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We
are pleased to present the following
excerpt from the book
Better: A
Surgeon's Notes on
Performance
by Atul Gawande
Metropolitan Books -
April 2007
On
Washing Hands
One ordinary December day, I took a
tour of my hospital with Deborah Yokoe, an
infectious disease specialist, and Susan
Marino, a microbiologist. They work in our
hospital's infection-control unit. Their
full-time job, and that of three others in
the unit, is to stop the spread of
infection in the hospital. This is not
flashy work, and they are not flashy
people. Yokoe is forty-five years old,
gentle voiced, and dimpled. She wears
sneakers at work. Marino is in her fifties
and reserved by nature. But they have
coped with influenza epidemics,
Legionnaires' disease, fatal bacterial
meningitis, and, just a few months before,
a case that, according to the patient's
brain-biopsy results, might have been
Creutzfeld-Jakob disease -- a nightmare,
not only because it is incurable and fatal
but also because the infectious agent that
causes it, known as a prion, cannot be
killed by usual heat-sterilization
procedures. By the time the results came
back, the neurosurgeon's brain-biopsy
instruments might have transferred the
disease to other patients, but
infection-control team members tracked the
instruments down in time and had them
chemically sterilized. Yokoe and Marino
have seen measles, the plague, and rabbit
fever (which is caused by a bacterium that
is extraordinarily contagious in hospital
laboratories and feared as a bioterrorist
weapon). They once instigated a nationwide
recall of frozen strawberries, having
traced a hepatitis A outbreak to a batch
served at an ice cream social. Recently at
large in the hospital, they told me, have
been a rotavirus, a Norwalk virus, several
strains of Pseudomonas bacteria, a
superresistant Klebsiella, and the
ubiquitous scourges of modern hospitals --
resistant Staphylococcus aureus and
Enterococcus faecalis, which are a
frequent cause of pneumonias, wound
infections, and bloodstream
infections.
Each year, according to the U.S.
Centers for Disease Control, two million
Americans acquire an infection while they
are in the hospital. Ninety thousand die
of that infection. The hardest part of the
infection-control team's job, Yokoe says,
is not coping with the variety of
contagions they encounter or the panic
that sometimes occurs among patients and
staff. Instead, their greatest difficulty
is getting clinicians like me to do the
one thing that consistently halts the
spread of infections: wash our hands.
There isn't much they haven't tried.
Walking about the surgical floors where I
admit my patients, Yokoe and Marino showed
me the admonishing signs they have posted,
the sinks they have repositioned, the new
ones they have installed. They have made
some sinks automated. They have bought
special five-thousand-dollar "precaution
carts" that store everything for washing
up, gloving, and gowning in one ergonomic,
portable, and aesthetically pleasing
package. They have given away free movie
tickets to the hospital units with the
best compliance. They have issued hygiene
report cards. Yet still, we have not
mended our ways. Our hospital's statistics
show what studies everywhere else have
shown -- that we doctors and nurses wash
our hands one-third to one-half as often
as we are supposed to. Having shaken hands
with a sniffling patient, pulled a sticky
dressing off someone's wound, pressed a
stethoscope against a sweating chest, most
of us do little more than wipe our hands
on our white coats and move on -- to see
the next patient, to scribble a note in
the chart, to grab some lunch.
This is, embarrassingly, nothing new:
In 1847, at the age of twenty-eight, the
Viennese obstetrician Ignac Semmelweis
famously deduced that, by not washing
their hands consistently or well enough,
doctors were themselves to blame for
childbed fever. Childbed fever, also known
as puerperal fever, was the leading cause
of maternal death in childbirth in the era
before antibiotics (and before the
recognition that germs are the agents of
infectious disease). It is a bacterial
infection -- most commonly caused by
Streptococcus, the same bacteria
that causes strep throat -- that ascends
through the vagina to the uterus after
childbirth. Out of three thousand mothers
who delivered babies at the hospital where
Semmelweis worked, six hundred or more
died of the disease each year -- a
horrifying 20 percent maternal death rate.
Of mothers delivering at home, only 1
percent died. Semmelweis concluded that
doctors themselves were carrying the
disease between patients, and he mandated
that every doctor and nurse on his ward
scrub with a nail brush and chlorine
between patients. The puerperal death rate
immediately fell to 1 percent --
incontrovertible proof, it would seem,
that he was right. Yet elsewhere, doctors'
practices did not change. Some colleagues
were even offended by his claims; it was
impossible to them that doctors could be
killing their patients. Far from being
hailed, Semmelweis was ultimately
dismissed from his job.
Semmelweis's story has come down to us
as Exhibit A in the case for the obstinacy
and blindness of physicians. But the story
was more complicated. The trouble was
partly that nineteenth-century physicians
faced multiple, seemingly equally powerful
explanations for puerperal fever. There
was, for example, a strong belief that
miasmas of the air in hospitals were the
cause. And Semmelweis strangely refused to
either publish an explanation of the logic
behind his theory or prove it with a
convincing experiment in animals. Instead,
he took the calls for proof as a personal
insult and attacked his detractors
viciously.
"You, Herr Professor, have been a
partner in this massacre," he wrote to one
University of Vienna obstetrician who
questioned his theory. To a colleague in
Wurzburg he wrote, "Should you, Herr
Hofrath, without having disproved my
doctrine, continue to teach your pupils
[against it], I declare before God
and the world that you are a murderer and
the 'History of Childbed Fever' would not
be unjust to you if it memorialized you as
a medical Nero." His own staff turned
against him. In Pest, where he relocated
after losing his post in Vienna, he would
stand next to the sink and berate anyone
who forgot to scrub his or her hands.
People began to purposely evade, sometimes
even sabotage, his hand-washing regimen.
Semmelweis was a genius, but he was also a
lunatic, and that made him a failed
genius. It was another twenty years before
Joseph Lister offered his clearer, more
persuasive, and more respectful plea for
antisepsis in surgery in the British
medical journal Lancet.
One hundred and forty years of doctors'
plagues later, however, you have to wonder
whether what's needed to stop them is
precisely a lunatic. Consider what Yokoe
and Marino are up against. No part of
human skin is spared from bacteria.
Bacterial counts on the hands range from
five thousand to five million
colony-forming units per square
centimeter. The hair, underarms, and groin
harbor greater concentrations. On the
hands, deep skin crevices trap 10 to 20
percent of the flora, making removal
difficult, even with scrubbing, and
sterilization impossible. The worst place
is under the fingernails. Hence the recent
CDC guidelines requiring hospital
personnel to keep their nails trimmed to
less than a quarter of an inch and to
remove artificial nails.
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 of.
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.
Atul
Gawande, a 2006 MacArthur fellow, is a
general surgeon at the Brigham and Women's
Hospital in Boston, a staff writer for
The New Yorker, an assistant
professor at Harvard Medical School, and a
frequent contributor to The New England
Journal of Medicine. Gawande lives
with his wife and three children in
Newton, Massachusetts.
Copyright
© 2007 by Atul Gawande and reprinted
with permission.
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