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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 .”
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