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.
(I deleted the opening paragraph, which referred to a now-defunct link.)
Policy of Truth 
During the last month of her life, my mother was in isolation for a C. diff. infection. A nurse told me frankly that the C. diff. was iatrogenic. Yet on her death certificate there was no mention of C. diff.; the cause of death was listed as Alzheimer’s. Now she did suffer from some sort of dementia toward the end, and for all I know it was Alzheimer’s; I certainly claim no expertise in such matters. But during my many consultations with her docs during her final years, NOT ONCE did any of them mention Alzheimer’s. They talked instead about her more extreme forms of delusional loopiness being caused by various infections (not C. diff.) in her legs, and indeed her lucidity tended to wax and wane with the successful or unsuccessful management of those infections. (Otherwise, while her memory and other cognitive skills certainly declined, to the end of her life she never lost the ability to communicate [except when under extreme sedation to stop her from trying to get out of bed or to pull out her catheter or flail at the nurses], and she never, e.g., forgot who I was. And during the loopiness phases, at her most delusional she was often highly articulate.) The reference to Alzheimer’s made its first appearance on her death certificate.
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“at her most delusional she was often highly articulate”
For example, at one point, while lying down, she was convinced that she was standing up. When I tried to bring her some water, she perceived the glass of water as being sideways, and tried to grab it from me and turn it right side up (from her perspective; that would have been turning it sideways in reality) in order to prevent it from spilling. When I argued with her (I know you’re not supposed to argue with delusional patients, but my mother and I had been arguing with each other for the past five decades and neither of us was of a temperament to stop now), pointing to various things she admitted being able to see in the room as evidence that I was the one standing up and she was the one lying down, she replied “You’re awfully stubborn. I hope you don’t talk to your students this way — they’ll think you’re crazy.” — which was so weirdly authentically my mother’s familiar, maddeningly stubborn, matter-of-fact voice emanating from this batshit loopiness.
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Another example: the last time I saw her, she’d been fairly unresponsive during my visit, but as I went to leave I leaned down and kissed her, and suddenly she lit up, and said “A kiss! It’s Christmas in July!” Still unwilling to leave her delusions uncontradicted, I told her it wasn’t July, to which she responded, in her for-God’s-sake-don’t-be-dim voice, “it’s the name of a movie.” Which of course it is.
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I’m torn by your comments. On the one hand, I feel as though they speak for themselves, and a response would ruin their poignancy and gravity. On the other hand, they so perfectly illustrate what I’ve been trying to say in my last few posts that I feel I have to respond.
It almost goes without saying that those are touching and beautiful vignettes of your mother.
On C Diff: the nurse who described it as iatrogenic was almost certainly correct. But this gives me the occasion to let loose with a pent-up frustration I’ve had on this issue for a solid eight months. So I apologize for the fact that I’m no longer talking about your mother. I’m ranting about the iatrogenic nature of C Diff in hospitals.
I lost count of how many C Diff rooms I cleaned when I worked for OR EVS. They’re the hardest rooms to clean–a misery, frankly. The general procedure is: you “gown up” with additional PPE on top of the PPE you’re already wearing. You bring everything to the room you’re about to clean, on the understanding that once you go in, you can’t emerge until you’re done. You figure out what you need to clean the room, and (a separate inference), what you’re going to take with you inside the room. (For instance, you need mops, but once you dunk and wring them, you leave the bucket outside. Etc. In general, you only bring into the room what absolutely has to be brought in.)
You walk in, and close the doors. You collect the trash, and put it at one end of the room; you’ll collect it later. You then clean every surface in the room twice (including, to some extent, the ceiling, but excluding most of the walls)–once with bleach, and once with hydrogen peroxide. You then mop the floor with a detergent, then scrub it with plain old water. At this point, you’re “done enough” to open the doors, throw the trash into a bin, and take off your gown and gloves. You then bring an ultraviolet robot into the room, and run it for about 25 minutes. Then you prep the room for the next case coming in. Depending on the size of the room, this whole process takes, on average 90 minutes to two hours.
