By Alicia Cole
While no one could have imagined the scale and magnitude of the COVID-19 pandemic now plaguing us, advocates have long been pleading for more attention dedicated to infection prevention, increased resource allocation for environmental services and better training of hospital environmental services (EVS) staff. All legitimate concerns which the coronavirus made very publicly apparent to the entire world.
In a sad twist of ironic foreshadowing, the title of my 2018 keynote presentation to 6,000 infection preventionists and members of the Association of Professionals in Infection Control and Epidemiology (APIC) at its 45th annual meeting was, “Now More Than Ever, Patients Need You!” I could never have known how this clarion call would be a harbinger of days to come.
The campaign for cleaner, safer hospitals began for me in 2006, though not in the traditional infection preventionist way. I earned my medical stripes playing a nurse on “Beverly Hills 90210” and a doctor in the California statewide campaign to help stamp out childhood obesity. Outside of acting, my healthcare experience was limited to mammograms and acupuncture for menstrual cramps. When I entered the hospital in August 2006 for elective removal of two small fibroids, I had no idea the plot-twist my life was about to take. I share my story and the journey of recovery, living through not one, but multiple healthcare-associated infections (HAI). Statistics are important, however with each number, is a life, full of potential, hopes and dreams, that can all be changed in the blink of an eye, when evidence based processes and procedures break down and shortcuts are taken.
Following the procedure, I left the operating room with a fever, nausea, and chills – all classic signs of sepsis which were dismissed as “a bad response to the anesthesia.” These symptoms never subsided and within days my abdomen was swollen, red and hot to the touch. I was in horrible pain. I never had surgery before, so my parents traveled in from Ohio to assist me during what was meant to be a two-week recovery. As my condition rapidly worsened, my mother closely observed each dressing change and looked after me while the nurse removed my bandages.
On the fifth day post-surgery, my mother noticed a tiny black dot which had suddenly appeared out of nowhere just above the inflamed incision. She immediately asked the nurse to call for the doctor, but the nurse was reluctant. In just the one hour it took the doctor to return to my bedside, the black dot morphed into a quarter-sized pustule; in that moment, my world and the trajectory of my life was forever changed.
Before we knew what hit us, my mother was wearing gloves and assisting my doctor, at his request, in a bedside surgical procedure. He instructed her on how to hold my mid-section steady while he pulled a plastic-wrapped scalpel out of his scrub pocket to reopen the incision. Together they pressed and squeezed on my skin, using 4x4 gauze fluffs to soak up the brown fluid that was oozing out of the opening. Next, he cautioned that I needed to be very still, and told my mother it was important to hold me steady. Then he cut open the two rows of sutures deep in my abdomen. Within moments, I cracked my right lower molar in half while clinching down in pain.
From that point forward my temperature rarely dropped below 103. My two-day “routine” hospital stay descended into a two-month nightmare battle to save my life from the ravages of sepsis, Pseudomonas, MRSA, VRE, and necrotizing fasciitis. There were five additional surgeries, nine blood transfusions, and a near amputation of my left leg. During that time, I was in several different wards and interacted with multiple departments within the facility (ICU, med-surg, transport, imaging, etc.)
Most providers only see the condition of a facility in their area and while hospital administrators typically visit many departments, it is usually from a “walk-through” vantage.
From our observations, it is not hard to see why 2 million American patients per year acquire an HAI while seeking care. Many times, trailblazing, innovative procedures and treatments are performed on us in less than acceptable environments. Such was the case at my hospital. Some were so blatantly egregious that after a visit with me, one of my friends called her mother, a retired survey supervisor with the California Department of Public Health and asked her how to file a complaint.
After a year of complaints, and investigations, federal officials found my hospital to be in violation of 10 federal laws and five state rules for unsanitary conditions in their operating rooms, failures of infection prevention and control, and failure to report infections to the health department as mandated.
