I get the need (I suppose) to see the bright side of things as expressed in this article on LinkedIn, especially after the misery of the COVID-19 pandemic. Hospital workers did great things during the pandemic, and can be justifiably proud about the good they did. But I wish I had thirty minutes with a hospital executive at the level of Mikelle Moore below, to give them a small dose of some realities with which they seem oddly unacquainted.
For at least six months now, hospital spokespersons have been coming before the public to assure would-be patients that hospitals have been thoroughly scrubbed clean of potential infectious agents, most of all SARS-CoV-2. So, they insist, “hospitals are safe,” and no one should hesitate to go. This video below is typical of standard-issue hospital propaganda.
No, hospitals are not safe. The video above, like so many in its genre, above confuses de jure policies with de facto realities. Yes, policies are in place “to ensure safety.” But as should be obvious, a policy’s being in place doesn’t ensure safety. People have to be following it, all the time, and to the last letter or decimal place. Even if they are, adherence to policy is not sufficient to ensure that a hospital is 100% infection free, or 100% safe. Nothing can do that.
The issue of hospital-acquired infections (HAI) long pre-dates COVID, and remains an unresolved issue at most ordinary, not-for-profit community hospitals. As a general rule, and despite the cavalier references made to it in the video above, Environmental Services (EVS, responsible for hospital cleaning) is understaffed, underpaid, under-trained, over-worked, poorly equipped, and unintegrated into the larger decision-making processes of the hospital. Communication between EVS and clinical staff, and EVS and administration, is often poor, hindered by the unapologetic ignorance of both clinical staff and administrators with respect to what it is that EVS actually does. On top of this, a surprisingly large number of hospital workers, within EVS and otherwise, resist getting vaccinated. If you add ordinary error to this mix, you get a recipe for plenty of hospital-acquired infection. That’s how this kind of thing happens.
There’s no need to pretend, and no room for pretense. Even a cursory search through the medical-literature database yields dozens upon dozens articles on this topic (probably more). None that I’ve read gives the sense that victory over HAIs is in hand, or even in sight. If anything, most articles on the topic are too optimistic, and are in any case, focused on the wrong things. Yet the PR story in health care remains upbeat, from hospital to hospital, from system to system, from talking head to talking head. “Hospitals are clean; don’t hesitate to come, y’all!” Not that anyone writing the PR scripts has done any of the cleaning, or even taken a good, hard look at it.
Hospital administrators wonder a lot about the crisis of confidence hospitals have suffered during the pandemic. There’s no need to wonder. Just immerse yourself in some hospital PR on this subject, then walk into virtually any institution’s ICU, ED, or OR without announcing your presence or identity, and observe. If you look with impartial eyes, what you’ll see is the gigantic distance between theory and practice, between talk and reality, between the cleanliness you’d like to imagine and the disease vectors that actually thrive on the hospital’s floors, walls, and equipment, alongside patients, visitors, and staff. You’ll likely see an overburdened EVS staff cutting corners to do what needs to be done by end-of-shift, all to avoid running up a tab on overtime, the radix malorum of hospital personnel management.
I doubt that 1 in 10 hospital administrators–from unit directors up to Chief Medical Officers–has a detailed understanding of how a given EVS crew cleans a given hospital unit. Yes, they have a generalized sense that the crew goes in and cleans things in the ED, the ICU, the OR, or a given ward. But how? What exactly do they do to get the job done right? What exactly do they need to do it well? What kinds of errors can be made, why are they typically made, and what should be done to reduce their frequency? And sorry to be gauche, but what would it cost to fix the problems that need fixing?
The answers to these questions are not self-evident. Contrary to popular belief, EVS does not consist of some brainless set of rote tasks that any idiot could do. It’s difficult, detail-oriented work–as detail-oriented as anything that any white-collar worker in finance ever does, and with much higher clinical stakes. Put the wrong figure into an Excel spread sheet while you’re doing billing or collecting, and the hospital loses money. Miss a spot of C Diff, and someone gets C Diff. Clean a COVID+ room the wrong way, and you’re spreading COVID all over the place. Job listings for white collar work often make “detail oriented” part of the requirements for the job. I sometimes wonder whether the people who write these ads, or answer them, have any idea of the detail orientation required to do blue collar work. The truth is, EVS in the ED, ICU, and OR makes Accounts Receivable and PR look like child’s play.
The hard truth is that hospital executives do not understand EVS at the fine-grained level required to make decisions about it, or to judge its efficacy. Since they don’t, an obvious question arises: how can they pronounce so confidently on the results of what EVS does? What gives them the confidence they seem to assume when they write what they write, and say what they say on the topic? My answer? They bluff. But it’s a serious question whether executive-level bluffing is enough to keep patients safe from hospital-acquired infections.
Hospital-acquired infections have colossal adverse effects, both clinical and financial. They affect individual patient outcomes, hospital-wide outcomes, employee attendance, community public health, and the financial bottom line. The lesson COVID should have taught us is that American health care has a real epidemiological problem to solve within its hospitals, one much broader than COVID itself. Hospitals will only be safe once hospital-acquired infections become a thing of the past. But they’re not a thing of the past. They threaten to remain a part of every hospital for the foreseeable future.
Yes, there’s a time to celebrate, to self-congratulate, and to pat one another on the back. But that can’t come at the expense of some painful lessons learned. Pathogens are a deadly, merciless enemy–far more virulent and unrelenting than terrorists, undocumented immigrants, or even cancel culture warriors. If you want something to fight, try fighting them. But you can’t smile your way, or clap your way, through a fight like that. You have to fight to win. That’s what I wish I could ask one of these hospital executives: are you in this to win? Because the people who are, are earning a wage that barely keeps them afloat, are often working with substandard equipment, and have workloads that make yours seem like a joke by comparison.
Yet they–we–are still in it to win. In other words, we’ve made our choice. It’s a question what choice our bosses, directors, and Senior Vice Presidents intend to make, and yet another question, when. We have no choice but to wait. But the pathogens aren’t waiting for anyone.
The views I express in this post are entirely my own, for which I take full responsibility, and do not represent the views of my employers, Aergo Solutions and Hunterdon Healthcare.