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Infection epidemic carves deadly path

Poor hygiene, overwhelmed workers contribute to thousands of deaths
By Michael J. Berens Tribune staff reporter July 21, 2002 A hidden epidemic of life-threatening infections is contaminating America's hospitals, needlessly killing tens of thousands of patients each year. These infections often are characterized by the health-care industry as random and inevitable byproducts of lifesaving care. But a Tribune investigation found that in 2000, nearly three-quarters of the deadly infections--or about 75,000--were preventable, the result of unsanitary facilities, germ-laden instruments, unwashed hands and other lapses. The industry's stance also obscures a disturbing trend buried within government and private health-care records: Infection rates are soaring nationally, exacerbated by hospital cutbacks and carelessness by doctors and nurses. Deaths linked to hospital germs represent the fourth leading cause of mortality among Americans, behind heart disease, cancer and strokes, according to the federal Centers for Disease Control and Prevention. These infections kill more people each year than car accidents, fires and drowning combined. Hospital infections often are preventable by adopting simple, inexpensive measures. Strict adherence to clean-hand policies alone could prevent the deaths of up to 20,000 patients each year, according to the CDC and the U.S. Department of Health and Human Services. "The number of people needlessly killed by hospital infections is unbelievable, but the public doesn't know anything about it," said Dr. Barry Farr, a leading infection-control expert and president of the Society for Healthcare Epidemiology of America. "For years, we've just been quietly bundling the bodies of patients off to the morgue while infection rates get higher and higher." Hospitals provide ideal reservoirs for germs, with temperature-controlled environments

and a steady stream of germ-carrying strangers pouring through the doors each day. Germs that wouldn't be harmful to healthy people in their homes or at work can turn deadly for patients too young, too old or too weak to fight the infection. In Chicago in 1998, as fever-ridden health-care workers tended to patients and as others worked without always washing their hands, eight children died of an infection that spread from the Misericordia Home on the Southwest Side into a hospital. The flulike outbreak, which the city of Chicago never revealed to the public, was halted weeks later after three dozen sick health-care workers were ordered to stay home. In a Detroit hospital, as doctors and nurses moved about the pediatric intensive care unit without washing hands, infections killed four babies in the same row of bassinets, according to court records and interviews. But it took three months for administrators to close the nursery for cleaning. Staphylococcus germs thriving inside a West Palm Beach, Fla., hospital invaded more than 100 cardiac patients, killing 13, according to court records. The survivors underwent painful and debilitating surgery, as rotting bone was cut from their bodies. The health-care industry's penchant for secrecy and a lack of meaningful government oversight cloak the problem. Hospitals are not legally required to disclose infection rates, and most don't. Likewise, doctors are not required to tell patients about risk or exposure to hospital germs. Even a term adopted by the CDC--nosocomial infection--obscures the true source of the germs. Nosocomial, derived from Latin, means hospital-acquired. CDC records show that the term was used to shield hospitals from the "embarrassment" of germ-related deaths and injuries. To document the rising rate of infection-related deaths, the Tribune analyzed records fragmented among 75 federal and state agencies, as well as internal hospital files, patient databases and court cases around the nation. The result is the first comprehensive analysis of preventable patient deaths linked to infections within 5,810 hospitals nationally. The Tribune's analysis, which adopted methods commonly used by epidemiologists, found an estimated 103,000 deaths linked to hospital infections in 2000. The CDC, which bases its numbers on extrapolations from 315 hospitals, estimated there were 90,000 that year. The CDC links infections to patient mortality both directly and indirectly. Direct cases typically involve patients who specifically died of complications caused by an infection. Indirect cases involve infections that played a major role in a patient's death, but may not have been the primary cause. Though CDC officials now say they believe most hospital infections are preventable, the

