This article was originally published in Maclean's Magazine on June 23, 2008
Hospital-acquired Infections - Are They Avoidable?
Doctors and nurses in this country are increasingly at war with the very buildings in which they must deliver their most urgent care - our HOSPITALS. One front in this conflict opened in the fall of 2006, when doctors at the Sault Area Hospital, in the northern Ontario steel town of Sault Ste. Marie, realized that the C. difficile cases they were seeing had moved beyond the realm of the normal. So alarming was the outbreak, and so difficult did it become to eradicate, that even veteran nurses were soon recalling the sci-fi horrors of The Andromeda Strain. In the previous six months, they had recorded 50 cases, double the number generally seen each year. More troubling, patients infected with the C. diff. bacteria - a feces-borne pathogen that causes intestinal swelling and diarrhea - grew sicker and stopped responding to routine treatment, making it likely that a lethal Quebec-based strain, linked to some 2,000 deaths in that province, had migrated north. Soon, doctors feared the outbreak had caused as many as 26 deaths. "For Sault Ste. Marie," says Vicky Willet, the hospital's infection-control practitioner, "this was our SARS."
Called north as a consultant, Dr. Michael Gardam, director of infection prevention and control at Toronto's University Health Network and a key player in the 2003 SARS crisis, instructed staff to isolate patients immediately after they began suffering from diarrhea and urged hospital managers to install portable sinks (handwashing is key to infection containment) and costly equipment to dispose of contaminated patient waste. Chief of staff Dr. Al McLean, managing an already overcrowded facility, wrestled with finding space, eventually dedicating whole areas in the hospital to the crisis. Staff doubled their housekeeping efforts, even confiscating waiting-room magazines that might spread the infection. "If you thought you had budget problems before, just wait over the next few months," McLean said at the time. "The housekeeping budget is going to double."
But as they twisted floors into quarantines and blasted surfaces twice daily with germicide, Gardam, McLean and his staff were battling more than C. diff. - they were at war with an outmoded hospital design that actually encouraged its spread. Given what we know now about how to build hospitals, post-SARS, with an alphabet soup of antibiotic-resistant bugs flooding wards and a 1918-calibre pandemic forever waiting in the wings, such steps should not have been necessary. The Sault outbreak demonstrated what a growing body of medical evidence already suggests - bad hospital designs can kill. According to a landmark Canadian report published in 2003 in the American Journal of Infection Control, more than 8,000 die in this country each year after contracting infections in hospital - over double the number killed in car accidents. The provinces spend billions on the 220,000 who become infected annually - patients who remain in hospital longer and depend on increasingly exotic, costly antibiotics. Those costs weigh on health care systems already groaning under budget constraints, wait lists and staff shortages.
Yet a number of hospitals built in recent years in the U.S., Europe and even in Canada using design principles proven to curb such outbreaks - simple things like more handwashing stations and a toilet for every patient - have reduced hospital-acquired infections by as much as 70 per cent, a boon to both patient health and cost-efficiency. The success of these cutting-edge facilities has vaunted the private room, once considered something of a luxury, into the realm of a health care necessity, not just for the very ill but for all. "Within hours of having a roommate, you start to share the same microbial flora," says Dr. Richard Van Enk, epidemiologist at Bronson Methodist Hospital, an all-private-room facility in Kalamazoo, Mich. "People come in and out, people cough, you touch things, share the same bathroom."
Research suggests single-bed rooms alone can reduce infection rates by up to 45 per cent; imagine rolling the mortality meter back from 8,000 to 4,000 dead in Canada due to hospital-acquired infection. Such evidence persuaded the American Institute of Architects to call for 100 per cent private rooms as the minimum standard for medical-surgical and postpartum nursing units in general hospitals in its most recent "Guidelines for Design and Construction of Health Care Facilities," a document adopted at least in part by 42 U.S. states.
Still, even as we launch into a hospital building boom, no jurisdiction in Canada has yet adopted binding guidelines to ensure that these design solutions, more expensive to construct but cheaper to run in the long- term, will get retrofitted into older hospitals, or incorporated into new ones. "If you wanted a definitive guide to new hospital builds for 2008 for Canada - it does not exist," says Dr. John Conly, a specialist in infectious diseases at the University of Calgary who helped conceive the design of one of Canada's most progressive hospital wards. "I believe there's a crying need to have such a document."
So much is at stake. Early in 2007, the Sault hospital announced a $9-million shortfall, citing its C. diff. crisis as a significant contributor (it cost the hospital $5 million, says chief nursing officer Johanne Messier-Mann). At about the same time, the provincial coroner released the findings of an investigation into the outbreak, concluding that of the 26 deaths reviewed the bacteria had been directly involved in 10 and contributed to eight others. All that despite the heroic efforts of the Sault hospital's staff, who fought the illness, and hospital managers, who communicated to the public with unusual candour and transparency.
