Wringing Our Hands Over Infection Control

Importance of Calcium

My earlier comments prompt clarification. The foundation from which medicine derives its right to treat the patient is flawed and in need of replacement. Until medicine changes its philosophy, patients will continue to suffer at their hands. Here we must separate the heroic and life-saving skills of the emergency room specialists. These teams of trauma specialists are owed our respect and gratitude.

It is allopathic medicine that is wrong. It is just plain wrong. Wrong in the sense of not right, in error, false, untruthful, say it all the ways we can because the medical foundational philosophy is unscientific.

If the body has a fever - it is wrong to express itself using that physiological response and so the doctor advises to act against the fever-causing, fever-producing mechanism, interfere with the body's natural response and do the opposite. This is the literal definition of allo-pathy - do the 'opposite pathos.'

If the body (there are some exceptions to this) is using inflammation for its sequence of healing steps, the doctor advocates anti-inflammatories in recognition of the body's error in judgement.

Readers may find a most helpful tool for maintaining immunity against all vectors of infection to be calcium. I am reminded of the study done, I may mistakenly say Columbia, that measured various indicators upon admission to the hospital. They found the most reliable indicator for predicting outcome of the interaction - i.e., if the patient recovered and how quickly, was the level of ionized calcium in the blood.

Electron microscopy has revealed a calcium cloud that surrounds the material to be acted on by the immune system and enzymes are drawn into the cloud to dis-mantle the offending molecules.

We need to protect ourselves against all enemies - foreign and domestic. This is done with a strong standing army of immune soldiers and internal observation/recognition system to properly identify threats both real and imagined. Real threats are the things we encounter from the natural world and imagined are those we encounter from the hands and needles of the afore-mentioned errors in medical judgement and philosophy. We have been deceived to believe unhealthy things about our bodies. It is our health. Health is the outcome of choices made over time. Health is no one else's responsibility but our own. We have no one to blame but ourselves for the state or pictire of health we represent. The very skin on our faces tells everyone what we do with our bodies - whether we eat well, exercise and drink sufficient water or we do not. Health is not insurance coverage. Good insurance itself may get you killed from procedures they pay for that you may not really need.

I do not apologize for the wake-up tone of this post. We as a species have abandoned our niche and our relationship with our host planet. We are treating our gracious life-giving host, most shabbily. Our poor health, cancer epidemic, autism plague, threatening bird flu, etc., are warning us.

Basics of Hand Hygiene

The solution to what appear to be paradoxical results in the cited study may be very simple. The authors of the Rupp paper used a hand hygiene product with insufficient antimicrobial activity, in other words, their product was insufficient at killing microorganisms on hands. We should keep in mind that it is not the ritual act of performing hand hygiene that prevents hospital infections, but instead the killing or elimination of microorganisms on hands that does so. Already good old Semmelweis 160 years ago showed very clearly that handwashing (which is now known to be insufficient at eliminating microorganisms from hands) was inferior to hand antisepsis with an agent that is now known to kill microorganisms on hands very effectively. If one uses a hand antiseptic with insufficient antimicrobial activity, then one has no advantage over traditional handwashing.

Hospital Infections

Environmental cleaning, surveillance, hand washing, active detection and isolation are all parts of the bundle which are needed for effective and sustained control of MRSA and other resistant organisms. But if we are to believe what the CEO of a tech company is telling us, it can't be done without his company's technology. If so, how do we explain Northern Europe, Western Australia and numerous domestic institutions that have controlled these bugs for decades without such complex and expensive technologies?

In 2003, the Society of Healthcare Epidemiology of America canonized an approach for controlling these organisms in American healthcare institutions. In addition to the aforementioned successes, the 2003 SHEA guideline is supported by about 200 studies attesting to its efficacy and approximately 15 studies showing it to be cost-effective. It's not technology and it's not knowledge that has been lacking, it's simply lack of implementation of evidence-based techniques and true healthcare leadership.

handwashing is overrated

It is terribly short-sighted to believe that hand washing and isolation are the most effective ways to fight the spread of MRSA.

Every day, otherwise healthy patients go into hospitals for regular treatment and end up with MRSA, C-Diff, VRE, or flu – despite being in a private room and having a caregiver with gloves and good hand washing.

So what else is going on?

There is no single answer. But one compelling clue is that two-thirds of hospital-acquired infection cases are now found in the general patient population, compared to just two percent 30 years ago.

One possibility may be that hospitals are overlooking and under-protecting their most widely-travelled employees.

Each day, housekeepers, transporters and their supervisors walk into hospital rooms without knowing infected patients have been there. So every day, people who cover the most ground in the hospital are inadvertently exposed to infection. Because these workers continue about their business without knowing they’ve been exposed, the risk of wider contamination is almost a certainty.

