With the worldwide emergence of H1N1 influenza and the World Health Organization’s declaration of a flu pandemic on June 11, 2009, there is great concern regarding the issue of infection control. Yet, much of what we see and hear is narrowly focused on the ability of hand-washing to prevent the spread of the H1N1 influenza virus that threatens the lives of young and old alike. It is a familiar story that was also trotted out when other infectious diseases such as MRSA, C. difficile, and Norwalk virus emerged.
The focus on hand-washing is certainly also evident in Ontario where former Health Minister George Smitherman said, “Being very vigilant on the issue of hand-washing is known to be the single biggest thing that can be done to protect against the spread of superbugs and other infections.” It is a message echoed by hospital CEOs such as Dr. Kevin Smith (not a medical doctor) of St. Joseph's Healthcare Hamilton who said, “We are really focused on hand-washing -- every patient, every time, with or without gloves, hand-washing, hand-washing, hand-washing.”
What is needed to control infection?
While there is no denying that hand-washing is a worthwhile and hygienic practice, my experience in the housekeeping department at St. Joseph's Healthcare Hamilton has taught me that regular hand-washing is only part of the solution that will lead to the reduction in the frequency and severity of deadly outbreaks besieging Ontario hospitals. What is also needed to enable a well-functioning housekeeping department to provide the sterile environment is an end to the contracting-out of cleaning services in Ontario’s hospitals. Effective patient treatment and safeguarding the broader public requires the much improved treatment and training of support workers to ensure a professional and long-term cleaning staff in every hospital.
As it stands, these important goals have yet to be realized because of the negative effects of privatization in Canadian health care which have resulted in the deterioration of specialized cleaning services and the proliferation of infectious outbreaks. Instead of being a refuge for the sick, Ontario’s increasingly privatized hospital services have become laboratories for the breeding of superbugs and other pathogens. Meanwhile, just as Nero fiddled while Rome burned, politicians and hospital administrators in Ontario have been trumpeting the wonders of hand-washing because it is cheap and easy. The simplistic focus on hand-washing also does not deal with the question of who provides cleaning services in our hospitals.
Why are public cleaning and disinfecting services important?
In a hospital setting, especially in a large urban hospital such as St. Joseph's Healthcare Hamilton (SJHH), a well-functioning housekeeping department is essential to limit and contain the level of environmental contamination that exists with so many people working or receiving medical treatment in close proximity. Indeed, all manner of bodily effluence (fecal matter, blood, phlegm, etc.) can be found on environmental surfaces such as walls, floors, chairs, handrails, tables, light switches, door knobs, phones, TVs and converters, call bells, bed rails, taps, cabinets, medical equipment and personal effects. Without the specialized cleaning services provided by a professional, dedicated housekeeping department (more properly described as infection control technicians, rather than “housekeepers”), pathogens such as C. difficile, VRE, MRSA, Norwalk virus and influenza can survive in the healthcare environment for months at a time.
With these conditions the need for a comprehensive and effective infection control strategy that protects hospital staff and patients from deadly pathogens is greater than ever, especially with the emergence of H1N1 influenza. However, like so many other hospitals in Ontario, SJHH has been quietly out-sourcing support services at its various sites despite a mounting body of evidence that this policy leads to a substandard level of cleanliness. For example, with the high turnover rate of low-paid contract workers, knowledge of proper cleaning techniques and procedures is undermined. The problem is compounded by inadequate training and supervision. Out-sourcing and the attendant job uncertainty and lack of recognition of skills and training has a negative effect on performance by creating low worker morale. This fact is particularly important when the job requires regular cleaning of fecal matter and other biological hazards.
Administrative and private sector mismanagement
Even in those areas of SJHH where support services such as housekeeping are still performed “in-house” there is cause for concern because the management of these departments has been out-sourced. Private service companies like Marriott and Sodexho originated in the hospitality industry and not the healthcare field. Therefore they have no experience with the specialized cleaning techniques required in a hospital setting.
A common complaint from co-workers was that supervisors “don't know the job” and would often contradict one another. These are the same supervisors that would tell workers they can “skip some cleaning” or that “some cleaning is more important than others.” That may be the case in a motel where Room 5A is probably not all that different from Room 5E, but it is certainly not the case at a major urban hospital such as SJHH. In short, the infection control challenges faced in units such as 8 Rehab, 3 Nephrology, and 4 Medical Assessment Unit are unique and require workers with specialized training, skills, and experience to properly clean and disinfect, not just “tidy.”
