A Modest Proposal To Reduce Hospital Infections
September 26th, 2012
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A few months ago my grandmother fell down and broke her arm. (Before anyone asks, she is fine now. They set the bone and she was in a sling for a couple months, but fully recovered.) The day after she fell I went to visit her in the hospital. She was admitted to Yale New Haven hospital and was staying in a bed in one of their general wards, about six floors up from the main entrance. Yale New Haven has an excellent reputation and is regarded as the best hospital in the immediate area.
However, there is something that really struck me in a bad way upon visiting: it really seems the hospital could be doing a lot more to keep germs out. Upon entering, I came to a receptionist. She was barely paying attention, asked me to sign in and gave me a laminated pass (which I can only guess how many people had touched and how many rooms it had been to.) She didn’t look me over to see if I looked reasonably clean or even if I appeared queezy and feverish. I could have been coughing and had a runny nose and she probably would not have objected.
After getting the pass, I walked down the hall toward the elevators. Before getting on, I stopped in the mens room and spent several minutes scrubbing my hands and forearms. This was not required, of course, but there as a men’s room there so I figured it was a good idea. Unfortunately, the lavatory had an air-type hand dryer with a nasty looking button to start it. I pushed that with my elbow. Then I kicked the door open (because it had a door, as opposed to the kind of lavatory where the door is open and there is a turn going in to keep it private).
As I approached the elevator, I encountered the first sign that the hospital cared at all about germs: a station where alcohol-based hand sanitizer is dispensed. Depsite having washed my hands, I also used the hand sanitizer. Of course, this was not mandatory and I saw plenty of people walk by without using it. It seems it was little more than a suggestion, although a damn good one.
The elevator was operated with the standard grubby-looking plastic push button. One would think in this day and age, there would be a better way, like some kind of proximity sensor you wave your hand in front of, but apparently this had either not occurred to the hospital or was not a priority. The elevator, like all construction in the hospital, was made of the standard materials: rough plastic paneling, dry wall and so on. I think I would have felt a bit better if more things had been made of stainless steel or porcelain, which give bacteria nothing to cling to and are easy to clean, or, better yet, anti-microbial copper plated material.
Am I overreacting?
Obviously I’m not a doctor and perhaps I should bite my lip when it comes to such healthcare policy, but the fact of the matter is that hospitals are well known for being breeding grounds for infection. The term is nosocomial infection: infections developed by hospital patients (and sometimes staff) primarily due to the conditions within the hospital.
It’s not hard to see why this would be a problem. A hospital places a large number of people in a small area, many of whom have weakened immune systems or are already very sick. Many have been opened up for surgery and others use devices like respirators and catheters, which provide an easy way for bacteria to enter the body.
These infections can be even worse than those normally encountered in every day life. Because the same bacteria is prone to repeatedly infecting those receiving medical care, there is an extremely high incidence of antibiotic resistant bacteria. Indeed, some of the worst, most aggressive multi-antibiotic resistant bacteria strains seem to have initially evolved in hospitals or other healthcare facilities. Even those that are of relatively minor concern to healthy individuals can take root in the hospital system and become persistent problems, easily spreading from hospital to hospital as staff, patients and equipment is transferred.
Yes, it is a huge problem!
In the United States alone, close to one hundred thousand deaths occur per year as a direct or indirect result of nosocomial infection. More than a million and a half people are diagnosed with them, and while most survive, a nosocomial infection can turn an otherwise routine two day hospital visit into weeks of intensive care. Untold billions are spent on treating these infections per year. The problem is not just American, however, but exists in every industrial country. In many EU countries, upwards of ten percent of admitted patients will come down with some form of nosocomial infection. Even Switzerland, despite having a healthcare system often cited as one of the best in the world, has an extremely high rate of nosocomial infection, with upwards of 14% of hospital patients becoming infected.
Like so many problems in the healthcare field, nosocomial infections have far reaching effects on the system as a whole. Their expense drives up the cost of healthcare as a whole. When patients have to stay longer to recover, more beds are occupied. The time and efforts of doctors are spent treating these infections. Insurance rates are driven up. The increase in antibiotic resistance means that ever more exotic and expensive antibiotics need to be used.