Still, had an architect drawn up a blueprint for a nasty outbreak, it would look little different from the Sault hospital as it was in the fall of 2006. "If he wasn't in the hospital, he'd be alive," said one perceptive family member of a C. diff. victim. Patients shared cramped rooms of up to four beds each. In some areas as many as eight patients shared a toilet, ideal for spreading C. diff. because the bacteria oozes spores that survive for months in the absence of proper cleaning. In 2006, sinks were still located at a distance from patients - often in a utility room down the hall - making frequent handwashing stops by physicians, nurses and staff impossible (they generally used the sinks of the sick). A lack of storage space hindered the separation of clean equipment - wheelchairs, walkers and canes, say - from used equipment, promoting cross-contamination. At the same time, budget constraints had caused managers to cut back on cleaning staff. Glenda Hubley, president of the Ontario Nurses Association local and a nurse in the Sault for decades, recalls the facilities as "filthy. The toilets were awful. Worse than the garage."
Shown the plans of a facility by Canadian health care professionals working on an outbreak - he won't say if it was the Sault, though the similarities are striking - Roger Ulrich, a health care design expert at Texas A&M University, was horrified. "I had to conclude," he says, "that the obsolete design was a significant contributor to the outbreak." Ulrich, who believes hospitals should be designed based on rigorous medical research, contends that something as apparently mundane as a hospital's floor plan - few private rooms, say, or more than one patient per toilet - can make containing outbreaks almost hopeless once cases begin piling up. For Gardam, the Sault was yet another case of same old, same old. "If I'm being called in for a hospital-wide outbreak, it's usually not in a new facility," he says. "Ethically, we can't build hospitals the way we used to."
Surely, with the expertise of Gardam, Ulrich and others available, we're no longer building hospitals the way we once did, in Sault Ste. Marie or anywhere. Right? Well, not exactly. According to Gardam, Ulrich was shocked to see the plans for a new facility that - again, much like the Sault, where a brand new hospital is due to open in 2011 - was due to begin construction within months of an outbreak and had already been approved by the Ontario Ministry of Health and Long-Term Care. That design still featured a high percentage of multi-patient rooms, as much as 75 per cent in medical-surgical areas. "You're building," Gardam recalls Ulrich telling him, "a 30-year-old hospital - today."
Ulrich is the grandfather of "evidence-based design," a movement of architects and physicians who recognize the critical, quantifiable role played by hospital buildings in the health outcomes of patients. If poorly planned facilities make us sick, research suggests that good HOSPITAL ARCHITECTURE curbs infection, improves patient health - reducing hospital stays and consumption of medication - and lessens the risks of medical error. It does all this at less cost in the long run than the institutions of our "general hospital" past. The need for good design only intensifies as hospitals confront more antibiotic-resistant bacteria and older, more acutely ill patients. In 2003, Ontario's SARS epidemic put thousands into quarantine, infected 375 and killed 44. Last month, opposition parties called upon Dalton McGuinty's Liberals to probe 260 C. diff.-related deaths at seven provincial hospitals in recent years; the pressure persuaded Health Minister George Smitherman to order that all facilities must now report C. diff. cases.
Other antibiotic-resistant bugs like methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Staphylococcus aureus (VRSA) are on the rise and multiplying fast. The Canadian Nosocomial Infection Surveillance Program, or CNISP, reported a nearly tenfold increase in the rate of MRSA infections between 1995 and 2006; between 2005 and 2006 alone, incidences rose 2.7 per cent. Based on data collected by CNISP, researchers extrapolated that 11,700 patients acquired new MRSA infections in Canadian hospitals in 2006. Some 2,300 died. The rise is so swift it can be dizzying: "In 2004, approximately five per cent of all the staph we had were MRSA," says Dr. Donna Holton of rates at the Peter Lougheed Centre, the hospital from which she oversees infection prevention and control for much of Calgary. Now, "we're sitting parked at 35 per cent. It's gone from five per cent to 35 per cent in three years. You kind of feel that."
The complexities of hospital design are head-scratchingly myriad. Infection prevention experts pore over clean-air-exchange stats, eschew organic materials like wood that are prone to mould, shudder at the grouted junctions between ceramic tiles where grime collects, and debate the minutiae of what floorings can better withstand harsh hospital cleaners. Other things are less obvious. Sound-absorbing floors and ceiling tiles can cut down on broken bones to reduce hospital stays. How? Patients, particularly elderly ones, require fewer sleeping pills on quiet wards and therefore wake up less groggy and fall-prone, says Karen Parent, a former Queen's University medical researcher who now runs her own consulting firm.
