Hospitals Gear Up on Cleaning

Story first appeared in The Wall Street Journal.

An environmental services director at Hunterdon Medical Center, uses a swab to swipe a bedside tray table in a freshly cleaned patient room. She then dips the swab into a hand-held device that can detect bacterial contamination in less than a minute.

The reading is in the safe zone by most industry standards. But at Hunterdon, it will trigger a repeat visit from the cleaning crew to wipe out lingering bacteria.

The environmental services director and her colleague Hunterdon's infection-prevention director, are on the front lines of one of the most critical battles in health care—keeping virulent hospital infections at bay. Nationwide, about one in 20 patients entering a hospital will get a potentially deadly infection, accounting for some $33 billion in preventable costs, according to the federal Department of Health and Human Services. Dangers lurk not only in vulnerable places like operating rooms. Recent studies have shown that some of the most common surfaces, from sink faucets to TV remote controls, can harbor the most deadly bacteria.

Besides increased diligence, the Hunterdon team is mobilizing new technologies, including bathing patient rooms with germ-killing ultraviolet light. Specialized computer software tracks new outbreaks of infection. And a new generation of powerful disinfectant products are used to kill even some of the most potent germs, especially Clostridium difficile, or C. diff, which is linked to some 14,000 U.S. deaths a year.

Many hospitals have succeeded in driving down the rates of some once-common infections, including MRSA, a type of staph bacteria that doesn't respond to some antibiotics. Changed medical practices have helped, including keeping patients in intensive care hooked up to ventilators only for as long as is necessary. Helping to spur action: The government has set a goal of reducing hospital infections and other preventable problems by 40% by next year from 2010 levels. The Center for Medicare and Medicaid Services has stopped paying to treat some infections acquired in the hospital. And facilities with the highest rates of hospital-acquired conditions will face reduced federal payments starting in 2015.

Hunterdon cut its rate of C. diff infections by 79% and reduced MRSA by 66% between 2006 and 2011. A bug called VRE that was on the rise for several years dropped 23% at Hunterdon last year. The hospital's successes led the Association for Professionals in Infection Control and Epidemiology, an industry group, to ask the Hunterdon team to help launch "Clean Spaces, Healthy Patients," a national program that includes Web-based seminars aimed at infection-control officials and cleaning staff.

Hunterdon Medical Center, which has 178 beds, has many of the same hygiene challenges that face numerous other U.S. hospitals that are large and aging. And most of Hunterdon's rooms are semiprivate, shared by two patients, making them more difficult to keep clean. Prompting Hunterdon to overhaul its methods was a growing threat from a strong strain of C. diff in 2004. At highest risk for C. diff are patients, especially older adults, who are on antibiotics for other infections. The drugs destroy good germs that protect against infection for several months, during which time patients can get sick from C. diff picked up from contaminated surfaces or spread from a health-care provider's hands.

The hospital began isolating patients who had contracted C. diff and asked doctors to restrict the use of the antibiotic Cipro. But it was becoming clear that spores could survive for weeks, even on a doorknob. Alcohol-based hand sanitizers didn't kill C. diff, and hand-washing wasn't sufficient.

So the hospital adopted new, stronger soaps containing the antiseptic chlorhexidine for staffers and patients. Cleaning crews began using bleach and a more potent form of hydrogen peroxide. Rooms were scrubbed as never before: In rooms where C. diff patients had been treated, even the curtains were taken down and cleaned.

The environmental director coaches cleaning staff on the importance of disinfecting "high-touch" surfaces on which germs can linger. One current focus: the remote control devices whose buttons allow patients to watch TV or call a nurse. Cleaning staff are encouraged to speak up if they feel they are being rushed to clean a room.

The visual checks traditionally done to confirm a room was clean are no longer sufficient.

The Hunterdon team conducts random audits with the swabbing device on about 300 surfaces a month. Some 95% to 100% of checks get a passing grade, up from 75% when the hospital acquired the device in 2009.

There are costs involved. Besides hiring additional staff, including more cleaners, Hunterdon administrators invested about $81,500 in rapid-testing equipment for the microbiology lab to detect C. diff and MRSA from patient samples. New, washable computer keyboards for nursing stations—to eliminate the problem of bacteria on standard models—cost about $15,000. The hand-held device to test surfaces for contamination using a special light assay cost about $3,000 to purchase and up to $1,500 monthly to operate.

Many hospital administrators still don't understand they have to spend money if they want to cut costs related to infection, such as isolating patients with c. diff. and readmitting patients to hospitals if infections worsen.

Hunterdon also pays $100,000 in annual fees for its computerized surveillance system for its lab. This uses patient samples to determine when organisms are present that show unusual resistance or a particular pattern of spreading—a task that was previously impossible with stacks of paper reports.

To motivate staff, Hunterdon uses a government video-training program called "Partnering to Heal." It includes a dramatic film of a young patient who dies from a MRSA infection after multiple failures of hospital staff to follow preventive steps. The hospital also produces a newsletter, "BugBytes," that celebrates successes and passes along infection-prevention tips. And doctors who adhere closely to the guidelines are awarded a model stethoscope made of chocolate.

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