One thing that is well known about nosocomial infections is that the vast majority are preventable. It’s impossible to ever get the number down to zero, because it would not be fiesable to completely sterilize everything in a hospital and provide all patients with complete atmospheric isolation from everyone else. Moreover, many would prefer the small risk of infection if the alternative were to be completely kept away from family and treated with telemanipulators.
But just cutting down on nosocomial infections by 75 or even 50 percent would mark a massive improvement in patient care and a huge financial savings for healthcare providers. Methods of reducing nosocomial infections are well established. They include extreme vigilance of visitors, requiring everyone to wash their hands frequently, better isolation of patients, frequent cleaning and sanitation of all surfaces, the use of anti-microbial surfaces and so on. Most hospitals do practice these to some extent, but the differences can be demonstrated by the fact that some hospitals do vastly better than others when it comes to nosocomial infection rates and that implementation of rigorous programs to control infection have been demonstrated effective.
Why, then, are extremely rigorous programs for cleanliness and infection control universal?
I believe the answer is simple. The hospitals generally don’t have much economic incentive for them. When someone enters a hospital and acquires an infection, they need to receive a great deal more treatment, including antibiotics and extended stays. Someone has to pay for that, but it’s not the hospital itself. In the United States and other countries with private health insurance programs, the money comes from the insurance provider. The hospital not only does not hurt financially, but benefits from the infection as a chance to sell more services.
This problem does not go away with nationalized healthcare. Even if the hospital is government administrated, the hospital and its management are not directly responsible for the costs. They just send the bill for the services up to the government to be paid.
Here, therefore, is my proposal: if you enter a hospital without an infection and acquire it while at the hospital, or if a surgical wound becomes infected, despite being properly dressed and cared for after the procedure, the hospital foots the bill for all treatment that is directly or indirectly associated with the infection and is required to provide any treatment necessary regardless of the cost.
Is this an unfair burden? I don’t think so. In criminal law, the burden of proof is usually “beyond reasonable doubt,” but in civil law, where the question comes down to who is financially responsible for something, the burden is often just probable fault. If you go to a hospital and get an infection, it’s not unreasonable to presume that there was probably something that could have been done to prevent it. Since its the job of the hospital to provide safe and effective care, if you get an infection, they have failed to do so and should have to pay for the costs resulting.
This entry was posted on Wednesday, September 26th, 2012 at 6:38 pm and is filed under Bad Science, Good Science, Misc, Politics, personal. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.
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September 26th, 2012 at 10:36 pm
Strangely enough I just watched an episode of NOVA on smart materials which discussed a plastic sheeting that bacteria can not stick too. This material modeled after shark skin would be used to cover surfaces in hospitals and clinics sharply reducing the chance that infectious organisms would be transmitted.
Details here: Sharkskin Solutions
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September 26th, 2012 at 10:56 pm
That would certainly help, but even just using the measures that exist now to their maximum extent would be an improvement. Also, as far as materials go, just using a lot less porous materials and stuff that is polished metal or porcelain would help. Making visitors wash their hands would help.
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September 26th, 2012 at 11:14 pm
The issue boils down to the fact that it is getting difficult to find personnel that will do a good job at these tasks at a price we can afford. This is not just the case with healthcare but in food handling as well. We are going to have to move to high tech solutions to these issues like special surfaces, radiation or perhaps robotics simply because it will not be possible to find the right people to do them.
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September 27th, 2012 at 8:22 am
HyGreen claims that their “hand hygiene reminder system” reduced infection rates at Miami Children’s Hospital by 89%.
If I remember correctly, it incorporates an alcohol sniffer into a healthcare worker’s ID badge. If the worker enters a patient room and the sniffer does not detect alcohol vapors, it beeps at the worker as a reminder to use hand sanitizer. I haven’t read thoroughly on the subject or inspected the study methodology, but if the PR materials are to be believed (and it seems plausible to me), it’s a very simple way to drastically reduce infections at hospitals.
