Better (3 page)

Plain soaps do, at best, a middling job of disinfecting. Their detergents remove loose dirt and grime, but fifteen seconds of washing reduces bacterial counts by only about an order of magnitude. Semmelweis recognized that ordinary soap was not enough and used a chlorine solution to achieve disinfection. Today's antibacterial soaps contain chemicals such as chlorhexidine to disrupt microbial membranes and proteins. Even with the right soap, however, proper hand washing requires a strict procedure. First, you must remove your watch,
rings, and other jewelry (which are notorious for trapping bacteria). Next, you wet your hands in warm tap water. Dispense the soap and lather all surfaces, including the lower one-third of the arms, for the full duration recommended by the manufacturer (usually fifteen to thirty seconds). Rinse off for thirty full seconds. Dry completely with a clean, disposable towel. Then use the towel to turn the tap off. Repeat after any new contact with a patient.

Almost no one adheres to this procedure. It seems impossible. On morning rounds, our residents check in on twenty patients in an hour. The nurses in our intensive care units typically have a similar number of contacts with patients requiring hand washing in between. Even if you get the whole cleansing process down to a minute per patient, that's still a third of staff time spent just washing hands. Such frequent hand washing can also irritate the skin, which can produce a dermatitis, which itself increases bacterial counts.

Less irritating than soap, alcohol rinses and gels have been in use in Europe for almost two decades but for some reason only recently caught on in the United States. They take far less time to use--only about fifteen seconds or so to rub a gel over the hands and fingers and let it air-dry. Dispensers can be put at the bedside more easily than a sink. And at alcohol concentrations of 50 to 95 percent, they are more effective at killing organisms, too. (Interestingly, pure alcohol is not as effective--at least some water is required to denature microbial proteins.)

Still, it took Yokoe over a year to get our staff to accept the 60 percent alcohol gel we have recently adopted. Its introduction was first blocked because of the staff's fears that it
would produce noxious building air. (It didn't.) Next came worries that, despite evidence to the contrary, it would be more irritating to the skin. So a product with aloe was brought in. People complained about the smell. So the aloe was taken out. Then some of the nursing staff refused to use the gel after rumors spread that it would reduce fertility. The rumors died only after the infection-control unit circulated evidence that the alcohol is not systemically absorbed and a hospital fertility specialist endorsed the use of the gel.

With the gel finally in wide use, the compliance rates for proper hand hygiene improved substantially: from around 40 percent to 70 percent. But--and this is the troubling finding--hospital infection rates did not drop one iota. Our 70 percent compliance just wasn't good enough. If 30 percent of the time people didn't wash their hands, that still left plenty of opportunity to keep transmitting infections. Indeed, the rates of resistant
Staphylococcus
and
Enterococcus
infections continued to rise. Yokoe receives the daily tabulations. I checked with her one day not long ago, and sixty-three of our seven hundred hospital patients were colonized or infected with MRSA (the shorthand for methicillin-resistant
Staphylococcus aureus
) and another twenty-two had acquired VRE (vancomycin-resistant
Enterococcus
)--unfortunately, typical rates of infection for American hospitals.

Rising infection rates from superresistant bacteria have become the norm around the world. The first outbreak of VRE did not occur until 1988, when a renal dialysis unit in England became infested. By 1990, the bacteria had been carried abroad, and four in one thousand American ICU patients had become infected. By 1997, a stunning 23 percent of ICU patients
were infected. When the virus for SARS--severe acute respiratory syndrome--appeared in China in 2003 and spread within weeks to almost ten thousand people in two dozen countries across the world (10 percent of whom were killed), the primary vector for transmission was the hands of health care workers. What will happen if (or rather, when) an even more dangerous organism appears--avian flu, say, or a new, more virulent bacteria? "It will be a disaster," Yokoe says.

