Swine flu?

The Centers for Disease Control and Prevention (CDC) has updated its instructions for the public, for health professionals, and for laboratories regarding the swine influenza A virus (H1N1) that has been identified in Mexico and in parts of Texas and California.

There is a story in today's New York Times about the possible swine flu infection of students at a school in Queens, NY. Some students were reportedly in Mexico recently.

Now is the time to remind ourselves about lessons learned from the SARS outbreak in 2003 -- just in case the N1H1 virus turns out to be highly contagious and an international threat.

On March 7, 2003, different SARS patients reported within hours of one another to different hospitals in Vancouver and Toronto, Canada. According to the subsequent report by a Canadian Commission, the health care personnel responded differently in each city. As I have written before:

Because the Vancouver hospital followed strict precautions, there was no SARS epidemic in British Columbia. In Toronto precautions were inconsistently used. As a result, 44 people died in Ontario and 375 became sick with SARS. 'Of the…people who contracted SARS in Ontario,' says the [Commission's] report, '72 percent were infected in a health care setting….[and] 45 percent were health care workers.' In Vancouver only one health care worker contracted SARS.

If standard precautions are not used consistently by health care workers, we put ourselves at risk. Worse, we become part of the chain of infection for others.

With a new strain of swine flu in the news, it seems a good time for all of us in health care to remind ourselves about the importance of following standard precautions 100% of the time.

All fish swim in the same water

Before I began the blog, I wrote weekly messages as short letters to the employees, physicians, volunteers, and auxilians of Community General Hospital – to all the members of the CGH family. Hand washing, infection control, and standard precautions have been consistent themes. Here are excepts of past letters that have not been posted as blog entries.

From “All fish swim in the same water,” March 5, 2005
“If you saw a co-worker or someone from another department fail to wash hands, what do you do? Be embarrassed for them? Bite your tongue and say nothing? I suggest that you say something, such as: ‘Excuse me, did you forget to wash your hands? You must have a lot on your mind – just trying to help.’

“The fact is, hand washing is often done privately. Most of the time there is no one to remind us, just a sign (on the wall)…and that little voice in our heads that tells us to do the right thing. All of us who work in health care share the responsibility for keeping our patients and our co-workers safe. That responsibility starts with hand washing….

“In the aquarium all fish swim in the same water. In our world, we breathe the same air and touch the same surfaces. We touch our patients. Hand washing is not something to take for granted.”

From “Why the obsession about hand washing?,” March 19, 2005
“Nationally, statistics show hospital personnel comply with hand washing requirements only 54% of the time. That is shocking. At CGH our compliance last year averaged 90%. That is almost twice the national rate, but it is not good enough. Even a single instance of noncompliance could put an employee or a patient at risk of infection.”

From “A culture of safety,” July 3, 2005
“Last month the State Legislature passed a bill that will require hospitals to report publicly infection rates for surgical wound infections and for bloodstream infections related to central lines in ICU patients…..

“This particular bill received a lot of attention statewide and across the nation, thanks to publicity generated by the Committee to Reduce Infection Deaths (‘RID’), a non-profit organization that has worked to require the public reporting of hospital infection rates. I wrote to RID earlier this year in support of its efforts…”

From “Not Halloween masks,” October 29, 2005
“As you can see, [hand hygiene] compliance in October is 95%. That sounds great, but consider this as you look around the cafeteria. Of the 99 other people there, who are the five who, on average, fail to wash their hands? When it comes to infection control, we cannot be satisfied with 95% – 100% has to be the goal.”

That's Mitchell Brodey, MD, Hospital Epidemiologist, in the photo, above. Actually, it's a photo of the life-size cutout of Dr. Brodey that makes its way around the hospital to remind everyone at CGH about the importance of hand washing. Dr. Brodey's doppelganger has been "on duty" since September, a companion to the life-size cutout of Sue Chamberlain, RN, CGH's Infection Control Program Director, who has "patrolling" the halls and departments since July.

A tale of two cities

I remember going [to work] Saturday morning and I said to my husband… “I’m going to go, but I am so afraid”….I thought I was the next one to get [SARS]….’cause all our nurses were falling down.[1]

Those are the words of a nurse from Ontario Province as quoted in a report by a Canadian Commission that has examined the SARS epidemic of 2003. It is a cautionary tale for hospitals and governments about controlling the spread of infection.

