When hospitals want to make a name for themselves, they spend on reputations and technology—on the esteemed surgeon or the top-of-the-line gamma knife and the star radiologist to operate it. Such investments attract publicity as well as patients seeking the best available health care. Lately, though, some hospitals have been making an unexpected discovery. The kinds of expenditures that truly improve patient care are often not directed at the top of their pay scale, with the famous specialists, but rather at the bottom, with the anonymous janitors.
Hospitals have reached this realization while trying to cope with an alarming trend. Over the past decade the organisms that cause most infections in hospitalized patients have become more difficult to treat. One reason is increasing drug resistance; some infections now respond to only one or two drugs in the vast armamentarium of antibiotics. But the problem also arises because the cast of organisms has changed.
Just a few years ago the poster bug for nasty bacteria that attack patients in hospitals was MRSA, or methicillin-resistant Staphylococcus aureus. Because MRSA clings to the skin, the chief strategy for limiting its spread was thorough hand washing. Now, however, the most dangerous bacteria are the ones that survive on inorganic surfaces such as keyboards, bed rails and privacy curtains. To get rid of these germs, hospitals must rely on the staff members who know every nook and cranny in each room, as well as which cleaning products contain which chemical compounds.
“Hand hygiene is very, very important,” says Michael Phillips, a hospital epidemiologist at New York University Langone Medical Center who has been studying this problem. “But we are coming to understand that it is one of just several important interventions necessary to break the chain of infection that threatens our patients.”
The infectious organisms that require all this extra effort became a serious problem around 10 years ago. The first outbreaks were caused by vancomycin-resistant Enterococcus, or VRE, and Clostridium difficile, known as C. diff, followed by a group of bacteria collectively referred to as highly resistant gram-negative organisms: Escherichia coli, Klebsiella, Pseudomonas and Acinetobacter.
This varied lot enters hospital rooms via multiple avenues. Acinetobacter and Pseudomonas prefer to live in the soil and water, but they are carried into hospitals from the outside world on people's shoes and clothes. In contrast, VRE, E. coli, Klebsiella and C. diff thrive inside human beings. These bacteria enter hospitals in patients' intestines and escape when bedbound patients suffer from diarrhea, contaminating the air and equipment around them.
The new scourges are particularly tough to clear away for several reasons. The gram negatives, for instance, have a double wall that gives them extra defenses against antibiotics and shields them from damage by other compounds, including cleaning chemicals. Many of the bugs can survive in low-nutrient environments, such as glass, plastic, metal and other materials that make up a hospital room. Consider VRE. One strain that caused an outbreak at the University Medical Center Utrecht in the Netherlands grew in a lab dish for 1,400 days after being dried in a test that mimicked what might happen in a patient's room. (MRSA also survives on surfaces, but for much shorter duration.)
Because of such abilities, the latest bacterial threats create an infection risk at least as great as health care workers' contaminated hands. “It forces us to raise the cleanliness of the hospital as a clinical issue, just as washing our hands is a clinical issue,” says Cliff McDonald, a medical epidemiologist at the U.S. Centers for Disease Control and Prevention.
Within hospitals, these resistant, hardy organisms are ubiquitous. A review article last year found that 10 percent of hard and soft surfaces in hospital rooms may be contaminated with gram-negative bacteria and that 15 percent of them may be contaminated with C. diff. A study at the University of Iowa Carver College of Medicine, published online in April, demonstrated the potential infection risk posed by the privacy curtains around hospital beds. In an initial survey, 95 percent of curtains in 30 rooms harbored VRE or MRSA. When the curtains were replaced, 92 percent became recontaminated within a week.
Operation Clean Team
Recently hospital cleanliness has become a matter of reputation, especially since the federal government's Hospital Compare Web site started posting institutions' rates of health care–associated infections. Cleanliness is also becoming a bottom-line issue: in 2008 the federal Centers for Medicare and Medicaid Services ceased reimbursing hospitals for the treatment of any infections that those hospitals caused—a controversial carrot-and-stick venture that, according to new research, has successfully begun to lower infection rates.
Institutions also employ infection-control specialists, who track infections and investigate their causes. Yet when the problem is bacteria on surfaces, eliminating them depends on the building-services crews. “This is the level in the hospital hierarchy where you have the least investment, the least status and the least respect,” says Jan Patterson, president of the Society for Healthcare Epidemiology of America. Traditionally, medical centers regard janitors as disposable workers—hard to train because their first language may not be English and not worth training because they may not stay long in their jobs.
At N.Y.U. Langone in 2010, Phillips and his co-workers launched a pilot project that redefined those formerly disposable workers as critical partners in patient protection. Janitors, they realized, know better than anyone else which rails are touched most frequently and which handles are hardest to clean. The Langone “clean team” paired janitors with infection-control specialists and nurses in five acute care units to ensure that all high-touch surfaces were thoroughly sanitized. In its first six months the project scored so high on key measures—reducing the occurrence of C. diff infections and the consumption of last-resort antibiotics—that the hospital's administration agreed to make the experiment routine procedure throughout the facility. It now employs enough clean teams to assign them to every acute care bed in the hospital.
Even the most aggressive disinfecting regimen might miss something, though. Thus, some researchers are tackling a once unheard of goal: rooms that clean themselves. Most of their early work focuses on engineered coatings and textiles that rebuff infectious organisms or kill them.
A company called Sharklet Technologies imprints the surface of catheters with a pattern that mimics the scaly texture of sharkskin, an innovation inspired by the realization that sharks, unlike whales, do not develop encrustations of algae. In the company's peer-reviewed research, the engineered surface makes it difficult for bacteria to cling and multiply.
Other projects capitalize on the long-recognized antiseptic properties of precious metals, chiefly silver and copper. Metal ions seem to interfere with crucial proteins within bacterial cells. Those results are similar to the effect of some antibiotics, but the metals, unlike drugs, do not provoke resistance.
Research by the company EOS Surfaces shows that bacteria in patients' rooms cannot survive on wall panels sheathed in copper, and a study funded by the Department of Defense at three hospitals, including Memorial Sloan-Kettering Cancer Center in New York City, demonstrated an association between copper-coated “high touch” surfaces in rooms—the call button, intravenous pole and bed rails, among others—and lower infection rates. PurThread Technologies is developing a proprietary alloy of copper and silver, which it melts into polyester and spins into yarn that is eventually woven into textiles ranging from sheets to scrubs.
Infection-prevention specialists think these efforts are promising but still preliminary. Most have not been tested in randomized clinical trials that could record whether the engineered surfaces were solely responsible for reducing patient infections.
“They need a lot more work, but I do think they will be a part of the solution,” says Eli Perencevich, an infection-control specialist at the University of Iowa and interim director of the Center for Comprehensive Access and Delivery Research and Evaluation at the Department of Veterans Affairs, who consults for PurThread. Yet, he adds, they will be one additional weapon against infections, not a replacement for other strategies: “We can never let go of making sure that surfaces are cleaned and that health care workers wear gloves and wash their hands.”