Anything short of a Semmelweis-like obsession with hand washing has begun to seem inadequate. Yokoe, Marino, and their colleagues have now resorted to doing random spot checks on the floors. On a surgical intensive care unit, they showed me what they do. They walk in unannounced. They go directly into patients' rooms. They check for unattended spills, toilets that have not been cleaned, faucets that drip, empty gel dispensers, overflowing needle boxes, inadequate supplies of gloves and gowns. They check whether the nurses are wearing gloves when they handle patients' wound dressings and catheters, which are ready portals for infection. And of course, they watch to see whether everyone is washing up before patient contact. Neither hesitates to confront people, though they try to be gentle about it. ("Did you forget to gel your hands?" is a favored line.) Staff members have come to recognize them. I watched a gloved and gowned nurse come out of a patient's room, pick up the patient's chart (which is not supposed to be touched by dirty hands), see Marino, and immediately stop short. "I didn't touch anything in the room! I'm clean!" she blurted out.

Yokoe and Marino hate this aspect of the job. They don't want to be infection cops. It's no fun, and it's not necessarily
effective, either. With twelve patient floors and four different patient pods per floor, they can't stand watch the way Semmelweis did, scowling over the lone sink on his unit. And they risk having the staff revolt as his staff did against him. But what other options remain? I flipped through back issues of the
Journal of Hospital Infection
and
Infection Control and Hospital Epidemiology
, two leading journals in the field, and the articles are a sad litany of failed experiments to change our contaminating ways. The great hoped-for solution has been a soap or a hand rinse that would keep skin disinfected for hours and make it easy for all of us to be good. But none has been found. The situation has prompted one expert to propose--only half jokingly--that the best approach may be to give up on hand washing and get people to stop touching patients altogether.

We always hope for the easy fix: the one simple change that will erase a problem in a stroke. But few things in life work this way. Instead, success requires making a hundred small steps go right--one after the other, no slipups, no goofs, everyone pitching in. We are used to thinking of doctoring as a solitary, intellectual task. But making medicine go right is less often like making a difficult diagnosis than like making sure everyone washes their hands.

It is striking to consider how different the history of the operating room after Lister has been from that of the hospital floor after Semmelweis. In the operating room, no one pretends that even 90 percent compliance with scrubbing is good enough. If a single doctor or nurse fails to wash up before coming to the operating table, we are horrified--and certainly not shocked if the patient develops an infection a few days later. Since Lister we have gone even further in our expectations.
We now make sure to use sterile gloves and gowns, masks over our mouths, caps over our hair. We apply antiseptics to the patient's skin and lay down sterile drapes. We put our instruments through steam heat sterilizers or, if any are too delicate to tolerate the autoclave, through chemical sterilizers. We have reinvented almost every detail of the operating room for the sake of antisepsis. We have gone so far as to add an extra person to the team, known as the circulating nurse, whose central job is, essentially, to keep the team antiseptic. Every time an unanticipated instrument is needed for a patient, the team can't stand around waiting for one member to break scrub, pull the thing off a shelf, wash up, and return. So the circulator was invented. Circulators get the extra sponges and instruments, handle the telephone calls, do the paperwork, get help when it's needed. And every time they do, they're not just making the case go more smoothly. They are keeping the patient uninfected. By their very existence, they make sterility a priority in every case.

Stopping the epidemics spreading in our hospitals is not a problem of ignorance--of not having the know-how about what to do. It is a problem of compliance--a failure of an individual to apply that know-how correctly. But achieving compliance is hard. Why, after 140 years, the meticulousness of the operating room has not spread beyond its double doors is a mystery. But the people who are most careful in the surgical theater are frequently the very ones who are least careful on the hospital ward. I know because I have realized I am one of them. I generally try to be as scrupulous about washing my hands when I am outside the operating room as I am inside. And I do pretty well, if I say so myself. But then I blow it. It
happens almost every day. I walk into a patient's hospital room, and I'm thinking about what I have to tell him concerning his operation, or about his family, who might be standing there looking worried, or about the funny little joke a resident just told me, and I completely forget about getting a squirt of that gel into my palms, no matter how many laminated reminder signs have been hung on the walls. Sometimes I do remember, but before I can find the dispenser, the patient puts his hand out in greeting and I think it too strange not to go ahead and take it. On occasion I even think, Screw it--I'm late, I have to get a move on, and what difference does it really make what I do this one time?