Among the violations, my hospital was cited at the highest level possible “Condition Not Met” for unsanitary conditions in their operating rooms. My heart sank as I read those words. I thought back to how horrible I felt while attempting to recover from that first surgery, already in the throes of sepsis. Patients openly exposed on an operating room table are the most vulnerable they will ever be in life. They are enticing prey to a host of pathogens, which leaves little room for error when it comes to cleanliness. Here are just a few of the other insights gained during that federal validation site visit: Inspection of an operating room being turned over and cleaned for a new case revealed paper postings inside plastic sheet protectors hanging on every wall and doorway. Hospital tape was used for many of these postings, including cloth tape, which was visibly soiled. The nurse manager stated in an interview that many of these postings were originally inside a book, but the staff would take them out and hang them on the wall. The sheet protectors on the main OR door were full of dust and dirt.
While looking at the ceiling and wall above the doorway, there were visible splashes and spots that had been missed by the environmental service personnel. Again, the manager stated that the room should have been cleaned before and after the patient comes into the OR for their surgeries.
The hallways surrounding the ORs were full of equipment and beds, including C-arm fluoroscopy machines and microscopes. These pieces of equipment were very dusty and dirty. Many of the bed pads were soiled with tape remnants covering cracks in the plastic coverings.
The epidemiology nurse pulled off the tape and stated, "it's only tape." The nurse manager stated that "this was not the way these things should be stored" and if there were cracks, then the pads should be removed, discarded, and replaced with new pads, not taped.
This kind of attitude dismissive of dirt, dust, and dirty tape is an indicator of a culture that does not value attention to detail. It was evident not only in the operating rooms, but clearly visible in other ways throughout the facility.
Healthcare experts say that keeping a hospital clean is crucial for the prevention of HAIs, and that reducing infections would save not only lives, but also money for the cash-strapped U.S. healthcare system. It’s one of the reasons the EvSOP© program requires that every participating hospital have a C-suite champion that acts as an advocate for substantive empowerment and support of the EVS department on their journey through the playbook towards zero infections.
Oftentimes patients observe hygiene issues in a facility, but do not feel comfortable bringing it to the attention of their care provider. They do not want to be viewed as complaining or nit-picking about things unrelated to their direct care. I had such an incident during my hospital stay. At one point following my seventh surgery, I was having a difficult time maneuvering to the restroom. I was attached to two IV poles: one on either side of my bed. One held five antibiotics and a TPN bag of nutrition. The other held four bags of antibiotics, pain medications, and had a wound VAC attached. Navigating all those items was quite a challenge. Going to the restroom required a nurse and a CNA moving each pole while I utilized a walker.
Attempting to help and also free up time for her staff, the nurse manager recommended that for the time being I use a bedside commode. It seemed like a good idea to me and I was willing to try it. However, when they brought the commode, I looked it over and immediately changed my mind. As politely as I could, I said, “I’m sorry I don’t want to use this one. Can you please bring me another one?” When the nurse manager came in, she was bewildered and asked, “Is there a problem?” I explained that it was not clean, and that I really would like another unit. She assured me I had nothing to worry about, that it had been thoroughly cleaned before they brought it to me, but that she was willing to have someone wipe it down again right away in front of me.
The CNA returned with her trusty disposable wipe and attempted to clean it off. I thanked her and said how much I appreciated the effort, but I still did not feel comfortable using the bedside commode. At this point the nurse manager was visibly frustrated and annoyed, and flat out sternly said, “Well, what’s the problem!” They were being very kind and trying to help me, so I felt bad and extremely uncomfortable about speaking up. I did not want to embarrass anyone, yet the commode remained visibly dirty.
From my position as a patient lying in the bed, I could see a perspective they could not. Clearly, the underside of the commode hadn’t been cleaned in ages; It was a speckled mosaic of dried urine and diarrhea splatter. Finally, I acquiesced to my discomfort and spoke up. I asked the nurse manager to turn the commode over. Her embarrassment was immediate. The tremble in her voice as she apologized profusely let me know she was sincerely mortified, and I felt horrible.
This is just one of the experiences that showed me everyone responsible for the patient, whether direct or indirect, should have their training be under the umbrella of “patient-centered” care. We need to shift the paradigm from just cleaning the room, to cleaning and disinfecting the room starting from the patient nucleus and expanding outward.
