Our dirty, C diff friendly hospitals

MDs must lead the way in hygiene. Money helps, too

By Gillian Woodford

Room of Horrors To raise awareness about medical errors among hospital staff during Patient Safety Week in late October, Brandon Regional Health Authority set up a Halloween-themed 'Room of Horrors' contest, with an unhealthy array of risky practices on display. About 200 staffers took part. "The staff were requested to write downone risk or error identified during their tour throughthe Room of Horrors," says Quality and Risk Manager Kristi Chorney. "All staff were able to do this easily." How many errors can you spot? click here for answers

Photos: Brandon Regional Health Authority

It was the nightmare everyone had hoped wouldn't come back. Once again the hypervirulent NAP1 strain of Clostridium difficile paralyzed a Quebec hospital. Within three months, the superbug had infected 31 patients; by mid-November, 12 of them were dead.

McGill University infectious disease expert Dr Vivian Loo admits she wasn't surprised when she heard the news that the hypervirulent strain of Clostridium difficile had ravaged Honor�-Mercier Hospital in St-Hyacinthe, just north of Montreal. "With this type of organism there's no reserve left if there's a lapse in infection control."

That's exactly what happened at St-Hyacinthe. A leaked internal report from October warned of poor hygiene practices at the hospital. Stringent infection control measures were put in place, but too late to stop the deaths. It was revealed, for instance, that three patients who died had used the same bed, and that toilets that were to be cleaned hourly were only being done daily. A coroner's inquest is underway.

HISTORY REPEATS
The infamous Quebec C diff outbreak of 2003-4 has now been linked to some 2,000 deaths. A damning report blamed poor hygiene standards, old facilities and budget cuts. The government coughed up $20 million for hospitals and made C diff reporting mandatory. But nobody ever figured out why or how NAP1 ended up a Quebec problem.

"Sometimes I wonder if we're just unlucky," says Dr Loo. "SARS went to Toronto, and Quebec got C diff."

Quebec is of course not alone in dealing with this virus. The strain has been found in seven other provinces. An outbreak at Sault Ste-Marie's only hospital has just been contained and a coroner's inquest requested into the 19 C diff-related deaths there.

When it realized it had a problem it could no longer contain, Sault Area Hospital took the unusual step of drafting in an outsider, Dr Michael Gardam, director of Infection Prevention and Control at the University Health Network at U of T and a veteran of the SARS outbreak, to help. "This speaks to their determination to control this," he says. It seems odd that the Sault's larger C diff body count has received much less publicity than St-Hyacinthe's. Dr Gardam attributes this to the Quebec media's interest in C diff, but also to the Sault hospital's transparency. He adds that he understands why hospitals like Honor�-Mercier try to keep things under wraps. "It's like airing your dirty laundry — nobody wants these stories getting out." But he emphasizes that the less open a hospital is, "the longer it takes to get things under control."

When he first arrived in Sault Ste-Marie, he immediately unleashed what he calls his "shotgun therapy" approach. First, he changed the antibiotic formulary, choosing antibiotics not associated with C difficile. Next, he hired 19 new housekeepers. "Cleaning was reasonable," he says, "but they needed to be way more vigilant." Like Honor�-Mercier, the Sault hospital is an old facility, with few private rooms, making isolation tough. Still, they isolated suspicious cases as best they could and started patients on therapy even before the test results were back. "One of the big problems was that there were four days between test results, and the infection could have spread to other patients by then. So we got the lab to do same day testing." That was in early November; within two weeks Dr Gardam had seen a dramatic drop in new cases.

SILVER LINING
Things had been going so well in Quebec. In mid-November, just after the St-Hyacinthe inquest was ordered, the province's public health director Dr Alain Poirier announced that new C diff cases are down by 60% since the peak in 2004. The hospitals where Dr Loo works — the Montreal General and the Royal Victoria — haven't had outbreaks in at least a year and a half, she says. And the government funding helped. "Before the $20 million injection we took it seriously, but it was frustrating trying to fight it without the resources."

They decided to use their share of the money to improve infection control. "There was a ward not being used, so we opened it up. Now instead of having four patients using one toilet, we only have two patients per room. We hired more housekeepers. We also bought more dedicated equipment, like blood pressure cuffs, so they can be decontaminated." They also measure their infection rates on a weekly basis. She adds that regular rounds from the infection control practitioners and a good relationship with the microbiology lab has helped immeasurably.

COMING CLEAN
Most experts believe that C diff will never be eradicated from hospitals, but that its spread from patient to patient can be. So why, despite all the evidence that good, simple hygiene practices are the only way to go, can't we keep our hospitals clean? "When hospitals are experiencing a problem, all of a sudden everyone's very vigilant. When there's a perception that everything's ok, we become slack again," says Denise Gravel, an epidemiologist at the Public Health Agency of Canada.

There's also a lot of evidence out there to suggest that physicians are among the worst offenders when it comes to basic handwashing practices.

"As a physician, handwashing was never emphasized to me," agrees Dr Gardam. "I remember rounding on multiple patients and us never washing our hands in between. Physicians need to realize it's one of the most important things they can do for their patients. We also need to remember that younger doctors learn by modelling older doctors."

"I trained myself to handwash after studying in infectious diseases," he adds. "Now it's like putting on my seatbelt — it's automatic."

Another thing is making sure the facilities exist. A lot of hospitals, particularly older ones, simply don't have a lot of sinks that are easily accessible. Alcohol-based cleansers have made things easier, though they're still not quite as effective as good old soap and water.

So how can we get doctors and other staffers to stay vigilant about infection control?

"It goes beyond telling them to wash their hands," says Dr Gardam. "They have to be fully educated as to why it's so important."

Dr Loo (who confesses she washes her hands "constantly") thinks physicians need to understand there are other consequences of lax infection control. "Patients stay longer in hospital when they get these infections," she notes. "This is particularly important for surgeons — if they want to bring more patients in, we need to discharge the other ones."

"We need to find non-punitive solutions," cautions Dr Micheline Ste-Marie, a pediatrician at the Montreal Children's and a patient safety advocate. We need to remember there's a human aspect to all of this. "Healthcare workers don't deliberately set out to harm patients. Everyone's working their butts off," she says. "And after your twelfth hour on duty, you're entitled to forget to wipe down a surface." She points out there's more to the St-Hyacinthe story than the headlines suggests. "They've gone through a lot," she says. "Last year they had to move out of their hospital into an older facility because of mould in the walls. It's been a horrendous year for the staff."

But she stresses we still need to learn from our mistakes, and "reinforce the primary rules of engagement." You guessed it: "Handwashing, handwashing and more handwashing — with soap and water!"