Inadvertent exposure occurs because of the way most hospitals communicate, or rather fail to communicate, isolation to staff. Many infection control nurses must still prepare “blocked” room lists by hand. Very often, those lists are outdated even before the nurses leave their offices.

By failing to alert environmental services and transport personnel in advance, hospitals deny them the opportunity to protect themselves from exposure and make them a walking vector for continued contagion.

Also, the need for terminal clean procedures is overlooked, so litters and wheelchairs go without antimicrobial wipe downs. And the infection chain continues.

Consider also that infected patients are taken for testing, sometimes two or three times daily. They are transferred to other units. They are eventually discharged. The people who move them and clean up after them are the ones most likely to be exposed without knowing it.

What can be done?

To protect both workers and patients throughout the hospital, patient flow technology is now available which automatically alerts staff of isolation conditions when a page goes out to clean a room. So workers not only know what they are facing, they know to bring the proper equipment for their own protection and optimal hygiene. That same technology, accessed via PDA, can give infection control nurses a mobile visual reference tool to help them assess isolation needs as they make clinical rounds.

This capability is even more vital now that a new strain, known as community-associated MRSA, is spreading outside the hospital. MRSA-CA has the potential of becoming more lethal since it is often misdiagnosed as the hospital-acquired version and treated with the wrong drugs, which could possibly increase its resistance.

In general, patient movement, or the lack of it, is emerging as an important factor in the spread of MRSA. Studies in Great Britain say the most crowded hospitals - with bed occupancy over 90% - had MRSA rates 42% higher than average. The studies concluded that “boarding” emergency patients in close proximity while they wait for inpatient rooms presents a risk of cross-infection.

With most of America’s 4,600 hospital EDs “at” or “over” critical capacity, these findings shouldn’t be ignored. But information technology has an important role to play here as well. Emergency room overcrowding is caused by log jams in patient traffic, due primarily to poor communications and conflicting priorities. Patient flow technology provides real-time information which can avoid those log jams, reducing or eliminating the need for boarding.

The British studies also found that overcrowding pressure denied hospital staff the time to thoroughly disinfect beds and surrounding areas. Improving patient flow can remove the “urgency” associated with overcrowded conditions, so those tasks can be completed in a reasonable time.

While isolation has reduced infection in some U.S. hospitals which also take extra precautions, like requiring workers to wear gloves and gowns for every contact, isolating patients can be extremely difficult in “overcrowded” hospitals.

Without real-time knowledge of bed status throughout the institution, non-infected patients can be mismatched with infected ones. However, those “mismatches” can now be largely avoided because of improvements in patient flow processes, combined with advanced patient flow technology. These advances allow for more flexibility in making room assignments and blocking access to rooms with infected patients.

About 30 percent of hospitals are already using information technology to track and manage hospital-acquired MRSA. Another 50 percent are actively considering it. These include automatic surveillance systems, rapid-testing devices, and computer systems which allow hospitals to pull data from bedside monitors, lab-test results and more to identify problem areas quickly.

The fight will take more than a single solution. The very presence of MSRA disproves the theory that there is a silver bullet for infection. It’s going to take a great deal of effort on many fronts. Communicating information about isolation in real-time, reducing overcrowding and smoothing out the patient flow process are powerful weapons in the war against MRSA that hospitals cannot afford to ignore.

Patients with hospital-acquired infections are seven times as likely to die as the average patient. In 2005, nearly one in five of the 94,000 hospital-acquired MRSA cases was fatal. Deaths that experts say were largely preventable.

Infection Control

I notice the common theme of CEO and Leadership responsibility in most of the comments. I agree that we must have resources from and support by the top ranking decision makers in our hospitals. The reality for a rural hospital is that there are no resources to be had. Our hospital is a rural 50 bed hospital of which the majority of our patients are Medicare and Medicaid and we do upwards of 6 million dollars in charity care annually as well. With less and less reimbursement and more mandatory participation in programs and reporting to an ever expanding number of organizations, there is a significant lack of resources to be utilized. Implementing programs with few financial resources means failure. The Infection Control, Quality, and Patient Safety Department is tapped out. Most rural hospitals have all of these areas in one department with one or two employees and somehow manage to fit in Employee Health and Joint Commission Certification as well. We are forced to take a conservative approach to MRSA and other MDRO prevention by focusing on isolation procedures, hand hygiene, and procedure precautions. Active surveillance may not be something we can implement at this point which may be unfortunate since we do have a population of community acquired infection and colonization that will not be identified upon admission to the hospital. When a rural hospital does MRSA cultures, it takes over 24 hours to get a result whereas a hospital with more resources most likely has a lab with newer technology that can get a result in less than 2 hours. Until the culture comes back, the person must be in contact precautions which then adds to costs.