The C Diff room is going to be one of 7-10 rooms you’re going to do on your shift, so once you’re done, you somehow prepare yourself to do the next eight or nine OR suites, followed by the locker rooms, the offices, the break rooms, and the halls.
Here is one very tiny detail that I doubt anyone outside of EVS in the entire hospital grasps. I said that every surface is wiped twice, once with bleach, and once with hydrogen peroxide. But the technique used for the two wipes is infuriatingly different. For the hydrogen peroxide wipe (which is always done second), one takes a microfiber rag and dunks it in a solution of Oxivir TB, then wipes the surfaces with a wet/damp rag.
http://solutionsdesignedforhealthcare.com/solutions/products/disinfectants/oxivir-tb-rtu
But the bleach wipe is done by taking 6″ x 5″ wipes out of a canister, much like this one, and wiping the entire OR suite with them:
https://www.officedepot.com/a/products/1630225/Clorox-Healthcare-Bleach-Germicidal-Wipes-6/
Pause on this for a moment. An OR suite is a relatively large room, full of surfaces and equipment. Who would think to wipe down such a room with 6×5 inch wipes? It’s not easy to wipe them with wet rags, but fine; with effort, it can be done. But 6×5 wipes? A 6×5 wipe is the size of an index card. You might as well try to clean the room with an arsenal of toothbrushes. I can’t describe how maddening this was. But we learned to take it in stride. What else were we going to do? Initiate a revolution over bleach wipes?
Why not just take a fucking rag and dunk it in a bleach solution, just as is done with the hydrogen peroxide wipe? Because that is not protocol. The protocol, which has no rationale beyond being protocol, is that one must wipe an entire OR suite with 6×5″ bleach wipes.
By the time you’ve finished the bleach wipe part of the procedure, trust me, you have long since stopped caring about motherfucking C Diff (or alternatively, if you’re like me, you’ve now developed a desire for a rage-induced jihad against C Diff, which includes killing absolutely everything in the OR, including your co-workers, then emerging from the OR suite, and killing everyone else). But of course, once you’ve finished the bleach wipe part of the procedure…you’re only about a third done with the room!
You’re doing this for $14 an hour.
If you don’t finish the rest of your allotted tasks for the night by the end of the shift, and decide to take overtime to finish them, you will be reprimanded for the money you just wasted on overtime. But if you avoid overtime by leaving the tasks undone, you will be reprimanded for leaving the tasks undone. And if you do the same tasks off the clock, you are breaking the law, because no one is allowed to work off the clock. Try to get out of that bind while caring with the same intensity throughout about the importance of reducing hospital acquired infections.
This happens every day, five to seven days a week.
Once you see this dynamic in action, or better yet, live it, you realize why C Diff is iatrogenic. All it takes is one guy slacking off with the 6×5″ wipes once when no one is looking. If that spot never gets hit again that night, but has C Diff on it, and then comes into contact with a patient…well, figure out what happens.
Of course, C Diff is not the only infectious disease we face in the OR. There’s MRSA, VRE, HIV, hepatitis, COVID, etc. etc. Lots of room for error.
You would think: if the stakes are this high, and you want to avoid error, you need to develop a systematic method for avoiding error, and make sure not to overtax the people tasked with functioning as your vaunted “last line of defense against hospital acquired infection.” But no one in health care thinks this way. The fixation that drives things seems to be revenue cycle management. How do we save money? How do we hurry EVS up so that they move faster than they’re currently moving? The implicit premise of the latter question is: why are they so slow? But try to answer that by coming up with a non-snarky answer about 6×5″ bleach wipes.
Here is a very, very cynical take on the whole thing. If a patient dies of iatrogenic C Diff, and that fact is nowhere mentioned on her death certificate, what incentive does the institution have for changing the way it handles C Diff? What’s the worst that can happen to them? Irfan Khawaja will write a cutting comment about them on Policy of Truth? They can probably survive that.
Now multiply that one case by thousands upon thousands. That’s what we’re dealing with.
https://www.cdc.gov/media/releases/2015/p0225-clostridium-difficile.html
I have things to say about other aspects of your comment, but I feel the darkness and despair coming back, so let me leave it there.
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