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September 27th, 2012 at 8:46 am
My understanding is one of the bigger challenges is simply getting doctors going on rounds to wash up between patients, although I also understand hospitals are finally starting to get serious about things like that. While it would be good to see janitorial staff constantly on rounds disinfecting door knobs and elevator buttons, it seems less likely a family member or friend is going to pick something up in transmit to the patient’s room and deliver it, unless the person had a compromised immune system due to an organ transplant or AIDS, in which case I would think visitors would be discouraged anyway. Otherwise, I would think the visitor would be put in as much risk as the patient.
Another contributor has nothing to do with hospitals themselves but the practice of feeding antibiotics to chickens and other livestock, which helps them gain weight faster but in the process encourages the development of MRSA and other resistant bugs.
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September 27th, 2012 at 9:45 am
DV82XL said:
But aren’t some of the things highlighted here less related to actual practices in cleaning and more to just not seeming to give a flying eff? It wouldn’t cost a whole lot more some sinks and hand sanitizer in front and tell all visitors that they could not enter if they didn’t very thorough wash their hands. It would not cost more to tell those controlling entry to glance over people and ask if they felt sick and suggest some might be better off not visiting.
Blubba said:
Or try to design the whole place with contamination in mind, like alternatives to button-operated elevators and knob-operated doors.
Blubba said:
But this is written from the perspective of a visitor. Can’t we validly assume if that if they make so little effort at hygiene for visitors that they probably do so at all areas? Isn’t it just good practice to make sure everyone, visitors, doctors, nurses, orderlies etc all follow some basic practice like hand washing and not touching too many surfaces? Not carrying in potentially hazardous contaminated materials?
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September 27th, 2012 at 10:45 am
Q said:
Yeah. That was pretty much my point. There does not seem to be a lot of effort going into this.
Blubba said:
That may cause issues with antibiotic resistance in general, but not so much with getting an infection at the hospital.
DV82XL said:
Technology, design, common sense, enforcement and more labor for cleaning will all be needed.
One thing that I’ve read is that the cost of hospital infections is so high that even if you need to spend quite a bit in combating it, you can still walk away with a net gain.
This is why I think the financial aspect and using it as an incentive should be considered. Hospitals will find it much cheaper to implement good cleaning policy if the alternative is being faced with the cost of the infections, which they generally don’t have to be the ones to pay.
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September 27th, 2012 at 3:16 pm
The problem for doctors and nurses is that constantly washing the hands with an alcohol based hand sanitizer quickly dries out the skin. Things get pretty painful after a few days of having to clean your hands very often. I’m pretty sure most healthcare staff is more than aware of the need for good hand sanitation. It’s just that they also need to protect themselves from destroying their skin.
(I’ve got some experience in this area myself, having worked in a cleanroom producing medical products.)
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September 27th, 2012 at 10:08 pm
This guy said:
I just got a flu shot and thanked the nurse for using the hand cleaner. She mentioned that the current brand didn’t dry out her hands like the previous brand. Most brands contain some hand lotion, apparently with varying degrees of success. Dry hands are a hazard because the skin can crack.
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September 28th, 2012 at 12:03 pm
This has become a big issue in the UK and the consensus is that the hospitals can do much more than they do. The rate has gone up a lot and infections get harder to treat with antibiotics. Some high profile cases happened with people who went in healthy and with minor conditions and got deadly infections.
I like the idea of making it a financial pressure issue, but not sure how that would work out with NHS hospitals, since the finance is managed centrally and its not like they send the bill up in the way privates do, but it could well work with private hospitals.
Money wise the fact that doing more would save money, because the investment is rewarded greatly by the lesser expenditures on treatment is a point that has been made, but the way budgeting is done can be short sighted and they only see the immediate savings of cutting cleaning expenses. Thats how it operates. Prevention is always undervalued.
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September 28th, 2012 at 3:44 pm
Over here (I’m on the same side of the Pond as Mark) there are many reasons for the upsurge in hospital acquired infections.
