Visitors riding the elevators at Cedars-Sinai Medical Center in Los Angeles find themselves face-to-face with colorful floor-to-ceiling posters on the inside doors.
"Zero is the Greatest Number," reads the logo, part of the prestigious hospital's campaign to drive down to zero the number of infections within its walls. The posters appear in all 42 elevators in the facility, reminding employees and assuring patients and visitors that Cedars has infections in its sights.
The posters signal a sea change in the hospital world. Barely a decade ago, few people talked openly about hospital-acquired infections.
Even within medical circles, some did not yet realize that virulent bacteria picked up in hospital settings -- from unwashed equipment or even unwashed hands -- could lead to severe illness and even death. Many who did were loath to step forward to criticize colleagues' practices or sully a facility's reputation.
Today, after years of internal scrutiny and reforms, growing numbers of California hospitals are placing the problem in full public view.
Some hand out brochures to incoming patients and their families. Some give patients their own bottles of hand sanitizer and encourage them to ask doctors and nurses if they have washed their hands -- a technique used at Riverside Community Hospital in Riverside.
Even more surprising, officials at a number of facilities are talking openly to journalists about infection rates and plans for improvement, some prompted by the Dec. 30 release of the California Department of Public Health's first-ever report of infection rates for hundreds of general acute-care hospitals statewide.
MORE GOING PUBLIC
California is the 27th state to make such a report public, under a law championed by Riverside County resident Carole Mossafter the infection and death of her 15-year-old son.
The internal campaign within some hospitals is even more sweeping.
Santa Clara Valley Regional Medical Center in San Jose was a leader among Bay Area hospitals in embracing new practices to curb infections. The new report shows that the 575-bed hospital has among the lowest rates in the state for central line bloodstream infections that can sicken seriously ill patients who must be fed and medicated through catheter lines.
Early on, the hospital changed the way its staff inserted those lines deep in a patient's chest. It adopted a series of steps or "bundles" developed by the Institute for Healthcare Improvement, a respected nonprofit group in Cambridge, Mass., said Nancy Johnson, the hospital's infection manager.
"The key was that the administration got on board. They empowered the nurses to do a checklist to make sure the central lines were being inserted correctly," Johnson said. "They could basically stop whoever's inserting the line and tell them that they haven't met the criteria -- that they can't insert the line."
To give nurses that responsibility can upend a hierarchy in which doctors give the orders. And doctors are sometimes reluctant to change, Johnson said. "People have their own way. They want to do it that way. It's, 'Why do you want me to do it that way?' "
Santa Clara's infection numbers fell. But vigilance is needed to keep them low, Johnson said. Today the staff treats every bloodstream infection as a significant event, identifying ways that it could have been averted and circling back to make sure corrections were made. And the effort involves more than a few infection experts, she said.
"I can't stress enough that it has to be everyone. It takes the whole system. The administration. The direct caregivers. The finance department."
A number of other hospitals in California also have reduced infection rates with so-called "bundles" or checklists, including Riverside County Regional Medical Center, Arrowhead Regional Medical Center in Colton, UC San Diego Regional Medical Center and USC University Hospital in Los Angeles.
One key step is assuring that a line is removed when a patient no longer needs it, said Kim Delahanty, administrative director of infection prevention, clinical epidemiology and tuberculosiscontrol at the UC San Diego hospital. The longer a line remains, the greater the danger of infection.
"We look at that every day and say, 'Is this line necessary?' " Delahanty said.
Some hospitals are scrutinizing their use of antibiotics to guard against multi-drug resistant organisms such as MRSA, or methicillin-resistant Staphylococcus aureus, and picking antibiotics that are less likely to promote resistance. Antibiotic stewardship programs are now in place at USC University Hospital and Los Angeles County-USC Medical Center.
"We want to use antibiotics appropriately," said Dr. Paul Holtom, hospital epidemiologist at both hospitals and a USC associate professor of medicine and orthopedics.
As hospitals retrain housekeepers and install hand-sanitizer dispensers in their hallways, they're finding bacteria in unexpected places.
Cedars-Sinai sent out inspectors to search for spots where bacteria can hide. They tested the "privacy curtains" encircling patient beds and were stunned to find that 30 percent of the curtains hosted multi-drug resistant organisms.
"When people walk in the room, the first thing they do is move the curtains aside," said Dr. Michael Langberg, the hospital's chief medical officer and co-chairman of its lead committee on infections.
So the staff ordered new curtains of the kind used in many British hospitals because they are stronger and easier to launder. They are sprayed daily with disinfectant. And they are tested regularly for drug-resistant organisms, Langberg said.
For the past five quarters, he added, the curtains have tested organism-free.