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Infection control ‘undercover’: a patient experience

  • S.J. Dancer
    Correspondence
    Corresponding author. Address: Department of Microbiology, Hairmyres Hospital, Eaglesham Road, East Kilbride G75 8RG, UK. Tel.: +44 (0) 1355 585000; fax: +44 (0) 1355 584350.
    Affiliations
    Department of Microbiology, Hairmyres Hospital, East Kilbride, UK
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Published:January 09, 2012DOI:https://doi.org/10.1016/j.jhin.2011.12.003
      As a National Health Service microbiologist and former editor of the Journal of Hospital Infection, most of my professional time is spent managing nosocomial infection. Becoming a patient was not part of the job plan until a sudden accident on holiday compelled hospital admission. It was an opportunity to experience infection control in the real world and one that could not be ignored. Bedbound, and ‘undercover’, this patient witnessed the ward-based impact of infection control in hospitals in two countries.
      The accident dislodged three intervertebral discs, warranting immediate admission into an acute trauma ward in Italy. There were no privacy curtains; no lights other than a fluorescent ceiling strip; no nurse call button; no electrical equipment; no soft furnishings; and no alcohol gel. There is an expectation that relatives provide basic hospital care in this part of Italy, and this, in part, reflected the paucity of nursing staff. The ward sink was used only by visitors. None of the doctors cleaned their hands during the ward rounds, despite moving from patient to patient. No hand hygiene opportunities were offered to patients after toileting, nor before or after eating.
      If hands were ignored, basic cleaning certainly was not. Given minimal clutter in the bay, two domestic personnel obtained easy access to all dark corners. The floor was vacuumed, then mopped, and all beds and lockers moved for cleaning purposes. Window blinds, cupboard, door handles, wall fixtures and light switches were also wiped over everyday, with the sink and taps receiving attention twice daily. Overbed tables were cleaned before and after meals, with bathrooms scoured twice a day. Whereas visual appearance of cleanliness should be of little consequence to a microbiologist, witnessing the effort involved in cleaning this ward certainly allayed any fears of encountering long-lasting dirt (and microbes).
      • Kramer A.
      • Schwebke I.
      • Kampf G.
      How long do nosocomial pathogens persist on inanimate surfaces? A systematic review.
      • Dancer S.J.
      Mopping up hospital infection.
      Clinical stabilization allowed transfer to a Scottish hospital by air ambulance. Despite prompt magnetic resonance imaging, busy nurses did not remove a defunct intravenous (IV) cannula for a day. This contrasted with the voracious speed at which meticillin-resistant Staphylococcus aureus (MRSA) swabs were offered, which occurred within minutes of admission.
      • Hassan K.
      • Paturi A.
      • Hughes C.
      • Giles S.
      The prevalence of methicillin resistant Staphylococus aureus in orthopaedics in a non-selective screening policy.
      • Dancer S.J.
      Considering the effect of universal MRSA screening.
      The IV site was not included in the MRSA screen, despite obvious inflammation.
      • Dancer S.J.
      Considering the effect of universal MRSA screening.
      The infection control policy on this trauma ward did, however, encompass a ban on flowers, presumably because they represent nursing time to manage, as well as providing an impediment for surface cleaning.
      • Day G.
      • Carter N.
      Wards of the roses.
      Domestic staff could not hope to emulate the comprehensive efforts observed in the Italian hospital, since cleaning this busy, cluttered ward posed a herculean challenge. The toilet attracted more cleaning attention than peoples’ hands did, in that staff cleaned, or checked, the toilet at least five times every 24 h. This seemed a bit excessive when hand hygiene was often ignored, along with door handles. Handles are obviously touched far more frequently than the toilet, and could easily provide a safe haven for pathogens.
      • Kramer A.
      • Schwebke I.
      • Kampf G.
      How long do nosocomial pathogens persist on inanimate surfaces? A systematic review.
      • Oie S.
      • Hosokawa I.
      • Kamiya A.
      Contamination of room door handles by methicillin-sensitive/methicillin-resistant Staphylococcus aureus.
      The best trigger for hand hygiene was the flashing blue light at the ward entrance. Everyone wandered by rubbing their hands.
      • Davis C.R.
      Infection-free surgery: how to improve hand-hygiene compliance and eradicate methicillin-resistant Staphylococcus aureus from surgical wards.
      Unable to escape surgical intervention, the patient was transferred for neurosurgery. The room was visibly grubby on admission, with litter on the floor and a waste bin containing used clinical dressings. Close examination of the bathroom revealed dirty toilet and shower, which required energetic attention from relatives using disinfectant wipes. They then tackled hand-touch sites around the bed, particularly cot-sides resplendent with blood splashes. During transfer to the operating theatre, various items (notes, spare blanket) fell onto the floor in a public corridor and were replaced on the bedcover. Is there an infection risk from patients’ belongings falling onto the floor? Or from returning patients’ feet into bed after contact with a hospital floor? Two days after surgery an MRSA swab was taken when one of the nurses noticed that a box required ticking.
      What sorts of practices catch a microbiologist’s attention? Hand hygiene, obviously, but no one could fail to notice poor cleaning, misfitting policies and universal staff shortages. Did staff clean their hands before providing care? No, usually not. Was the patient touched? Yes, every day. Staff generally cleaned their hands after clinical examination, presumably because protection of self seems to be the obvious trigger for performing hand hygiene, and not protection of patient.
      • Scheithauer S.
      • Oberröhrmann A.
      • Haefner H.
      • et al.
      Compliance with hand hygiene in patients with meticillin-resistant Staphylococcus aureus and extended-spectrum β-lactamase-producing enterobacteria.
      • Erasmus V.
      • Daha T.J.
      • Brug H.
      • et al.
      Systematic review of studies on compliance with hand hygiene guidelines in hospital care.
      Hand hygiene notices papered the walls of the UK hospitals. If they were supposed to empower this patient to challenge to staff over their hand cleaning, then they failed utterly.
      • Pittet D.
      • Panesar S.S.
      • Wilson K.
      • et al.
      Involving the patient to ask about hospital hand hygiene: a National Patient Safety Agency feasibility study.
      Brusque attitude from nurses intimated a less than welcome response if anything had been said, and there was real concern over timely pain relief.
      • Burnett E.
      • Lee K.
