On Tuesday, October 25, my mother-in-law entered a prominent Pittsburgh hospital to undergo a routine surgical procedure. She was at the hospital to have cataract surgery performed. Before getting into her situation, the following factual information should be disclosed.
This year, great medical newspapers, like the Pittsburgh Post-Gazette have reported that nearly 2,000,000 U.S. citizens acquire an infection as a consequence of treatment in a U.S. hospital and that 90,000 people die as a consequence. The average hospital infection rate is five percent of all hospital admissions. The death rate is higher than the death rate of breast cancer. A copy of the official report can be found in an online newspaper: www.governing.com.
So, back to my mother-in—law. I must say that each person who treated her and prepared her for surgery was very nice to her. Each staff member was courteous and respectful of this 84 year old mother, grandmother and great-grandmother.
In the interest of time, let me focus on the pre-operative observations. One nurse, to be delicate, was ministering to the needs of her nose with her fingers and hand. She immediately went to a man and administered eye drops to his eyes and then to my mother-in-law to put in her eye drops. All three procedures were ungloved, done in rapid succession; no hand washing was performed. As a matter of fact, not one nurse nor employee in the pre-operative setting wore gloves as they prepared a group of patients for surgery. Another nurse had an interesting pre-surgical technique. She reviewed the medical record of each patient by putting two of her fingers in her mouth every time she turned a page in the medical record and then, without washing her hands, pulled back the eye lids of an elderly gentleman to examine his eye and surrounding tissues. Another nurse had something; ironically, bothering her eyes and rubbed her eyes with two fists and then, without washing her hand or wearing gloves, continued to touch the tissues surrounding the eyes of the patients being prepared for surgery.
Why did I not say something to someone in charge? Here are several lame excuses:
1. I knew my mother-in-law would have been uncomfortable with me complaining about her treatment, just before going to surgery.
2. Even though this is a form of “Russian Roulette”, I knew the odds were in her favor. Nineteen of twenty patients escape the American hospital without an infection.
3. Somewhere in my base fears was the anxiety that someone would retaliate or insult my mother-in-law because of my complaining.
4. Last, and the most honest answer, despite all of my bluster in writing, when the chips were down, I was gutless to say something in my mother-in-law’s defense.
I am truly ashamed. I love my mother-in-law. She has been feeding me for nearly forty years.
So, why are healthcare personnel so sloppy when it comes to the most basic and, perhaps, the most important infection control technique - hand washing.
That answer is deeply rooted in a very simple explanation. Hospital organizations are generally not organized or managed to change the culture with respect to infection control. How can I be so sure? Well, you do not have to go very far in Pittsburgh to dismiss two myths about infection control:
Myth # 1: Infections are an inevitable consequence of interacting with the American Hospital.
Allegheny General Hospital has provided national leadership in demonstrating that the impossible can be attained in eliminating hospital acquired infections through a commitment to patient safety and process improvement. Their achievements are well documented, and the leadership of Allegheny General Hospital does not need me to tell their story. They are among a growing number of hospitals that are fighting back against cultural norms that permit sloppy infection control practices.
Myth # 2: Nurses and physicians are too busy to wash their hands.
In many hospital settings, this is not a myth. Nurses are frequently sent out to do the impossible without appropriate support, tools or training to be effective in their advocacy for the patient. A recent feature article in Newsweek singled out the nursing leadership of UPMC Shadyside Hospital for fundamentally reorganizing nursing to eliminate the sense of chaos so often experienced by practicing nurses. And, the nurses and nursing leadership at UPMC Shadyside Hospital have not stopped in their efforts to continue improving the working conditions for nurses at the hospital. Guess what? The nurses not only have time to wash their hands, they have time to wash their hands properly.
No, the unnamed Pittsburgh hospital was not trying to kill my mother-in-law. The nurses involved in her pre-operative care would be shocked to read this. They were nice people working in a hospital that has established low expectations for them.
My mother-in-law had a favorable surgical outcome as expected and did not acquire an infection. One in twenty mothers-in-law is not so lucky.
Republished with permission from the Hospital News Group
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