This incident highlights one of the other issues I have witness regarding EVS and housekeeping - the clear delineation of who is responsible for what. Was it the job of housekeeping to clean and disinfect the commode or is it the domain of a CNA? There needs to be better communication between clinical staff and environmental staff. That will be easier to achieve when members of the environmental team are viewed as “coworkers” rather than support, which allows for reciprocal respect. The EvSOP Playbook is a step in this direction through the promotion of a higher level of training, and certification to elevate the profession, backed by evidence based processes that create clarity to who cleans what, how, and when.
Many times, infection control issues are encountered and remain unresolved. Following my surgeries, when I had to ambulate the floor for exercise, I moved very slowly. Each of my parents had an arm and an IV pole. The more I walked the more it caused my wound bed to drain and sometimes, the seal around the plastic covering on my wound sprung a leak before I could make it back to my room. Whenever it happened, a trail of reddish-pink serosanguinous to sometimes creamy pink purulent drainage followed behind me. Not once was a call made to come clean and sanitize the floor, leaving other patients at risk who might unknowingly step in that trail. At best, someone would throw a white towel or sheet onto the floor and slide it back and forth with their foot, smearing the drainage across the floor until it dried.
Although I was only a doctor or nurse on TV, I knew that this and many of the other things I was observing were not appropriate. I made a vow that if I made it out of the hospital alive, I would do everything I could to bring awareness to these unnecessary hazards and help change the system.
While bedridden, I bought a ‘talk-to- type’ program and began using social media to share my experience with others. I researched and learned that over 100,000 patients like me did not survive their hospital-acquired infections. Personally, I witnessed that less than half of my caregivers washed their hands without any provocation from me. The more I learned, the angrier I felt, along with feelings of disappointment, and betrayal. I channeled my anger into videos and blogs documenting the struggles of harmed patients and in just a few months, the social media group I created for Survivors and families grew to more than 2,500 people.
My parents and I founded the Alliance for Safety Awareness for Patients (ASAP - http://patientsafetyasap.org ) to educate, protect and empower patients through knowledge and awareness of HAIs. As soon as I was well enough, I also began visiting medical schools and nursing programs and speaking on issues like patient safety and infection prevention.
In 2009, I was proud to co-sponsor two laws for public reporting of hospital infection rates and mandatory infection prevention education for all California healthcare workers with patient contact. SB158 and SB1058 are known collectively as “Nile’s Law” after Nile Calvin Moss, the son of fellow advocates Carole and Ty Moss. They had joined the networking group following the death of their 15-year-old at a children’s hospital in the middle of a MRSA outbreak.
In a somewhat “full-circle moment” I was appointed and served for nine years on the California Department of Public Health’s HAI Prevention Advisory Committee.
Ultimately in 2015, I was appointed by President Obama as a voting member of the Presidential Advisory Council for Combating Antibiotic Resistant Bacteria (PACCARB), a position I continued to serve under the Trump administration until the end of my term in February 2020. The same day the Coronavirus Task Force was first announced.
Above, Alicia Cole and former CDC director Tom Frieden as well as Alicia with former president Barrack Obama
As we think ahead now to a post-COVID-19 world, it is imperative that healthcare leaders and decision-makers shift their focus to the critical area of infection prevention and to providing a safe environment of care. There are already many evidence-based interventions that can be implemented to prevent infections and save lives. A true desire and will to do it are required, along with the commitment to allocate the right resources where the entire ROI is measured in lives saved, not just in the profit margins on a balance sheet, but weighing everything through the lens of Cost, Quality, and Outcome (CQO). It necessitates bold infection prevention champions taking the lead in their facilities and then replicating their passion and commitment to the patient across all departments – e.g. transport, EVS, nursing, and surgery. None of it will be easy, but neither is surviving, recovering from, and rebuilding a life after the devastation of an HAI. So, while it is a daunting task, we owe it to our patients to at least try.
Alicia Cole currently serves on the Patient & Family Executive Council for the Centers for Medicare & Medicaid Services Partnership for Patients 2.0. She also sits on the Environmental Services and the Education & Awareness Sub-committees of the California Department of Public Health’s HAI Advisory Committee. She also serves on the EvSOP© Advisory Council advocating for EVS and infection prevention professionals.