Private cubbyholes in emergency wards, meanwhile, apart from reducing the risk of infection, actually promote early and accurate diagnoses because patients are more likely to lie about their medical histories if they think other patients can hear them speaking with a doctor. Emergency wards with beds divided by nothing more than curtains make that difficult. "You have syphilis," says Gardam. "How am I going to have that conversation with you?"
Good hospital design can also cut down on such adverse hospital events as medication errors - think of actor Dennis Quaid's twin daughters, who almost died last fall after being given the adult version of a blood thinner at L.A.'s Cedars-Sinai hospital. Missteps like that tend to mystify until one considers how likely they become when stocking rooms remain ad hoc affairs, with little consistency from ward to ward or even floor to floor. Efforts toward standardizing hospital equipment and supply rooms - methods borrowed from industries so apparently far afield, say, as the airlines - promise to cut down on such errors, which the U.S. Institute of Medicine says are leading killers in that country. Combined with hospital-acquired infections, they cause more deaths than AIDS, breast cancer and car accidents. "There are a million lives lost a year due to medical error in the U.S.," says Dr. Kevin Smith, president and CEO of St. Joseph's Healthcare Hamilton. "There's no reason to believe that the extrapolation of American data isn't true in Canada."
Such numbers are hard to ignore. Yet in Canada no government-mandated guidelines exist to ensure good designs get built. While the Canadian Standards Association is working on national guidelines, they will not see publication until 2010. Ontario is developing a document, due for release by the fall, though the guidelines have been in development for years; Gardam refers to them as "the mystery guidelines nobody's allowed to talk about." Currently, says an Ontario Ministry of Health spokesperson, "hospitals are responsible for their own." That's not much of an assurance, Gardam says: "Considering how important this is, I don't believe it has the oversight you're looking for." In Canada, only the Calgary Health Region has adopted such a document (it calls for 80 per cent private rooms and no shared toilets), which it has used to leverage more money from the province. "We have an infection-control practitioner who sits on each one of the construction committees and they actually use that document to push the agenda," says Elizabeth Henderson, an epidemiologist with the Peter Lougheed Centre.
The lack of guidelines persists even while Canada undergoes a hospital building boom - one so rich that it tends to belie the notion we haven't got the money to build hospitals right. B.C. recently committed to something in the order of $800 million in infrastructure spending over the next three years, part of a $2.7-billion health sector capital plan. Alberta has spent $3 billion on health sector infrastructure since 2003 and projects another $4 billion in the next five years. In Ontario, 16 major projects began construction last year alone, amounting to some $2.9 billion in funding. The Ontario Hospital Association's Tom Closson projects Ontario will spend $5 billion more on such infrastructure over the next three years.
The absence of guidelines reflects a piecemeal approach to design oversight, one that makes it hard to know what the blueprints for new hospitals call for in terms of toilets and private rooms. In Montreal, the plans for two new McGill University Health Centre campuses are unusual for Canada because they include 100 per cent single-bed rooms. Things appear to be improving in Ontario - over the past year, Gardam has seen some proposals rejected for lack of single-bed rooms, for example - though the process is still mysterious. "I don't know if we're there yet in Ontario because I haven't heard of a new design that's planned where they have 100 per cent single rooms," he says. "It is a bit of a black box. How is a particular design approved and on what merits? Is it because it's cheap?" These facilities will likely remain active for the next half-century, making it critical that they be done right.
Consider one facility that is. At about the time the Sault hospital was managing its C. diff. outbreak in 2006, doctors at the Medical Ward of the 21st Century, a state-of-the-art acute-care ward completed in early 2004 at Calgary's Foothills Medical Centre, were just discovering how their new design was improving the health of their patients. By 2006, hospital-acquired infections on the ward, also called the W21C, had dropped 80 per cent; today they remain 70 per cent lower than the W21C's previous location, where shared rooms and toilets were the norm. "We saw the drop as soon as we went on the ward," says Dr. Barry Baylis, co-director for research and innovation on the W21C.
The 36-bed ward boasts 28 single-bed rooms, a one-bum-to-one-toilet ratio, and handwashing sinks placed in every patient room, bathroom, and liberally throughout the corridors. The toilets hang from the walls to facilitate cleaning. The sinks, triggered by sensor or foot pedal for hands-free use, are of a depth calibrated to reduce dangerous splashback. Buttressing a central nursing station are computers on wheels - dubbed COWS - often posted directly outside patient rooms so staff can input data directly into medical charts, thereby reducing distractions and consequent error.
The W21C's private rooms lead to more restful sleep and can accommodate family members, relieving stress in patients. Large, with decor reminiscent of a hotel for a more residential feel, they can accommodate whatever equipment a patient's condition might require, cutting down on the need to transfer the sick across the hospital, often a risk in terms of spreading infection. Each bed offers dedicated equipment - automated blood-pressure machines, say - so patients aren't put in contact with instruments that might be contaminated from elsewhere. Twinned medical fixtures above the beds permit two patients per room during crises, while the walls between some rooms collapse to form impromptu multi-bed quarantines.
