When it comes to cleanliness in the streets and hospitals – but maybe not inside homes – Israel is not at the top of the praiseworthy list. Way ahead of this country are medical centers in Denmark, Sweden, Switzerland, the Netherlands, Norway, Germany, South Korea, Australia, Singapore, and the United Kingdom.
Each year, an estimated 4,500 to 6,000 patients in Israel – 120-160 a day – pick up an infection with some type of dangerous pathogen in the wards that they didn’t have when they were admitted. This contamination has long been called nosocomial infections (from the Greek/Latin words for “disease comes from us” or “to care for disease”), but more recently, it is referred to as healthcare (or hospital)-acquired infections (HAI).
The situation is serious and the results tragic. Deaths occur not only among the elderly and those with weak immune systems but those of any age whose infection is not overcome by antibiotics. But not all the news is bad.
Prof. Yehuda Carmeli, a leading expert in infectious diseases at Tel Aviv University’s Medical Faculty and head of the Health Ministry’s Institute for Antimicrobial Resistance and Infection Control, insists that due to improved awareness of the problem and greater effort, there has been a decline of 50% to 70% in HAIs in the last 15 years and that 1,000 to 1,500 annual HAI deaths are prevented annually.
There are many logical reasons why Israel’s hospitals are not spotless and sanitary like those in Scandinavia. The World Health Organization (WHO) has stated that hospitals must have no more than 85% occupancy to be safe; beds in Israeli medical centers are usually occupied at over 100% and more, even before the flu season hits when the weather gets colder.
Hasty bed rotation
Highly professional cleaning teams that work shifts around the clock are hard to get and it is nearly impossible for hospital administrators to find budgets to employ them. Instead of one patient per room, there are usually three beds, and no empty rooms where intensive sanitization can be carried out. When somebody is moved in from a corridor, there is little time or to clean up next to the other beds.
“Cleaning workers are often bussed in from their homes in the morning, and it’s hard to do this in the afternoon and evening hours,” Carmeli told The Jerusalem Post in an interview. Most receive low pay, so it’s difficult to find professional teams that would come in and sanitize everything around the clock. It might help if salaries were raised, but even that wouldn’t solve the problem.”
Carmeli’s institute at the ministry employs four physicians with longtime expertise in infectious diseases and prevention, plus six nurses with a variety of specialties. He said the fight against hospital infections by creating infection prevention units, investing in opening “bottlenecks,” and special attention from hospital managements have undergone a revolution, but this is not enough.
“Areas must be restricted to infection-free activity in the wards including a dedicated cleaning staff. The level of cleanliness is particularly severe in the afternoon. The cleaning of the bed and its surroundings after the discharge of the previous patient is not carried out or not at a sufficient level.”
Blame the beds
HAIs come from a contaminated hospital environment – beds and medical equipment or from another patient. “Getting infected from hospital visitors or staffers is very minimal. Nurses in intensive care would have to disinfect their hands and arms scores of times per hour, so such a thing is impossible. Infection doesn’t occur inside operation rooms where hygienic levels are the highest,” Carmeli said. “If you are exposed to a pathogen that is resistant to antibiotics, it’s on your body and enters the bloodstream and the tissues.”
The numbers of HIA deaths are not set down in concrete. It is not listed as an official “cause of death” like a heart attack or stroke. The State Comptroller’s Report from 2012 that discussed it published only estimates. There is still a lot to accomplish, the professor said. “We are performing better than Greece or Italy, for example, where more die per capita from in-hospital infections. The Health Ministry has had a program since 2008 that was updated and boosted a few times, and our institute intervenes, especially in unusual cases.”
Carmeli spoke recently before the Knesset Health Committee on HIAs when MK Yonatan Mashriki convened an urgent meeting following the revelation at Haifa’s Rambam Health Care Campus of three types of antibiotic-resistant infections in some of the wards. “The Health and Finance Ministries must work towards a dedicated budget for preventing infections in hospitals in the state budget for 2025,” he said.
At present, for all the hospitals, a total of only NIS 50 million is allocated by the Health Ministry for this. Carmeli insisted that a NIS 500 million annual allocation is needed. “Infections resistant to antibiotics are a daily reality in hospitals, due to overcrowding and lack of sufficient cleanliness.”
COVID-19 lessons
During the COVID-19 pandemic, efforts were focused on saving patients, so there was little effort against HIAs, he said in the interview. “More beds, medical teams, and sanitation squads are needed. The healthcare budget in Israel is 7.5% of the GDP; in many advanced countries, it is twice as high, and that doesn’t include Switzerland or even the US. Israeli hospitals alone need NIS 8 billion more per year than they are getting,” he concluded. “With all the state budget cuts, this is impossible.”
Prof. Mical Paul, director of Rambam’s Infectious Diseases Institute, told the Post that it is a very large tertiary medical center that receives patients from all over the North and smaller hospitals that can’t handle the most-serious patients. Half of those infected with HAIs came from other hospitals.
“We were the ones who initiated the publication of news about the antibiotic-resistant bacteria to preserve our transparency. HAI infections are a well-known phenomenon throughout the health system. To control it, we closed the neurosurgery department to disinfect it for a week but the other departments remained open.”
The pathogens were found on a total of 50 patients and now, the number varies between 30 and 50. She added that if a patient has a resistant pathogen, he can’t be accepted for rehabilitation by another institution.
Prof. Shmuel Benenson, an internal medicine specialist and expert on infectious diseases is head of the infectious diseases prevention unit at Jerusalem’s Shaare Zedek Medical Center. The unit collaborates with all the hospital staff, including management, medical and para-medical workers, and logistics teams through education, guidelines, audits, and feedback. It is also actively involved in construction, disinfection, education, outbreak investigation, and more.
“It isn’t prestigious to be a cleaning worker, and their salaries are low. All hospitals are overcrowded. Sanitation doesn’t involve how a ward looks but how it is sanitized,” said Benenson, who previously fought infectious diseases at Kaplan Medical Center and Hadassah-University Medical Center.
“Emergency departments are always crowded, and we are working to reduce crowding and release patients as fast as we can,” he said. “We do tests to see if places were sanitized properly, and there are robots with ultraviolet light that can kill pathogens – but they don’t replace human workers.”