"Infections are one of the great secrets of the hospital," said Charles Inlander, a Pennsylvania health-consumer advocate who serves on a national health care quality panel for the Institute of Medicine. "It's the little souvenir you take home with you from your stay at the hospital."

Unavoidable infections

Health care workers say infections are a fact of life in hospitals because germs prey on people with weak immune systems.

People live longer, lead unhealthy lifestyles and go to hospitals with more complications. Experts say all of these factors increase their chances of infection.

Medical technology also comes with a price. The tools workers commonly use to save lives, such as catheters and ventilators, break the skin or create openings that allow bacteria to invade.

"There's only so much we can control, to be truthful," said Marian Pokrywka, an infection-control worker at UPMC Presby.

Patients argue it is because hospitals are full of weak and old people that health care workers need to be more vigilant.

Audrey McMullen, 77, of Scott, believes she picked up a debilitating staph infection after back surgery at Mercy Hospital in 2001.

The retired nurse, who calls herself a hand-washing fanatic, said her doctors told her staph infections are common after surgery, but she doesn't buy it.

She remembers that while she was recovering from surgery, a worker gave her a shot without wearing gloves or cleaning her arm with alcohol.

Her months-long ordeal scared her away from hospitals.

She said only in the last year has she been well enough to return to her old routines -- swimming every day and cooking soup for her neighbors.

"I will not go to a hospital again unless it's a matter of life or death," McMullen said.

She has reason to worry. A Trib analysis of Southwestern Pennsylvania hospital data from 2001 -- the most recent figures available -- found that elective-surgery patients were more likely to die if they developed an infection.

One of the worst killers is a blood infection known as septicemia. This infection, which is caused by germs that enter the bloodstream and starve

organs of oxygen, killed one in four of the 264 elective patients who developed it.

The analysis of 2001 data, based on hospital billing records, also showed that among elective patients such as McMullen, Mercy, Presby and Allegheny General Hospital reported higher-than-expected numbers of patients with surgical wound infections.

Allegheny General, for example, was expected to have 90 patients with surgical infections, according to a statistical analysis conducted for the Trib. But the hospital reported 131 -- or 46 percent more. The expected rates for each hospital are based on the types of patients admitted to that facility.

Presby had 29 percent more infections than expected; Mercy, 67 percent.

Some smaller community hospitals -- Suburban General, Frick, Mercy Providence and Mercy Jeannette -- had higher-than-expected numbers of patients with urinary tract and intestinal infections.

Suburban General, in Bellevue, reported 34 urinary tract infections, almost twice its expected rate.

UPMC Shadyside consistently reported lower-than-expected infection rates.

The Trib asked the hospitals to comment on the findings. Allegheny General, Suburban General, Frick and the three Mercy hospitals refused.

Officials at UPMC Presbyterian and Shadyside say they carefully monitor and control the spread of infections.

Dr. Carlene Muto, who heads Presby's infection-control program, said the hospital's surgical infection rates consistently fall below national averages.

"When we're not, which is on a rare occasion, is when we start the investigative process," Muto said, "and then we get together with the infectious disease folks and ... the surgeons who are actually doing the procedures, and figure out, 'Is something gone amok?'"

She declined to release the hospital's surgical infection data.

As simple as clean hands

The Centers for Disease Control and Prevention says about half of all hospital-acquired infections are preventable if health care workers always wash their hands. The CDC estimates that 2 million patients get these infections every year and almost 100,000 die from them.

On average, however, workers wash their hands only 40 percent of the time between patients, national studies show.

Bob Ferguson couldn't understand why the hospital workers who entered his wife's room did not always follow the strict precautions posted on the doorway.

The precautions were simple: Wash hands and wear gowns, gloves and caps.

Theresa Ferguson needed extra protection because she had intestinal bacteria and a staph infection that worked its way into her heart.

The nurses who gave Theresa Ferguson dialysis occasionally treated her without gloves or gowns, her family said. When they did wear gowns, they'd wear them only halfway up their arms.

Ferguson said he never saw the hospital chaplains and nuns who held his wife's hands follow any of the precautions. Neither did the cleaning crew.

"You're at their mercy," he said. "They need to find a way to protect people."

The hospital would not comment, citing patient confidentiality.