In my own experience I was routinely sent to clean areas for which I had not been trained and was often told by supervisors, “all cleaning is the same.” CEO Smith claims that SJHH is committed to “looking at anything else we can be doing differently” in housekeeping. Yet, the inconsistent provision of cleaning and disinfecting services will continue its downward trajectory as long as cleaners and their management continue to be contracted-out to private corporations. It is telling that by the time I left my position to return to school in January 2008, only one supervisor had been on the job long enough to make their way up the ranks of hospital cleaners at SJHH and they were laid-off in February 2009.
How are the federal and provincial governments responsible?
Aside from creating the impetus to out-source support services, funding cutbacks on the part of the federal and provincial governments have created several other problems that have contributed to the proliferation of hospital-acquired infections (HAIs). Evidence of these problems is found in the insufficient levels of front-line healthcare staff, increased workload with higher patient turnover (as lengths of stay in hospital decrease), and the lack of a sufficient number of private rooms needed for isolation. According to the Canadian Institute for Health Information, hospital spending across Canada on support services –- of which cleaning is a major component –- dropped from 26 per cent of expenditures in 1976-1977 to 16 per cent in 2002-2003. Hospital cleaning was cut an average of 1.8 per cent per year during this period.
While one may suspect the overuse of antibiotics as a contributing factor to the proliferation of HAIs, several clinical studies and audits have linked HAIs with understaffing, increased workload, high absenteeism and turnover of cleaning staff. Worsening patient outcomes have also been linked to increased reliance on temporary workers, inadequate training, and poor supervision of cleaning staff, contributing to the exponential increase in HAIs such a MRSA, VRE, and C. difficile over the past 15 years. The outcome of these public sector cutbacks is that more than 220,000 healthcare associated infections result in 8,500-12,000 deaths each year in Canada. And rates are still rising. The direct costs of hospital acquired infections in Canada are estimated to be $1-billion annually. These costs are borne by patients and volunteer caregivers as well as program expenditures for home and community care.
What can be done differently?
Instead of pursuing greater cuts to the public sector in accordance with their neoliberal agenda, governments in Canada could learn a great deal from the failures of the contracting-out experience in the United Kingdom. The key efforts to resist contracting-out of cleaning services in Wales and Scotland were able to cut down on infectious outbreaks. According to UK infection control expert Steve Davies, Canadian governments:
“...need to recognise that contracting out cleaning is part of the problem, not part of the solution. Canadian governments need to focus on saving lives, not on saving money. It is also important to locate cleaners as a valued and integrated part of the clinical team who should work closely with other healthcare staff in a coherent infection control program. Another step is to see the business case for high quality cleaning. Penny pinching in this area contributes to the enormous human and financial costs associated with infection outbreaks. Therefore it's necessary to rebalance the way healthcare budgeting takes place. Good quality cleaning is value for money.”
As it is, the fanatical focus on hand-washing on the part of politicians and hospital administrators is a convenient way to off-load the responsibility of infection control onto the individual. The truth of the matter is that infectious outbreaks are the result of systemic breakdowns caused by increased privatization and funding cutbacks.
Indeed, the infectious outbreaks that threaten the lives of hospital staff and patients are not the result of any inherent deficiency of the Canadian healthcare system. Instead they are symptomatic of a healthcare system that has been destabilised and undermined by insidious private interests and a compliant political élite. There is a clear neoliberal strategy to manufacture a crisis in order to create the illusion of disorder in the public system with the aim of increasing the private (read, for-profit) sector’s role in our healthcare system.
My time spent working at SJHH taught me that hand-washing is an important but ultimately complementary method of infection control, especially in an inner-city facility such as St. Joseph's Healthcare Hamilton. At SJHH there is a definite presence of infection but little control and not much of a strategy. Unfortunately, SJHH's laissez-faire approach to infection control and failure to restore cleaning and disinfecting services to previous standards will mean that the perniciousness of the viruses and bacteria sickening and killing its staff and patients will continue to spread.
While hand-washing is exalted as the panacea for the infectious outbreaks and superbugs that have plagued Ontario hospitals in recent months, the obsession with hand-washing on the part of politicians and hospital administrators is little more than a shameful, shameless attempt to wash their hands of the responsibility for a degraded healthcare system -- while the lives of hospital staff and patients hang in the balance sheet.
Steven Kennedy now lives in Waterloo, Ontario and is currently a student in the Graduate Political Science Programme at Wilfrid Laurier University.
This article originally appeared in the Socialist Project E-Bulletin and is republished here with permission.
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