Consider the following scenario: a young woman is raced to the hospital in serious heart failure. Over the following two days it is clear she will need surgery to repair a badly infected heart valve. A surgical team works late into the evening and although it was touch and go for a while, they are satisfied that her new valve is working well. She is transferred to the intensive care unit on antibiotics and rapidly improves to the point that she can be moved to the surgery floor 4 days later. Unbeknownst to her, she was moved into a 4-bedded room that 2 weeks ago had been used to cohort patients with C. difficile. The room had been cleaned many times since then; however housekeeping resources had been cut back on that unit several weeks ago and the staff were also facing considerable pressure from the ED to turn around rooms quickly.
Three days after her move she developed abdominal pain. Initially this was thought to be a normal postoperative ileus, but when she developed diarrhea the next day, C. difficile was considered. By the time her positive test result came back, her blood pressure had dropped and she needed to be transferred back to the ICU. She got worse over the next two days despite more antibiotics and had to be taken back to the operating room to remove her colon. Sadly, her already weak heart could not tolerate the shock of a second surgery and she died during the operation.
Stories like this are all too commonplace in our healthcare system although it is rare that we can pinpoint when a patient acquired the organism that will later result in a healthcare associated infection. Healthcare workers will go to extraordinary lengths to save a life, including learning the latest procedures and lobbying for the best technology, yet underpinning this drive to provide the best possible care, is the assumption that all the “basics” have been taken care of. Experience has taught us however that many basics such as equipment sterilization and environmental cleaning are far from perfect. Environmental cleaning in particular has frankly suffered from a general lack of appreciation of the importance of this function. Indeed, the recent attention being paid to healthcare worker hand hygiene and antimicrobial stewardship may have led some to believe that improving these alone will dramatically improve patient safety, yet as the above story illustrates, they may be necessary, but they are not sufficient.
Essentially all significant healthcare associated bacteria, including methicillin resistant Staphylococcus aureus (MRSA), Clostridium difficile, Vancomycin resistant enterorcocci (VRE), and multidrug resistant gram negatives (MDRGN) all have the ability to live in the healthcare environment for days, if not weeks to months. Multiple studies have shown that colonized or infected patients readily shed organisms into their environment where they can then take up home on surrounding surfaces such as bedrails, call bells, curtains, bedside furniture, and multiuse equipment such as blood pressure cuffs and pulse oximeters. Once present, all it takes is a touch for the organism to move to the next patient. It should come as no surprise that having a roommate increases ones chance of acquiring a hospital “superbug” and that staying in a single room will considerably decrease this risk.
Healthcare settings are not hotels. Not only must the healthcare environment look clean, but pathogenic organisms also have to be removed before the next patient shows up. People worry about the cleanliness of bedspreads in hotels, but if they knew that they were about to be admitted to a bed that had previously held a patient with C. difficile, I am sure they would be far more concerned.
Several improvements are necessary to ensure that our buildings and the equipment therein are not making our patients sick. Housekeeping staff need to recognize how important their job is, and their central role in keeping patients safe. Further they need the clear support of administrators and clinicians to be empowered to do the best job they can: this means providing them with the resources to do what is necessary. Until relatively recently, there was a lack of clear guidelines to map out what cleaning needs to be done, including where, what and how often. Now that these exist however, it is relatively straightforward to determine what resources are required. We need to move from thinking of environmental cleaning as an easy to scale back program in times of fiscal restraint to realizing that it is a service essential to patient safety. Patients shed and become colonized with pathogenic organisms 24 hours a day, seven days a week yet we continue to view environmental cleaning as very much a nine to five service.
Quantity isn’t enough: patients also need quality. Environmental services staff must know what needs to be cleaned and how to clean it with appropriate attention to detail. Furthermore, the choice of cleaning/disinfecting agent is also crucially important. Clostridium difficile is likely the best example of an organism that will frequently continue to spread unabated unless attention is paid to cleaning and disinfecting surfaces with an agent that can kill bacterial spores. In my experience, it is the widespread use of sporicidal agents more than any other intervention that leads to the control of runaway C. difficile outbreaks.
If we go back to the story at the beginning, think of the effort and money that went into saving a life, only to have it end tragically. Simply put, good environmental cleaning saves lives.
Dr. Michael Gardam
Dr. Michael Gardam is the Medical Director, Infection Prevention and Control, University Health Network and Women's College Hospital and Medical Director, Tuberculosis Clinic Toronto Western Hospital. As an Infectious Diseases Consultant, Dr. Gardam has provided support at the provincial, national and international level and is known internally as a Positive Deviance guru. As an “early adopter” he is always at the forefront of change within the medical community and is never one to shy from controversial questions. Dr. Gardam has published over 60 scientific paper and book chapters where his research interests focus on mitigating the spread of infectious diseases in both the hospital and community setting.