agency has not arrived at a precise number. The Tribune examined federal health inspection reports and other public documents from 2000--the latest year health-care records were available nationally--to estimate that 75,000 of the deadly hospital infections took place in conditions that were preventable. Deaths were considered preventable if patients contracted infections that were spread as the result of deficiencies documented by state, federal or health-care investigators. For every death linked to an infection, thousands of patients are successfully treated each year. And many hospitals battle infections with diligence and the latest technology. But the Tribune investigation found that breakdowns occur more frequently than patients suspect and that the consequences often are deadly. Government and hospital industry reports analyzed by the Tribune reveal that: - Serious violations of infection-control standards have been found in the vast majority of hospitals nationally. Since 1995, more than 75 percent of all hospitals have been cited for significant cleanliness and sanitation violations. In thousands of cases observed by federal or state inspectors, surgeons performed operations without washing hands or wearing masks. Investigators discovered flyinfested operating rooms where dust floated in the air during open-heart surgeries in Connecticut. A surgical assistant used his teeth to tear adhesive surgical tape that was placed across an open chest wound during a non-emergency procedure in Florida. - Hospital cleaning and janitorial staffs are overwhelmed and inadequately trained, resulting in unsanitary rooms or wards where germs have grown and multiplied for weeks, sometimes years, on bed rails, telephones, bathroom fixtures--most anywhere. Because of cost-cutting measures, U.S. hospitals have collectively pared cleaning staffs by 25 percent since 1995. During the same period, half of the nation's hospitals have been cited for failing to properly sanitize portions of their facilities, a shortcoming that can colonize new patients with lingering germs. - Hospitals are required to have professional staffs devoted to tracking and reducing infections, but rampant payroll cutbacks have gutted those efforts. These staffs have been reduced an average of 20 percent nationally in just the last three years. Many hospitals disregard the CDC's recommendation of at least one infection-control employee for every 250 beds. For three months in 2000, for example, Illinois Masonic Medical Center closed down its infection-control efforts because of lack of staffing, federal inspection records show. The 507-bed North Side hospital now has new owners and has hired three infection specialists.

The Tribune analysis of patient records shows that hospital-acquired infections contributed to or were the direct cause of death for at least four men and two women, ages 72 to 83, during the three-month period at Illinois Masonic. Four patients had respiratory infections; two had an infection that led to blood poisoning and caused inflammation of internal organs. Hospital officials said they could not verify the deaths based on the available information in state records, which omitted names. Federal inspectors determined at the time that Illinois Masonic had adopted a "complete disregard" for infection-control tracking. More recent inspection reports have found no problems with Masonic's infection-control program. Since 1969, when U.S. Surgeon General William Stewart confidently told Congress that the nation could "close the book on infectious diseases," hospital infection rates have quietly pushed higher each year, registering a 36 percent increase in the last 20 years, according to CDC records. Today, about 2.1 million patients each year, or 6 percent, will contract a hospitalacquired infection among 35 million admissions annually, CDC records show. The American Hospital Association said the last decade of unprecedented cost-cutting and financial instability has impacted all areas of hospital care, including infection control. Roughly a third of all hospitals are operating at a loss and a similar percentage are teetering on the edge of bankruptcy, according to the AHA. "It's had an effect on infection control and it's had an effect on our ability to recruit and retain workers. It's had an effect on our ability to invest in new and updated equipment as much as we would like to," said Rick Wade, AHA executive vice president for communications. "It's also a question in front of society: How much do you want to invest in high-quality, safe medical care?" Nurses, in particular, say staffing cutbacks have made the most basic requirements of their jobs difficult to fulfill, and a major study by the Harvard School of Public Health recently linked nurse staffing levels to hospital-acquired infections. The national study of 799 hospitals found that patients were more likely to contract urinary tract infections and hospital-acquired pneumonia if nurse staffing was inadequate. The study projected that the widening nursing shortage could create even more problems, such as higher mortality rates. "When you have less time to save lives, do you take the 30 seconds to wash your hands?" said registered nurse Trande Phillips, who works in San Francisco.