Not all the innovations are popular with staff or patients. Non-perforated ceiling tiles selected to cut down on dust actually ricocheted sound, making the central nursing station too noisy. Patients alone in private rooms report feeling isolated (one study found patients in single-bed rooms use more painkillers, suggesting self-medication for loneliness). Nurses who work alone at COWs rather than at nursing stations can also feel out of touch. Tools like Vocera, a largely hands-free device worn around the neck and reminiscent of the lapel pins in Star Trek - users simply "log on" to a network by saying their names - now permit W21C staff to more easily communicate with each other. Meanwhile, the one-toilet-per-patient ratio is maintained even in the ward's semi-private rooms with a loo that swings out from under a second sink (though staff have found patients dislike them due to a lack of privacy).
Still, the reduction in hospital-acquired infections at the W21C - now serving as a model for a new hospital under construction in Calgary's south end - are hard to ignore. Similar efforts elsewhere have also met with good results. Kalamazoo's Bronson Methodist, which moved into a 100 per cent single-bed building in 2000, recorded a 45 per cent reduction in infections on nine units that had previously featured semi-private rooms. "No architect that's worth anything would ever even think of proposing a multi-patient-room hospital anymore," says Van Enk. "It would be like trying to sell somebody a horse and buggy instead of a current automobile."
Good design is showing up in emergency wards and intensive care units too. Holton, who played a lead role in developing the Calgary Health Region guidelines, included in that document an edict that new facilities build into their emergency wards the capacity for two separate public entrances, which in the event of a SARS-like crisis could receive suspicious cases at one door, low-risk patients - broken arms and busted heads - at another. Chris Fillingham, lead architect for St. Joe's in Hamilton, was working on that project when SARS, an airborne virus, hit southern Ontario, an experience that transformed the hospital. Anticipating Holton's vision, Fillingham changed his plans to include the possibility of dual emergency entrances. Though he initially saw the emergency and critical-care wards as sweeping open spaces that encouraged ease of monitoring, SARS caused him to backpedal. "We went from a very open environment with clear sightlines and few walls to an environment that was constructed around managing air flow and places of lock-down," recalls Smith, St. Joe's president and CEO. Fillingham gave waiting rooms sliding glass doors for quick-service quarantines and upgraded the ventilation system so that doctors could draw in 100 per cent fresh air (it had earlier been designed to recirculate air as a cost-cutting measure).
Some, particularly those manning the funding levers in provincial health ministries, may ask what all this costs. In a health care climate defined by wait times and other deprivations, provincial governments still find it hard to swallow the higher capital costs of, say, private rooms. "I don't think any province that I'm aware of has really come around to it," Fillingham says. But Canada may not be able to afford to skimp. "The amount of money that's been spent on infections is astonishingly high," says Holton. Though Canadian numbers aren't available, recent estimates in the U.K., where one in every 10 patients contracts an infection in hospital each year and 5,000 die, suggest that infected patients stay 1½ times longer in care than they would otherwise, raising costs by $6,000 per patient. In total, the National Health Service spends $2 billion a year on people made ill in hospital. As these infections are in the main preventable, it's a sum bled for no good reason. "If you get the building wrong, the message from evidence-based design is, you worsen outcomes and increase operation costs - you spill red ink," says Ulrich. "And the punchline is, you hemorrhage that ink on an annual, recurring basis."
Though he won't discuss the specific capital costs of Kalamazoo's 100 per cent private-room hospital, Van Enk says Bronson Medical managed to recoup the investment within just three years. "After that, you're just saving, saving, saving, saving," he says. The move to single-bed rooms, he says, cut down dramatically on infection-related operational costs and - here the analogy with Canada breaks down - made Bronson Methodist more competitive with prospective clients. Ulrich, who advocates for private-room-only hospitals, says the costs of constructing them aren't prohibitive. While consulting with the NHS in the U.K. several years ago, Ulrich found private rooms swelled overall capital costs by a paltry four per cent.
The Sault hospital, now due to open its new building in 2011, had a fight on its hands with the Ontario government when, in the wake of its C. diff. outbreak, it sought to increase the number of private rooms in its planned facility. The building had already been designed, approved, cementing the deal. Yet, for all the harm it otherwise caused, the hospital's C. diff. outbreak re-lubricated the process; under pressure, the Ontario government upped the percentage of single-bed rooms in medical-surgical areas from 25 - to a whopping 50 per cent. Not exactly state-of-the-art, and likely not smart either. "They're behind the times," Van Enk says, of an approach common throughout Canada. "You're raising your costs overall. The private room over the life of the building is a cheaper facility." Ulrich is more impassioned: "It is life, it is death, it is health and it is huge amounts of money. Billions and billions of dollars."
Maclean's June 23, 2008