      • Rushmer R.
      • Ellis M.
      • Noble M.
      • Davey P.
      Healthcare-associated infection and the patient experience: a qualitative study using patient interviews.
      • Dancer S.J.
      Pants, policies and paranoia.
      If a Journal of Hospital Infection editor could not remind staff about hand hygiene, how do other less-informed patients manage? Why should a patient have to take responsibility for staff hand hygiene in any case?
      • Dancer S.J.
      Pants, policies and paranoia.
      • Gould D.
      • Hewitt-Taylor J.
      • Drey N.S.
      • Gammon J.
      • Chudleigh J.
      • Weinberg J.R.
      The CleanYourHandsCampaign: critiquing policy and evidence base.
      Patients are not only vulnerable, they are also extremely grateful for their care.
      • Burnett E.
      • Lee K.
      • Rushmer R.
      • Ellis M.
      • Noble M.
      • Davey P.
      Healthcare-associated infection and the patient experience: a qualitative study using patient interviews.
      Asking staff whether they had clean hands repudiates the latter and casts doubt on overall quality of care.
      What about cleaning? The Italian hospital was spotless but the Scottish experience was less than ideal. Domestic schedules could be constructed just by watching. Bed-frame, bed controls, nurse call, light switch, clinical notes, locker and overbed table are not cleaned by domestics but by nurses.
      • Anderson R.E.
      • Young V.
      • Stewart M.
      • Robertson C.
      • Dancer S.J.
      Cleanliness audit of clinical surfaces and equipment: who cleans what?.
      These frequently touched sites are known to accommodate pathogens but they received only an occasional flourish with detergent wipes.
      • Anderson R.E.
      • Young V.
      • Stewart M.
      • Robertson C.
      • Dancer S.J.
      Cleanliness audit of clinical surfaces and equipment: who cleans what?.
      • Dancer S.J.
      • White L.F.
      • Robertson C.
      Monitoring environmental cleanliness on two surgical wards.
      • Dancer S.J.
      • White L.F.
      • Lamb J.
      • Girvan E.K.
      • Robertson C.
      Measuring the effect of enhanced cleaning in a UK hospital: a prospective cross-over study.
      • Bhalla A.
      • Pultz N.J.
      • Gries D.M.
      • et al.
      Acquisition of nosocomial pathogens on hands after contact with environmental surfaces near hospitalised patients.
      • Carling P.C.
      • Briggs J.L.
      • Perkins J.
      • Highlander D.
      Improved cleaning of patient rooms using a new targeting method.
      Since hand hygiene compliance for a bed-bound patient approaches zero, any contact with nearby surfaces could potentially transfer pathogens to the patient. Who better to inoculate his or her own wound?
      • Banfield K.R.
      • Kerr K.G.
      Could patients’ hands constitute a missing link?.
      • Gagne D.
      • Bedard G.
      • Maziade P.J.
      Systematic patients’ hand disinfection: impact on meticillin-resistant Staphylococcus aureus infection rates in a community hospital.
      Cleaning specifications for domestic staff should encompass the sites that the nurses forget or do not have time to do.
      • Anderson R.E.
      • Young V.
      • Stewart M.
      • Robertson C.
      • Dancer S.J.
      Cleanliness audit of clinical surfaces and equipment: who cleans what?.
      • Lloyd-Hughes R.
      • Talbot S.
      • Jumaa P.
      Bedside Bibles, notes trolleys and other forgotten sites for cleaning.
      There was no help with cleaning hands before eating – whether with alcohol gel; or soap and water. An organism intent on accessing the gut, e.g. Clostridium difficile, would do well by contaminating a near-patient site – such as the overbed table.
      • Nerandzic M.M.
      • Cadnum J.L.
      • Pultz M.J.
      • Donskey C.J.
      Evaluation of an automated ultraviolet radiation device for decontamination of Clostridium difficile and other healthcare-associated pathogens in hospital rooms.
      Only the upper surface of this table was cleaned, not underneath where fingers touch.
      • Nerandzic M.M.
      • Cadnum J.L.
      • Pultz M.J.
      • Donskey C.J.
      Evaluation of an automated ultraviolet radiation device for decontamination of Clostridium difficile and other healthcare-associated pathogens in hospital rooms.
      Indeed, even if accessible, alcohol gel would have only offered false assurance, given the ability of C. difficile to withstand this product.
      • Tschudin-Sutter S.
      • Pargger H.
      • Widmer A.F.
      Hand hygiene in the intensive care unit.
      As already mentioned, patients’ hands are just as likely to transmit pathogens as those of staff – perhaps even more so.
      • Banfield K.R.
      • Kerr K.G.
      Could patients’ hands constitute a missing link?.
      Relatives’ hands are an additional risk, and often forgotten.
      • Gagne D.
      • Bedard G.
      • Maziade P.J.
      Systematic patients’ hand disinfection: impact on meticillin-resistant Staphylococcus aureus infection rates in a community hospital.
      There is no doubt that more nurses on the wards would lessen the workload, thereby promoting hygiene. Poor practices witnessed were not due to individuals but rather to the system in which they worked.
      • Goldmann D.
      System failure versus personal accountability – the case for clean hands.
      It was obvious to this patient that overcrowded wards, short staffing, antiquated guidelines, or ignorance of guidelines could explain most hygiene misdemeanours witnessed.
      • Humphreys H.
      Overcrowding, understaffing and infection in hospitals.
      Visible presence of infection control nurses on the ward might have improved hygiene attention, but given inadequate staffing, the term ‘flogging a dead horse’ springs to mind even if an infection control champion pops up occasionally waving a hand hygiene flag. When a patient arrested, the last thing anyone thought about was clean hands.
      Now safely returned to active microbiology, this personal experience of infection control can be considered against the increasing tide of multiply resistant organisms (World Health Organization, ‘Antimicrobial resistance: no action today, no cure tomorrow’; http://www.who.int/world-health-day/2011/en/index.html). What happens when the antibiotics finally run out? Colossal resources are required to procure a license for novel agents and pharmaceutical companies are reluctant to commit to development of anti-infectives. The only remaining course of action will be basic hygiene.
      • Dancer S.J.
      Hospital cleaning in the 21st century.
      How do we reverse widespread erosion of the importance of ‘clean’, let alone define its meaning, at the beginning of the twenty-first century? Presumably, when ordinary healthy people begin to die from untreatable infection.
      Despite all the effort at integrating good hygiene into hospitals, this unplanned ‘undercover’ audit revealed the true impact of infection control and found it lacking. This patient escaped complications but the way she now thinks about, and practices, infection control has changed forever.