Pittsburgh-area nurses say they barely have enough time to care for patients properly, let alone wash their hands after treating each one. They say a nursing shortage is overwhelming those who stay in the profession.

"When you are in a rush, you may not have the opportunity as much as you would like to wash your hands," said Lorraine Taliaferro, a registered nurse at West Penn Hospital in Bloomfield. "I try to wash my hands because I have young ones at home."

At Presby, internal observations obtained by the Trib show that in one intensive care unit, physical therapists, nurses and doctors who regularly worked in the unit were the best hand-washers. They washed about 80 percent of the time between patients.

The worst group included housekeepers, who never washed their hands, and some lab technicians, who washed their hands 5 percent of the time, according to the observations.

"The nurses were the most compliant. They always seem to do the best -- and that's a good thing because they are the ones who spend the most time in there," Muto said. "But even in baseline observations, we were above national levels."

At UPMC Shadyside, administrators found similar problems. Of the doctors they observed inserting intravenous catheters in patients, only four washed their hands beforehand.

"I found nothing that I was proud of, frankly, in those observations, except that I'm damn proud I did them," said Tami Merryman, UPMC Shadyside's vice president of patient care services.

"You have to be willing to find whatever you have -- good, bad or ugly," she said. "You'll never improve as an organization unless you look at what you're doing."

Both hospitals have started mandatory training and in-service credits to get workers to wash their hands. They are also monitoring their staffs' hand-washing routines.

UPMC and other local hospitals are making it easier for workers to clean their hands by installing dispensers with alcohol-based waterless gels in all patient rooms. The CDC-recommended lotions kill bacteria faster and better than soap and water.

During spot checks of patient floors at UPMC Presbyterian and Shadyside last spring, however, the Trib found several empty dispensers in the hallways.

UPMC officials said doctors have complained about the empty dispensers. John Innocenti, UPMC Presbyterian's chief operating officer, said the housekeeping staff is supposed to check the dispensers and fill them regularly.

Even full dispensers are no guarantee workers will use them. Attitudes, particularly among doctors, need to change, infection experts say.

A recent CDC study found that if supervising doctors don't wash their hands, the residents, nurses and medical students they oversee won't wash either. The study found that the influence of senior doctors was so strong that if they did not clean their hands while making rounds, the staffers with them washed only about 10 percent of the time.

Yet hospitals take little action against dirty doctors.

Locally, hospitals do not fine repeat offenders or revoke their privileges, even though they crack down on other problems, such as fining physicians who do not sign charts on time.

Hospital culture dictates that doctors are never wrong, health care workers say.

"There is an idea that the doctor is responsible and the doctor knows best," said Dr. Robert Muder, an epidemiologist at the Veterans Affairs Pittsburgh Healthcare System in Oakland. "The doctor is the captain of the ship, and if the doctor performs in a certain fashion, it is almost by definition correct."

Shattering the pristine image

Even when doctors or health care workers don't know best, hospitals can keep their actions secret in Pennsylvania.

Hospitals are not required to publicly report in-house infections. If too many infections break out in a particular unit or over a short time, hospitals must report the outbreaks to the state and county, but the information remains confidential.

State inspections offer a snapshot of daily hospital life, but even they are limited.

The Trib found that although the state is required to inspect hospitals for licensing every two years, 25 of 37 Western Pennsylvania hospitals had gone without an inspection for more than two years.

A review of some 350 state inspections dating to 1996 found inspectors spent more time reviewing hospital records than observing staff at work. Ten percent of the citations against hospitals were related to infection practices.

The state Health Department did not take any type of action against any hospital from 1994 to 2000. That's because, starting in 1994, the state stopped routine inspections, relying instead on the reports of a national accreditation agency.

Even when the accreditation agency did not inspect hospitals within the state's two-year limit, the Health Department routinely licensed the hospitals anyway.

State officials began their own inspections in the fall of 2001 after consumer groups complained that no one was sufficiently monitoring hospitals.

Sandra Knoble, the official who oversees hospital inspections, said the department has since beefed up its unit, from 13 to 54 inspectors responsible for the state's 300 facilities.

State inspections found unsanitary conditions ranging from dirty hallways to heating units stained with urine in patient bathrooms to workers with skin conditions who did not wear gloves.