The report focuses on two Canadian cities, Vancouver, British Columbia, and Toronto, Ontario. At 4:55 p.m. on March 7, 2003, an ambulance brought a 55-year old man to Vancouver General Hospital. About three hours later, at 7:45 p.m., a 43-year-old man went to Scarborough Grace Hospital in Toronto. Both patients had Severe Acute Respiratory Syndrome (SARS), but the course of SARS contagion was very different in the two cities.

Because the Vancouver hospital followed strict precautions, there was no SARS epidemic in British Columbia. In Toronto precautions were inconsistently used. As a result, 44 people died in Ontario and 375 became sick with SARS. “Of the…people who contracted SARS in Ontario,” says the report, “72 percent were infected in a health care setting….[and] 45 percent were health care workers.”[2] In Vancouver only one health care worker contracted SARS.

This “tale of two cities” demonstrates the importance of proper infection control procedures, including the use of personal protection equipment. It was a “combination of a robust worker safety and infection control culture at Vancouver General….[that] ensured…B.C. (British Columbia) was spared the devastation that befell Ontario.”[3]

I was recently at an out-of-town hospital with a relative, and I saw a very casual use of precaution gowns and virtually no enforcement of gowns for visitors. I was at a meeting this week where a lay person, who had been recently cared for at another hospital, told me stories to me about inconsistent infection control practices there. We know that health care people do not always follow standard precautions, as they should.

Interestingly, the spread of SARS in Canada was mostly within hospitals and not within the community-at-large. The report credits “bold public health efforts and stringent quarantine measures”[4] with stopping the infection in the general community.

At one point, when the epidemic subsided, the Ontario government officially lifted the emergency measures that had been imposed. Here’s what the Commission said happened next:

As soon as the precautions were relaxed…the disease surged back and spread…to patients, staff, visitors, and their families.

Stringent infection control and worker safety precautions, so recently relaxed, were imposed once more. Health care workers donned their N95 respirators and gowns and gloves again. As soon as precautions were reinstated, the disease again subsided.[5]

The value of hospital standard precautions[6] has never been more clearly demonstrated. Vancouver’s precautions stopped an epidemic before it started. Ontario’s inconsistent prevention measures allowed an epidemic to get started and, even after it was brought under control, to start a second time.

Despite the infection control system failures in Ontario, SARS was ultimately stopped, and the report credits the heroism of health workers for this:

SARS was stopped by the front-line workers and the scientists and the specialists who stepped up and who were not afraid to take strong measures that worked in the end.[7]

The SARS report shows the need for a culture of safety, a culture where every hospital worker knows, respects, and follows standard precautions. SARS was not immediately recognized as a new and serious illness. We don’t know the diseases we might face on any given day.

That is why 100% compliance with standard precautions is the way we protect ourselves, our patients, and our families.



[1] Spring of Fear, Volume 1, Executive Summary, The Commission to Investigate the Introduction and Spread of SARS in Ontario. The nurse’s quote is from p. 9. All four volumes of the Commission’s report are available at this web address: http://www.sarscommission.ca/report/index.html

[2] Spring of Fear, Volume 1, p. 12.

[3] Spring of Fear, Volume 1, p. 4.

[4] Spring of Fear, Volume 1, p. 6.

[5] Spring of Fear, Volume 1, p. 6.

[6] Standard precautions are safety measures for all patients who receive care, regardless of a patient’s diagnosis or known infection status, such as hand washing, the use of gloves, masks, and eye protection, face shields, gowns, etc.

[7] Spring of Fear, Volume 1, p. 10

Thank you, 95%

Community General Hospital has seen an increase in the percentage of hospital people (that includes doctors and employees) who comply with proper hand hygiene. In the first three months this year, we are averaging 95% compliance, compared with a 90% average in the past two years.

Three weeks ago I quoted a newspaper obituary for David Williamson Milne, a man who died in Kingston, Ontario on October 30, 2005. “The surgery was successful,” read the obituary.