I have a medical background and trained as what you would call a corpsman in the Royal Navy. Eight months of that training involved working on wards of different specialties.
We had two branches of nurse. The State Enrolled, who were considered the hands on practical nurse and State Registered who were trained to be the Staff Nurses and Sisters. The SEN training was two years, the SRN three.
In my opinion, when we scrapped one branch we scrapped the wrong one.
We kept the RN’s and ditched the EN’s. We then made nursing a degree qualification.
The first year of a nurses training now consists of psychology and sociology with absolutely no patient contact. I actually had to teach a friend of mine Anatomy and Physiology because that’s not covered until well into the second year.
Before this student nurses spent most of their time on the wards learning from the SENs and the first thing done when coming on watch was to ‘Damp Dust’. I.e. every member of staff went round every patients bed and wiped down the hard surfaces with disinfectant.
We also had permanent cleaners who were genuinely included as part of the nursing and medical team.
When my father was dying, about 10 years ago in Barts, it was three days before I found out he was supposed to be in isolation and barrier nursed.
When my Mother died last year I had to explain to a senior nurse where the Caecum was.
Nurses today are too posh to polish.
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September 29th, 2012 at 4:35 am
When you said a “modest proposal” I thought you were going to recommend eating the sick.
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September 29th, 2012 at 3:20 pm
Peebs said:
In many cases they are too overworked to take on such duties. The case load (or number of beds) a nurse is responsible for now, is far greater than in the past, as well they are now expected to assume more of the technical work that physicians once did. Add to that the cleaning staff (at least here) are often folks with a poor command of the working language, and do not have a real appreciation of the mechanics of disinfection, and it little wonder that things are not being done to spec.
The other thing is that all of us have been living in a fool’s paradise when it comes to infection in general due to the availability of antibiotics. When my father was young, death from bacterial infection was a common occurrence to the point where losing a relative or classmate was a regular event. People took things like quarantine seriously and these were rigorously enforced, however now I read that kids with pertussis are sent to school by parents unwilling to miss work with the result that we have had several outbreaks of this disease, exacerbated of course by the current anti-vaccination idiocy now in vogue.
Unfortunately as a group humans are not very good at projecting this sort of risk into situations were the tools we now have for dealing with it start to fail. One hopes that we will not get a lesson on the magnitude of that error before technology and processes are in place to cope.
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September 29th, 2012 at 5:48 pm
Your point is well made and well taken.
But the problem lays with the fact that nursing today is an academic and not a practical qualification.
A nurses experience should be on the wards, not in a classroom. That means doing ****ty jobs like emptying bedpans.
I am in total agreement with your assessment of the cleaning staff.
I once tried to set up a course with a formal qualification for cleaners (an NVQ).
It was greeted with much enthusiasm until my business plan was assessed.
I mentioned things like ‘Fomites’ and was immediately told that the whole.scheme was impractical.
If I meet a nurse these days and this subject comes up I ask them two questions.
1. When was the last time you emptied a bedpan?
2. What is a Fomite?
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September 29th, 2012 at 8:45 pm
Peebs said:
I am not sure the way things are organized in the U.K., but here in Canada we have Registered Nurses with University degrees, and various grades of Nursing Assistants (depending on Provence) with less training that empty bedpans and such. The issue is a skilled individual, trained to deliver medical services at a higher level that was expected from the job in the past shouldn’t be wasting time on matters that can be done by lower grades.
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September 30th, 2012 at 1:53 pm
I’m referring to their training.
Would one of the ‘lower grades’ be skilled enough to recognise if a patient was diarrhoeic, constipated, steatorrhoeic or melaenic?
You can tell a lot from a bedpan medically.
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September 30th, 2012 at 2:56 pm
peebs said:
I assume that the three years of post-secondary training NAs get would cover such things. (RNs on the other hand need a university degree)
The broader problem with trying to apply working conditions that were the norm in the past, particularly in jobs like nursing, is that women who once entered these professions because they had few choices if they wanted careers now have other options. Because they did not in the past, they were easily forced into doing things, like housekeeping in their institutions and other unskilled work, but now you could not attract the caliber of candidate to these jobs that the rising level of technical sophistication in health care needs if they know they will be treated like maids.