As a ranch wife, I have to address the comment by B. Allen of VA. America does not have a shortage of meat. It has too many crowded raising areas necessitating some use of antibiotics. However, most ranchers do not need to use antibiotics and when we do, it is usually one dose of PCN or other IM antibiotic. The animal is then not sold for butcher until months later so the antibiotic has ample time to be processed and excreted by the animals body. In feed lots, this may not be the case. I cannot speak to that as we sell our animals as calves. To decrease the use of antibiotics we need to focus on the overcrowding of chickens, pig, and cattle and the use of injury and feces control in these areas. Antibiotic use will not make or break the food market in America. We have more food than we can consume. Antibiotic use saves a few animals and is used occasionally to prevent spread of disease, but it is nothing compared to the overuse in humans.

Hand Hygiene

I read with great interest the report on the Hand Hygiene Study that was carried out at the University of Nebraska Medical Center under the direction of Dr. Mark Rupp (reported in Infection Control and Hospital Epidemiology, January 2008).

Hand hygiene compliance was reported to increase from 38 to 70 %. At first glance, it is surprising that the infection rate did not decrease. Most hand washing study reports, back to Semmelweiss (1846), indicate a decrease in infection rates when hand washing compliance is markedly increased. However, this may not always be the case when ‘waterless’ hand sanitizers are substituted for hand washing. A thorough review of the literature is needed regarding this subject.

There may be a reason why the use of ‘waterless’ hand sanitizers, in some studies, have been found to be ineffective in reducing infection rates. That is, an insufficient amount of ‘waterless’ hand sanitizer was dispensed to the hands of health care workers. The clinical studies that were carried out to justify the approval of use of ‘waterless’ hand sanitizers for inclusion in the FDA OTC Tentative Final Monograph for Over - the Counter Health – care Antiseptic Drug Products 59 Federal Register 31402 (June 17, 1994) were carried out using 3 – 5 mL of the product repeatedly applied to hands. We have tested the amount of ‘waterless’ hand sanitizer delivered from dispensers in various hospitals as well as the volume of sanitizer delivered from bottles and other containers of ‘waterless’ hand sanitizers. It has been found that as little as 0.33 mL is being delivered from some dispensers. The average volume delivered is about 1.5 mL – which is 50% below the lowest level of testing in the studies mentioned above.

Thus, ‘waterless’ hand sanitizers may do more harm than good – if health care workers falsely believe that their hands are properly sanitized when they are not. I believe that monitoring the amount of ‘waterless’ hand sanitizer being applied to the hands should be part of a hand hygiene monitoring program. The amount applied should conform to the effective amount as published in the FDA OTC Tentative Final Monograph (1994).

When hand washing becomes as commonplace in the hospital as wearing of seat belts

The latest quote I have read in a medical publication that made the most sense of late had to do with a change in culture. When hand hygiene becomes as commonplace as wearing seat belts, we will begin to see a difference. Healthcare workers as well as paients and families need to hold each other accountable for proper practice. This includes hand hygiene, disinfection, aseptic practice, sterilization, accuracy, and not over prescribing antibiotics.

The food industry also has a place in all of this as we count on antibiotics to increase our supply of meat.

Patient empowerment

Dear Mr. Comarow: The comments that you have posted are very meaningful, especially those from Michael in Maryland.

An honest and conscientious effort by hospital administrators and their boards to control these infections will get the job done. However, the old song keeps being sung;.."it is too costly ". Well, considering that the health care industry often fails to correct its flaws, perhaps a public outcry by an organization such as the AARP with thirty seven million members can make things happen. I am so convinced that such an organization providing consumers with the tools to evaluate the healthcare providers of this country could rattle the market share of many health care centers and lets face it, market share trumps everything in the competitive healthcare arena. Patient empowerment has to come in the form of an active, collaborative effort mandating a patient bill of rights( that does more than decorate the walls of hospital elevators) and real bedside advocacy. Producing more and more brochures to hand out to patients as they enter the hospital falls way short of the mark and offers nothing more than a "wink and a nod" towards patient safety and quality of care.

The Fresh Air Factor

Fresh air reduces infection rates better than anything else known to makind. Open the windows and let the breezes blow!

Toxicity not infection.

Until we realize the inseparable relationship between toxicity and infection we will continue to fail. Don't blame the garbage on the rats who come to eat it. Same with micro-organisms, who have shared the planet and our digestive tracts for millions of years. Does it strike anyone else as absurd that the highest form of life on the planet (man) has so focused and directed his attention and resources in a declared war against the lowest forms of life on the planet (microbes)?

The enemy is petro-chemical toxicity, aluminum, mercury, fluoride and chlorine, not the microbial flora. But the system exists to sell drugs and sell drugs it will, like vaccines - the great experiment with unknown results using unproven, untested, gene-altering retro-viruses. Pay no attention to that man behind the curtain - there is no link between vaccines and anything at all. They are absolutely good for people. Until people change, the health care system will not change. People need to stop believing in a medical 'Jesus', who will come and save them from themselves - it's your health - you built it just the way it is.