"When you're speeding up you have to cut corners. We don't always wash our hands. I'm not saying it's right, but you've got to deal with reality." Infection in an operating room A deadly outbreak that swept through a Connecticut medical center in late 1996 reveals how washing hands or wearing clean clothes can be as critical to a patient's life as a surgeon's skill. The outbreak, which received scant media attention, is detailed in thousands of pages of hospital records normally kept from public view but opened last year by the Connecticut Supreme Court after the hospital was sued. The case, which involves four patients who contracted infections inside Bridgeport Hospital, also exposes how the bottom line influences decisions that allow germs to flourish in what are supposed to be the most sterile quarters in a hospital. Operating Room 2, where up to one in five patients in 1997 contracted infections, epitomized the hospital's problems. The air often was contaminated by dust because of faulty ventilation, hospital records show. Flies buzzed overhead during open-heart surgery. Doctors wore germ-laden clothes from home into the operating room. Many never washed their hands. Gloria Bonaffini, 71, was wheeled into Operating Room 2 in December 1996 for what doctors considered routine coronary artery bypass graft surgery. Doctors told Bonaffini that she would be back home within the week, her husband recalled. Instead, an infection burrowed into her sternum, and she remained hospitalized for more than a year. "I asked a nurse what was wrong with Gloria," said her husband, Phil Bonaffini, 73, who later sued the hospital. "The nurse looked at me and very quietly said, `She has the infection.' "I asked, `What infection?' but the nurse ran away." On her 448th day in the hospital, Gloria Bonaffini died. Her death certificate indicated that heart problems had killed her. But medical records showed the presence of a staphylococcus germ. She contracted staphylococcus sometime during surgery, and symptoms of high fever and nausea began to flare within four days, hospital records show. The germ and resulting infections attacked most organs in her body and ultimately caused her heart to fail, records show.

Staphylococcus is typically spread by touch and is commonly found on the skin and nasal passages of healthy people. Most staph infections are minor, but for a heart patient, the bacteria can have grim consequences because they infect a person who already is weakened and often invade deep inside the chest during surgery. To gain access to the heart, doctors slice the sternum bone, a process known as cracking the chest. Germs carried by contaminated hands or instruments can become embedded in the bone before the sternum is fused back together. Removing contaminated bone often stunts the spread of infectious germs. However, in many cases, the germ can never be fully eradicated, hiding in the body and potentially flaring up weeks or years later. Bridgeport Hospital had wrestled with issues of infection control and deadly germs even before Bonaffini was operated on. "Bridgeport had a long history of high infection rates, but corrective action was not taken until it was too late," said attorney Peggy Haering, who represented Phil Bonaffini. "What became clear is that these infections were preventable." In 1995, hospital officials hired a respected nursing organization to survey the facility after a dozen patient infections were linked to unsanitary conditions. As a result, the Association of Perioperative Registered Nurses drafted a comprehensive report detailing a dozen deficiencies and specific improvements. However, many recommendations were ignored, court and hospital records show. The report's primary recommendation--and the most expensive to implement--called for replacing the air filtration system in Operating Room 2. Yet, the $20,000 repair price was deemed too costly at the time, hospital records show. Between October 1996 and January 1997, four other patients died "with probable hospital acquired" staph germs, according to a hospital memo obtained by the Tribune. The memo doesn't link the deaths directly to the germ, but in two of the cases, it contributed to the patient's "illness" or "demise," according to the memo. The infections at Bridgeport didn't always kill. Dozens of patients survived but with a lifetime of pain, hospital and court records show. In January 1997, during cardiac bypass surgery in Operating Room 14, Eunice Babcock, 59, became infected with staphylococcus. Doctors later removed much of Babcock's sternum, and the operation left deep, disfiguring scars on her chest. Doctors had to take her abdominal muscles and fold them over her chest cavity for protection. That procedure has impaired her ability to walk more than 20 yards without collapsing. Even as Gloria Bonaffini hovered between life and death in a coma, doctors at Bridgeport Hospital voted on April 21, 1997, against testing all patients for infection because it was

not "cost effective," according to minutes of a meeting by the hospital's infection-control committee obtained by the Tribune. Instead, the hospital decided to wait until patients showed symptoms before initiating tests and treatment, the records showed. At one point, hospital officials discussed the possibility of moving each infectious patient to a private room. But the infection-control committee decided the cost of more private rooms was prohibitive, internal hospital records show. Doctors and nurses assigned by administrators to examine the problem were shocked by what they found, court and hospital records show. A hidden camera was installed outside Operating Room2, and the tapes revealed that up to half of doctors, primarily surgical residents from Yale University, did not wash their hands before entering the operating room, according to hospital records. Operating rooms should be secured and sterile during surgeries, but nurses and doctors routinely stepped inside Room2, even while open-heart surgery was under way, to make personal calls on a phone mounted on the wall. Doctors also are supposed to change from street clothes into clean scrub outfits in a changing room at the hospital, but many doctors wore the scrubs home and back into the hospital the next day--and then directly into the operating room. Officials at Bridgeport Hospital, which settled the suits related to the outbreak for an undisclosed amount, acknowledge they could have been more aggressive in fixing known problems. "Nobody here intentionally spread germs, but we've learned that even the smallest breakdown in infection control can have devastating consequences," said hospital spokesman John Capiello. The non-profit, 665-bed hospital has undergone a $30 million remodeling in recent years. Improvements include updating air filtration systems in operating rooms; more patient isolation rooms; motion-sensitive sinks with timed release of water to encourage proper hand scrubbing; and waterless-soap dispensers for cleaning hands quickly. Doctors are never allowed to wear scrubs to work from home. The telephone in Operating Room 2 is off limits to anyone but the surgical staff. As a result, infection rates that once soared to 22 percent of cardiac surgery patients have been brought down to nearly zero during most months, according to the hospital. The Tribune verified the lowered infection rates with public health authorities and through independently obtained hospital records.