A few years ago, Paul O'Neill, the former secretary of the Treasury and CEO of the aluminum giant Alcoa, agreed to take over as head of a regional health care initiative in Pittsburgh, Pennsylvania. And he made solving the problem of hospital infections one of his top priorities. To show it could be solved, he arranged for a young industrial engineer named Peter Perreiah to be put on a single forty-bed surgical unit at a Pittsburgh veterans hospital. When he met with the unit's staff, a doctor who worked on the project told me, "Peter didn't ask, 'Why don't you wash your hands?' He asked, 'Why can't you?'" By far the most common answer was time. So, as an engineer, he went about fixing the things that burned up the staff's time. He came up with a just-in-time supply system that kept not only gowns and gloves at the bedside but also gauze and tape and other things the staff needed, so they didn't have to go back and forth out of the room to search for them. Rather than make everyone clean their stethoscopes, notorious carriers of infection, between patients, he arranged
for each patient room to have a designated stethoscope on the wall. He helped make dozens of simplifying changes that reduced both the opportunities for spread of infection and the difficulties of staying clean. He made each hospital room work more like an operating room, in other words. He also arranged for a nasal culture to be taken from every patient upon admission, whether the patient seemed infected or not. That way the staff knew which patients carried resistant bacteria and could preemptively use more stringent precautions for them--"search-and-destroy" the strategy is sometimes called. Infection rates for MRSA--the hospital contagion responsible for more deaths than any other--fell almost 90 percent, from four to six infections per month to about that many in an entire year.

Two years later, however, despite encouragement and exhortation, the ideas had spread to only one other unit in the hospital. Those other units didn't have Perreiah. And when he left the original unit for a different project elsewhere, performance on that unit began to slide, too. O'Neill quit the project in frustration. Nothing fundamental had changed.

The belief that something could change did not die, however. Jon Lloyd, a surgeon who had helped Perreiah on the project, continued to puzzle over what to do, and he happened across an article about a Save the Children program to reduce malnutrition in Vietnam. The story seemed to Lloyd to have a lesson for Pittsburgh. The antistarvation program, run by Tufts University nutritionist Jerry Sternin and his wife, Monique, had given up on bringing outside solutions to villages with malnourished children. Over and over, that strategy had failed. Although the know-how to reduce malnutrition
was long established--methods to raise more nourishing foods and more effectively feed hungry children--most people proved reluctant to change such fundamental matters as what they fed their children and when just because outsiders said so. The Sternins therefore focused on finding solutions from insiders. They asked small groups of poor villagers to identify who among them had the best-nourished children--who among them had demonstrated what the Sternins termed a "positive deviance" from the norm. The villagers then visited those mothers at home to see exactly what they were doing.

Just that was revolutionary. The villagers discovered that there were well-nourished children among them, despite the poverty, and that those children's mothers were breaking with the locally accepted wisdom in all sorts of ways--feeding their children even when they had diarrhea, for example; giving them several small feedings each day rather than one or two big ones; adding sweet potato greens to the children's rice despite its being considered a low-class food. And the ideas began to spread. They took hold. The program measured the results and posted them in the villages for all to see. In two years, malnutrition dropped 65 to 85 percent in every village the Sternins had been to.

Lloyd was bitten by the positive deviance idea--the idea of building on capabilities people already had rather than telling them how they had to change. By March 2005, he and Perreiah persuaded the veterans hospital leadership in Pittsburgh to try the positive deviance approach with hospital infections. Lloyd even convinced the Sternins to join in. Together they held a series of thirty-minute, small group discussions with health care workers at every level: food service
workers, janitors, nurses, doctors, patients themselves. The team began each meeting saying, in essence, "We're here because of the hospital infection problem and we want to know what
you
know about how to solve it." There were no directives, no charts with what the experts thought should be done. "If we had any dogma going in," Jerry Sternin says, "it was: Thou shalt not try to fix anything."