And again, the number of beds a given nurse needs to cover and the number of procedures that they are expected to do is also vastly different than in the past. It’s all very well to criticize things as they are now, and there are issues, but the answer is not to turn back the clock.
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September 30th, 2012 at 4:59 pm
Over here we have RN’s and Health Care Assistants.
HCA’s go through nowhere near 3 years training.
All I can assume is you’ve kept the system we discarded.
My point remains that nursing is a practical profession, only so much can be taught in a classroom.
It’s not just the physical act of emptying a bedpan, it’s the empathy and patient interaction involved in carrying out that simple act.
Plus, if a nurse has never had to do it, how can he or she expect to command respect when she details off a minion to do it.
Respect has to be earned. I respected every nurse I worked under because I knew they’d been there, done that and got the Tshirt.
As long as you’re saying it can be left to lower grades you have a class system.
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September 30th, 2012 at 10:25 pm
Right now we have a shortage of nurses. The fact is other less onerous jobs pay more and have better working conditions. I cannot see how instating a system where they would have to “pay their dues” by doing petty tasks like housekeeping is likely to attract more candidates to this field.
I’m in my sixties, and I remember the way new inductees into my field (aviation) were treated when I was young, and how the new crop was not subjected to this treatment to the disgust of the senior employees, but the fact is that times have changed and technical fields have gotten more complex and as a result the level of education those newly entering needs to be much higher. And make no mistake: technical fields are competing for quality labor and quality candidates for training, it’s not like the past where there was three bodies for every job. In this environment the practice of making the new guy pay his dues will only serve to drive good people away – I know places that have had to learn this the hard way.
Times have changed.
As for the existence of a class system who said there wasn’t one? Skills in any field are graded and pay, status and responsibility are made commensurate. I for one think that this is a good thing.
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October 1st, 2012 at 12:53 pm
This was one of those times were the comments were more interesting to read than the actual article.
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October 1st, 2012 at 3:16 pm
Please don’t think I’m stuck in the past with a rose tinted view of the golden days of nursing.
I realise change has to happen, more so in medicine than many other occupations. What I’m saying is we threw out the baby with the bathwater (over here we did anyway).
Sadly things like bedsores are commonplace in a lot of our hospitals.
I’m afraid that the only reason for that is poor and substandard nursing care.
Pressure area care (bedsore prophylaxis if you like) was drummed into all medical and nursing staff from the outset and if a patient developed one then faecal matter really hit the air extraction unit. Metaphorically speaking of course!
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October 3rd, 2012 at 5:40 pm
Peebs said:
Is it substandard nursing care because of substandard nurses, or is it the fact that there aren’t enough staff to do the sort of patient care they know needs to be done but can’t spread themselves thin enough? Again, this is an area that has effective technical solutions in the form of active anti-decubitus mattresses that should be the standard in all hospitals and is not. If we can’t afford the labor then we need to turn to technology to deal with the issues that this is causing.
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October 5th, 2012 at 12:57 am
Peebs, all your points are very good.
It is sad that it has beocme the accepted norm that a degree now merits the accepted status as “qualified” for anything.
While at the same time, because of poor regulation, sucess with hands on experience is no longer an accepted indicator of a persons ability.
I haven’t been involved the medical professions, but I would assume that it is the same as other endevors that require a very broad range of knowledge; working from the bottom up would create a better overall understanding of
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October 5th, 2012 at 1:02 am
… how to be (at a minimum) the most efficient at what you do.
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October 5th, 2012 at 4:01 pm
I haven’t heard pressure sores called decubitus for a while!
The point is that there is no need for expensive kit like the inflatable mattresses to which you refer except on high dependency units such as ITU or CCU. Get the nurses out of the classroom a bit more and onto the wards.