These unsanitary conditions breed germs that are then spread from the hands of health care workers and visitors onto bedrails, countertops and patients.

During a tour of UPMC Presbyterian in October 2002, for example, inspectors found dirty patient rooms, biohazard-waste and regular trash cans overflowing, and paper towels and wrappings littering the floor.

The inspection showed the staff was aware of the cleanliness problems but did not correct them.

"This is obviously not good," Dr. Loren Roth, the University of Pittsburgh Medical Center's senior vice president, said in a subsequent interview. "I'm a patient like you are. I like to walk into a hospital ... that is clean. This is independent of infections."

Innocenti, Presby's chief operating officer, said the hospital reminded nurses to empty waste containers and clean equipment regularly, ordered managers to inspect units more frequently, and hired a new company to restructure and manage housekeeping services.

A follow-up inspection by the state earlier this year found the hospital rooms satisfactory.

Trib visits to the same patient-care areas this spring found overflowing trash cans, empty hand-sanitizer containers and a used glove and mask on the floor of a room where a patient had a contagious illness. A follow-up visit Friday found similar conditions.

"We try to be perfect, but you're not going to be perfect when you're dealing with the magnitude of what we do," Innocenti said.

No one talks about it

Those who've lost loved ones to infections expect more accountability.

As Theresa Ferguson battled two infections that slowly ate away her organs, doctors told the Fergusons that she may have developed a third infection.

"I just about popped my cork," said her husband, Bob. "My wife was beside herself. Tears were coming out of her eyes."

Theresa Ferguson died in November 2002. Her cause of death was listed as an infection that inflamed the lining of her heart.

Bob Ferguson insists that hospitals need to answer to somebody.

"If hospitals felt pressure -- not necessarily lawsuit pressure, but if they were scared to death of somebody -- maybe then they'd tell the guy emptying the waste cans in my wife's room not to go in there until he'd put gloves and gowns on," he said.

Hospitals have traditionally fought attempts to make them more accountable.

"It's very anxiety-producing for a hospital to provide data if they know it's going to be compared against other hospitals," said Nancy Foster, a policy analyst with the Chicago-based American Hospital Association.

Administrators say hospitals deal with so many kinds of patients that it is unfair to compare them.

As a result, most efforts to gauge how often patients develop infections in hospitals are voluntary and confidential. Even then, hospitals are loath to participate.

In January, the Joint Commission on Accreditation of Healthcare Organizations urged hospitals to voluntarily report infections.

The commission, which collects data on unexpected hospital deaths and injuries, said the nation's hospitals have reported only 10 infection-related deaths in the last seven years.

"It is pitiful," said Dr. Robert Weiss, a vice president for the Chicago-based group.

The commission, however, does not require hospitals to report infection data in order to be accredited. It only requires them to have a program to fight infections.

Consumers can find out more about the appliances they buy than the quality of care in their local hospital, said Inlander, executive director of the People's Medical Society, a health care consumer group.

"Hospitals and doctors spend their life's work trying to create a mythical state of the quality of care ... the myth that the hospital is safe," Inlander said. "They don't want to air their dirty laundry."

Ten months after his wife's death, Bob Ferguson feels lost without the woman he was married to for 38 years.

Mementos fill the cramped office of their candy factory. Framed photos of the couple during a Florida vacation and a brunch last year at the Nemacolin Woodlands resort decorate the wall. A bobble-head doll of the mascot of Theresa Ferguson's beloved Penguins sits on top of a computer.

"I hear that 75,000 people die of staph infections in hospitals every year and you're not hearing a damn thing about it," Ferguson said. "If 75,000 people are dying, why aren't we talking about it?"

Two Trib reporters conducted interviews with more than 120 sources that included doctors, infectious disease experts, nurses, lawyers, hospital administrators, health care lobbyists, consumer advocates, patients who developed infections in hospitals and patients' families.

The Trib filed Freedom-of-Information Act requests with state and federal health agencies.

The reporters reviewed almost 350 state health inspection records for 39 hospitals in Allegheny, Armstrong, Beaver, Butler, Fayette, Greene, Lawrence, Washington and Westmoreland counties. The inspections dated to 1996 and included annual inspections, investigations resulting from complaints and follow-up documentation.