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.”