals to implement the recommended measures to reduce this unnecessary threat to patient lives.

  26. Katy
    Texas
    Reply

    I also hate to see health care workers wearing scrubs to the grocery store and other shops. It seems to me that they are carrying germs from hospitals to the public. One doctor in our neighborhood showed up at a block party wearing scrubs. It doesn’t take that long to change clothes.

  27. Nancy
    Reply

    I acquired an infection in the hospital during childbirth. It was initially mis-diagnosed. I am happy to be alive but it was a horrible experience and affects me to this day.

  28. Helen
    Reply

    I firmly believe they should do AWAY with the white coat status because it looks professional. Who cares about the White Coat??? Only the person wearing it. I care more about myself and others for germ free care. If it’s so important to some then wear disposable white after every patient! What’s more important your “professional” feeling or your patient??? Should be your patient!!!! Not yourself!

    Time to get it right folks. I have known many people getting infections after being in hospital and several dying from staf and other infections and they were young!!!!

    Let’s move on and get it cleaned up and right.

    We have become too laxed in this area. DR’s need to wash their hands before touching you and that goes for the nurse also. If you don’t wash wear rubber gloves. One or the other, washing is less expensive.

    Thanks for opportunity to have my say.

  29. Joan
    Santa Monica ca
    Reply

    I see Drs and nurses running around town for lunch and errands in their scrubs and white coats and have always thought how unhygienic that was. They also are allowed to come to work in their scrubs which means they have been in transportation.

  30. Gail
    Virginia
    Reply

    There is no mention of touch screens in this article. My husband had to go to the emergency room two days after outpatient hernia surgery, and I observed the nurse touching the computer monitor with the same gloved fingers she used to insert his catheter and empty the collection bag. I’ve observed similar behavior during other hospital stays. Those touch screens should be disinfected between patients.

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