Dave’s recovery was preceding well, thanks to the care of the [hospital] staff. Unfortunately, a series of hospital-acquired infections set back his progress and ultimately caused his premature passing.[1]

According to the Hand Hygiene Resource Center, “two million people become ill each year as a result of a hospital-acquired infection,” at a cost of some $4.5 billion. This week the Wall Street Journal reported “the rising alarm” that 90,000 hospitals deaths occur each year from these infections.[2] That translates to about 250 patient deaths each day! To put that number in perspective, last year CGH had an average daily census of 192 patients.

A review of 34 studies shows that “hand washing adherence among health care workers…varied from 5% to 81%” – with the average “only 40%.” Yesterday Sue Chamberlain, CGH’s Infection Control Program Director, told me there is a 1999 study by the Centers for Disease Control (CDC) that shows an average 54% of health care workers wash their hands as required. From this I conclude that the average hospital’s compliance is in the 40-50% range.

“‘It is no longer tolerable to accept noncompliance rates of more than 50% when we are dealing with critically ill patients,’” according to Dr. Don Goldman of the Institute of Healthcare Improvement (IHI) who was quoted in the Journal article. Dr. Goldman noted that computer-chip makers have better hand-cleaning performance than some hospitals.

At CGH nothing we do is more important than keeping safe the patients entrusted to our care. So I thank you for the increased vigilance that has boosted our hand hygiene compliance to 95%. We are at the very top of nationwide performance, ]something we should be proud of – and something very important for patients.

I do have a nagging question about the remaining 5%. Who would fail to wash hands and raise the risk of a potentially life-threatening infection for a patient in the next room, a colleague in the cafeteria …or for that matter, a loved one at home?



[1] “A Tipping Point,” CGH Family Letter, March 18, 2006.
[2] “Hospitals Get Aggressive About Hand Washing,” Wall Street Journal, April 5, 2006

A tipping point

“Some day, we may look back at this and say it represented a tipping point in public consciousness.”

That is a message I received yesterday from my colleague Peter McGinn, PhD, who is the President and CEO of United Health Services in Binghamton, NY. Peter copied me on an e-mail that he sent to his staff about an obituary that appeared in a Canadian newspaper five months ago.

In reprinting the obituary, I repeat Peter’s words to his staff: “Please read this very carefully – all the way through.”

On October 30, 2005, David Williamson Milne passed away at Kingston General Hospital after a battle with hospital-acquired infections. He was loved and is deeply missed by many.

David Milne was the kind of person that you got to know, and like, quickly. His friends were among society’s small and society’s great, and he treated each with equal respect and appreciation. His Scottish humor and laugh were infectious. Even in his last days he could make us laugh.

His family was the joy of his life and sustained him throughout. As the youngest of a large Manitoba farm family, he was his mother’s joy and primary recipient of her loving largess. He wedded his first love and childhood sweetheart, Catherine, who followed him from posting to posting, with one and then two children, Catherine Jr. and Jacqueline.

As a long-service pilot in the Canadian Armed Forces David Milne’s life was not without risk, but risk balanced in an equation with skill. His heart surgery was a risk, but it was balanced against the outstanding skill of Dr. Hamilton at Kingston General Hospital. The surgery was successful and Dave’s recovery was preceding well, thanks to the care of the KGH staff. Unfortunately, a series of hospital-acquired infections set back his progress and ultimately caused his premature passing.

Every year hospital-acquired infections cause or contribute to the death of more people than breast cancer, heart disease, and car accidents combined. Most of these infections are initiated by otherwise caring healthcare workers who forget or neglect to clean their hands.

And for each of those who, like our friend David, succumb to one of these unnecessary infections, there are many more who ache for their loss. These are not numbers on month-end reports. These are our fathers, our mothers, our children, and our dear friends, who are dying prematurely because of unclean hands. The little bit of extra time that it takes for healthcare workers to wash or to use an alcohol sanitizer is pittance compared to the waste of so many productive, loved and loving lives.

In honour and memory of David Williamson Milne a donation will be made in his name to the Community and Hospital Infection Control Association of Canada. His family and his extended group of friends openly urge those at Kingston General Hospital as well as healthcare workers everywhere to clean their hands before and after every patient contact. It is absolutely a matter of life and death.

Farewell to a dear husband, father and friend.