      Conflicts of interest

      The author once received funding from Unison for a cleaning project and continues to publish papers on hospital cleaning. There are no other competing interests.

      Funding sources

      None.

      References

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        Mopping up hospital infection.
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        The prevalence of methicillin resistant Staphylococus aureus in orthopaedics in a non-selective screening policy.
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        Considering the effect of universal MRSA screening.
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        Infection-free surgery: how to improve hand-hygiene compliance and eradicate methicillin-resistant Staphylococcus aureus from surgical wards.
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        Compliance with hand hygiene in patients with meticillin-resistant Staphylococcus aureus and extended-spectrum β-lactamase-producing enterobacteria.
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        Involving the patient to ask about hospital hand hygiene: a National Patient Safety Agency feasibility study.
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        Healthcare-associated infection and the patient experience: a qualitative study using patient interviews.
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        Pants, policies and paranoia.
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        Cleanliness audit of clinical surfaces and equipment: who cleans what?.
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        Measuring the effect of enhanced cleaning in a UK hospital: a prospective cross-over study.
        BMC Med. 2009; 7: 28
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        Acquisition of nosocomial pathogens on hands after contact with environmental surfaces near hospitalised patients.
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        Improved cleaning of patient rooms using a new targeting method.
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        Could patients’ hands constitute a missing link?.
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        Systematic patients’ hand disinfection: impact on meticillin-resistant Staphylococcus aureus infection rates in a community hospital.
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        J Hosp Infect. 2008; 69: 200-201
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        • Donskey C.J.
        Evaluation of an automated ultraviolet radiation device for decontamination of Clostridium difficile and other healthcare-associated pathogens in hospital rooms.
        BMC Infect Dis. 2010; 10: 197
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        Hand hygiene in the intensive care unit.
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        System failure versus personal accountability – the case for clean hands.
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        Overcrowding, understaffing and infection in hospitals.
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