I’m not alone is this school of thought. A lot of senior nursing and medical staff feel the same way.
DonM expresses my points but with much more brevity!
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October 5th, 2012 at 10:33 pm
This argument is becoming circular. Yes it would be great if things were done as they were in the past when labor was cheap and plentiful and those that were delivering these services were ether more committed, or more easily dominated, BUT that is not the case now.
You cannot make the sorts of demands on this generation in the workplace that we were burdened with in our day. The bottom line is that there are not enough of them, at the quality now needed to fill the spaces available, and there are others trying to hire from the same pool.
This is particularly true of women who still make up the bulk of new uptake into nursing. In the past it was one of the few careers an intelligent independent minded girl could aspire too. Now these women can do just about anything they want. In the past you could make these girls eat dirt because they had no other choice if they wanted a job, now you have to work to keep them.
This is not just women in nursing – its happening all over and businesses and industries of all sorts have to make adjustments to how they manage human resources and explore automation to replace labor to do the jobs that no one wants to do at the price we are willing to pay. This is just the new reality particularly in the West, and we all better get used to it. The Japanese saw this coming a long time ago, which is why they have invested so much time an money into robotics. We would do well to follow their lead in this regard.
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October 7th, 2012 at 5:23 pm
I agree the argument is becoming somewhat circular but your reference to the Japanese and to robotics leaves me baffled.
Lack of patient contact is at the very core of the problem.
I’m on my mobile (cell) at the moment so C&P is arduous but I’ll post a link referring to this very problem as soon as I can.
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October 7th, 2012 at 7:47 pm
Lack of patient contact is not the core of the problem, it is the symptom. The problem is a lack of manpower and the fact that the people that we do have are expected to deliver a far greater number of medical services than their predecessors were. It is all very well to talk about getting out and being with the patients but another thing altogether being able to do it, and modern nurses just don’t have the luxury of doing so. Those that make these sorts of broad statements need to back them up with some practical alternatives, and that is usually lacking.
Robotics is one potential alternative in that these may one day take on some of the routine work that sucks up human effort and time thus freeing people like nurses to spend more time doing things like direct patient contact.
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October 8th, 2012 at 3:38 am
Sorry but you are wrong. Lack of patient contact IS the core of the problem.
http://www.telegraph.co.uk/health/9593278/Nursing-care-in-crisis.html
Disgraceful and no excuse.
Those involved should be charged with manslaughter,
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October 8th, 2012 at 11:45 am
If this is the case in the U.K. it is indeed shameful and clearly things are not anywhere near as bad in Canadian hospitals even though we we have socialized health care too. This being so we are then obviously arguing from two very different perspectives and without any common ground between us. As a consequence of this realization I am dropping this discussion.
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October 10th, 2012 at 10:11 am
Mark said:
Actually it’s really really easy under the NHS : you simply make rates of infection a target issue and apply funding penalties to hospitals which don’t hit the target. This has been done, and with some success : http://www.nao.org.uk/whats_new/0809/0809560.aspx
DV82XL said:
This is a very important point. As little as forty years ago, becoming a doctor was incredibly difficult for women (my own mother quit a medical degree because of the abusive, chauvinistic environment) so smart, driven girls were aiming for nursing. Now it’s becoming something of a weak option – the smart, driven young women I know (with a love of science) have all studied genetics, pharmacology and medicine.
Peebs said:
Have to say I’m with DV8 on this : the lack of patient contact is a result of other pressures. Yes it has some tragic effects (that’s by no means the only article which could be cited) but it’s a result of the current healthcare climate in the UK: target setting (= dubious priorities), budget cuts (= staff cuts) and accountability (= excessive paperwork).
Returning vaguely to the original blog topic : would there be any worthwhile gain from having more (all?) staff and visitors wear surgeon-style face masks?
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October 12th, 2012 at 8:33 pm
It is clear liability isn’t properly distributed. Doctors are afraid of malpractice… but not because they give their patient a disease.
Also, washing your hands too often isn’t healthy, blisters. Probably best to put on your gloves and then wash those.
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