Why Aren't Hospitals Cleaner?

The following is a commentary by Betsy McCaughey, chairman of the Committee to Reduce Infection Deaths, a national effort focusing on hospitals. She was lieutenant governor of New York and has published widely in health policy.

Restaurants and cruise ships are inspected for cleanliness. Food processing plants are tested for bacterial content on cutting boards and equipment. But hospitals, even operating rooms, are exempt. The Joint Commission, which inspects and accredits U.S. hospitals, doesn't measure cleanliness. Neither do most state health departments, nor the federal Centers for Disease Control and Prevention.

No wonder hospitals are dirty. New data presented in April at the annual meeting of the Society for Healthcare Epidemiology of America documented the lack of hygiene in hospitals and its relationship to deadly infections. Boston University researchers who examined 49 operating rooms found that more than half of the objects that should have been disinfected were overlooked. A study of patient rooms in 20 hospitals in Connecticut, Massachusetts, and Washington, D.C., found that more than half the surfaces that should have been cleaned for new patients were left dirty.

Germ-coated. Sad to say, cleanliness is not a priority for hospital administrators or most medical professionals. A new University of Maryland study shows that 65 percent of physicians and other medical professionals admitted they hadn't washed their lab coat in at least a week, even though they knew it was dirty. Nearly 16 percent said they hadn't put on a clean lab coat in at least a month. Lab coats become covered in bacteria when doctors lean over the bedsides of patients who carry the organisms. Days later the bacteria are still alive, repeatedly contaminating doctors' hands and being carried to other patients.

From admission to discharge, Dr. Bernadine Healy preps patients and their families for major surgery
The CDC and other organizations urge caregivers to clean their hands between patients, and even advise patients to speak up and request that caregivers have clean hands.

That's a start, but it's not enough. As long as hospitals are inadequately cleaned, doctors' and nurses' hands will be recontaminated seconds after they are washed — when they touch a keyboard, open a supply closet, pull open a privacy curtain, or contact other bacteria-laden surfaces. In a recent Johns Hopkins Hospital study, 26 percent of supply cabinets were contaminated with a dangerous bacterium, methicillin-resistant Staphylococcus aureus (MRSA) and 21 percent with another stubborn germ, vancomycin-resistant Enterococcus (VRE). Keyboards are such reservoirs of deadly bacteria that a few hospitals are installing washable keyboards, including one that sounds an alarm if it isn't disinfected periodically.

Hand to mouth. Stethoscopes, blood pressure cuffs, and EKG wires are used on successive patients without being cleaned. Studies published as long ago as 1978 warn that blood pressure cuffs frequently carry live bacteria, including MRSA, and are a source of infection. In a newly released British report, one third of blood pressure cuffs were found to be contaminated with Clostridium difficile, a germ that can cause lethal diarrhea if it enters via the mouth. It's a short trip from a cuff to a patient's bare arm, then to the fingertips and into the mouth. At a hospital in Galveston, Texas, where a burn patient became infected with VRE, molecular typing traced the bacteria to an unclean EKG wire. The VRE on the wire had been left behind by a patient discharged 38 days earlier.

The good news is that a simple solution—thorough cleaning with ordinary detergents and water—curbs the spread of deadly bacteria. When researchers at Rush University Medical Center in Chicago trained the staff to soak surfaces with detergent rather than merely spraying and wiping, and to clean commonly overlooked objects such as telephones, remote controls, and faucets, the spread of VRE to patients was reduced by two thirds.

Even the cash-strapped British National Health Service recognizes that intensive cleaning is a bargain compared with the cost of treating infections. By nearly doubling cleaning-staff hours on one ward, a hospital in Dorchester reduced the spread of MRSA by 90 percent, saving 312 times the added cleaning costs.

Hospitals once tested surfaces for bacteria, but in 1970, the CDC and the American Hospital Association advised them to stop, saying testing was unnecessary and not cost effective. MRSA infections since then have increased 32-fold, and numerous studies have linked unclean hospital equipment and rooms to infections. Yet the CDC's latest guidelines still deem routine testing for bacteria unnecessary. "If you culture on a regular basis, you're always going to find something," says Denise Cardo, who runs the CDC's division of healthcare quality promotion. "You don't want the labs to be used for that instead of tests on patients."

Are we to believe that it is less important to test for bacteria in operating rooms than in hot dog factories?

Testing is essential because bacteria are invisible. A study in the Journal of Hospital Infection showed that 76 percent of various hospital sites checked by researchers had unacceptably high levels of bacteria, although only 18 percent of them looked dirty. In another study, Boston University researchers found that cleaning improved significantly once they sampled surfaces for bacteria and showed cleaning personnel the areas they had missed.

Unreasonable standard? You'd think that a hospital accredited by the Joint Commission would be clean, but it's no guarantee. California hospital inspectors, investigating complaints from the public, found that 25 percent of hospitals where conditions were unsanitary had been inspected and accredited by the Joint Commission within the previous year.

If Joint Commission inspectors walk into a noticeably messy and unclean patient room, they will trace back to find out how that happened, explains Robert Wise, vice president for standards and survey methods. Otherwise, Joint Commission standards don't specify how rooms should be cleaned or what bacterial levels are unacceptable. Asked whether bacterial levels should be measured, Wise answers: "You can only ask hospitals to do so much."

That seems to be the CDC's attitude as well. For over 30 years, the CDC has been collecting monthly data recording a sharp rise in drug-resistant hospital infections. A new report from a nursing organization, the Association for Professionals in Infection Control and Epidemiology, shows that the CDC has consistently underreported MRSA in hospitals, giving them an excuse to do too little.

In 2005, health officials in Ireland and Scotland began rating hospitals annually for cleanliness — red (the dirtiest), amber, or green — and publishing the ratings. The first-year results made headlines, putting pressure on the worst Irish hospitals to clean up and earn higher marks in 2006.

In England last month, Gregory Barker, a member of Parliament, rolled up his sleeves and worked a shift with the cleaning staff at a hospital in his district. "Hospital cleaning is a vital part of patient care," he said in a statement released by his office. Where are his counterparts in Washington, D.C.? Congress has been virtually silent about hospital infections — and no member has displayed any interest in picking up a mop.

By Betsy McCaughey