My grandmother refused to go to the hospital to give birth to any of her nine children; she viewed hospitals as germ-laden places where people went to die. In her day, maybe there was some truth to that view; but over time, as medical and surgical advances were made and as health care education improved, people were reassured that hospitals were safer places. Fast-forward to 2010, when the Agency for Healthcare Research and Quality reported that more than 42,000 patients (0.2% of all hospital stays) had a health care–associated infection in 2007. Despite national attention to this issue, the 2007 rate of such infections was the same as that for 2002.
While it's no surprise that hospitals are replete with bacteria, new reports are telling us the threat resides in places we might not have considered. A study published recently in the American Journal of Infection Control found that 63% of nurses' and physicians' uniforms contained potentially pathogenic bacteria, some of which were antibiotic resistant. At the 51st Interscience Conference on Antimicrobial Agents and Chemotherapy, held recently in Chicago, researchers presented their findings on hospital privacy curtains: two-thirds of swab cultures obtained from curtains used in two ICUs and a medical–surgical unit contained potentially pathogenic bacteria, including methicillin-resistant Staphylococcus aureus. Most curtains newly placed during the study became contaminated within one week of hanging. And in this issue of AJN, Nils-Olaf Hübner and colleagues report on their investigation of paper as a vehicle for bacterial cross-contamination in medical settings. They found that "bacteria not only survive on paper but can also be transferred from one person's hands to paper and back to another person's hands."
The need for infection control is clearer than ever. A host of national organizations, from the Centers for Disease Control and Prevention to the Joint Commission to the Centers for Medicare and Medicaid Services, are addressing that need through standards of care, compliance criteria, and financial incentives. Health care institutions are investing heavily in infection control measures, from constructing isolation rooms with regulated air flow and ultraviolet lighting to supplying gowns, gloves, face masks, and disinfectants. In some hospitals, patients are expected to be their own last line of defense: they're told to ask every person who enters their room "Have you washed your hands?"
I have to say that I don't like this last practice. It doesn't seem right to place the onus on the patient for policing our behavior. (What's next? Will patients be expected to ask "Did you review my medications to make sure there are no contraindications or potential interactions?" or perhaps "Are you using an evidence-based protocol when you change my dressing?") I do understand the rationale—hospitals are dangerous places, and the more that patients can be their own advocates, the better. But we shouldn't be touting it as a solution to the problem; it's just another work-around in a dysfunctional system.
We can reduce the incidence of hospital-acquired infections. The Institute of Healthcare Improvement, the World Health Organization, and others have launched various initiatives, including those supporting the use of checklists to ensure proper procedure and the use of evidence-based, best practice guidelines to prevent ventilator-associated pneumonia and surgical-site and central line catheter–related blood-stream infections, among others, with demonstrated success. Most of these initiatives don't involve high-tech, costly changes. They're built around fundamental aspects of nursing care, such as close monitoring of patients, assessing for indications of improvement or decline, teaching patients self-management skills—and washing one's hands between patients (and patients' paper). This is where we can reinforce the case for adequate nurse staffing, improve patient outcomes, lower costs and readmissions rates, and help facilities avoid financial penalties. It starts with simply washing our hands.