On its Web site, Bridgeport provides a clear warning about infections, a voluntary practice seldom adopted by hospitals and almost never with an acknowledgement that many cases are preventable. "Naturally, there are germs present in hospitals--treating germs is part of our mission! Therefore, it is possible to get sick from a stay in the hospital. Hospital-acquired illnesses are a major concern, especially since one-third to one-half of acquired infections may be preventable," reads the Web information. Bridgeport's battle with deadly germs belies the contention that infections are inevitable, said Dr. Zane Saul, director of infectious diseases at Bridgeport. "We aren't doing anything new today," Saul said. "We're just doing what we should have been doing all along." Germ warfare In the 1840s, a Hungarian-born physician, Ignaz Philipp Semmelweis, stood in a Vienna auditorium before his medical peers and proffered a controversial theory: Washing hands saved lives. When treated by doctors with unwashed hands, pregnant women often developed fatal infections following hospital births, but mothers rarely contracted infections if doctors thoroughly scrubbed their hands with soap and water, his groundbreaking study found. European doctors quickly embraced the soap-and-water regimen--the Semmelweis technique. Infection rates plummeted immediately. U.S. doctors debated the procedure for an additional two decades. By the end of the century, however, America developed a hospital system second to none, in part through an obsession with cleanliness. Prevention became a life-or-death necessity because almost any infection could kill. But by the 1950s, the widespread use of penicillin and other antibiotics allowed doctors to overcome once-lethal infections, and over the decades, prevention gradually became less of a priority. New generations of doctors have grown accustomed to responding to symptoms--wait until the patient is sick, prescribe a drug. Within the average U.S. hospital today, about half of doctors and nurses do not wash hands between patients, a dozen recent health-care studies show. The direct observations of federal and state inspectors in recent years underscore the carelessness that threatens patient health. In Baltimore, inspection records show, a doctor placed his stethoscope on the chest of a sweaty patient in the grip of pneumonia, then

walked to another room and placed the unwashed, moist device on the chest of a patient. The patient developed pneumonia. In Loyola University Medical Center in Maywood, a resident physician dropped a surgical glove on a dirty floor, picked it up, put it on his hand and changed the bloody dressing on the open wound of a burn patient. The hospital told inspectors that it has retrained the resident and others on its staff. All hospitals are required to adopt general infection-control standards to qualify for the federal Medicaid program, but each facility is allowed to draft its own rules on everything from potency of drugs to eradicating germs. Most hospitals, for instance, leave catheters connected to patients because CDC studies show that even daily removal exacerbates infection rates. But a few hospitals still work under the misguided belief that changing needles every 24 hours avoids infections, studies show. A checkerboard of local, federal and private health-care regulations does little to force hospitals to step up infection control. Most violations are quickly resolved by a hospital's promise to provide more training, federal records show. "Can you imagine the medical community outcry if even a single doctor died from germs because of a failure to wash hands?" said Mark Bruley, a forensic investigator who studies hospital conditions for ECRI, a non-profit laboratory near Philadelphia. "Health-care workers aren't the ones getting hurt. Because they don't always see the outcome, they are blind to problems." There is little incentive and, often, little time for doctors and nurses to comply with even basic standards. Nurses and other health-care workers complain that it's virtually impossible to wash hands between every patient contact, which could number 150 times or more a day in a busy hospital. A recent study showed nurses would spend 2 1/2 hours each day to wash hands thoroughly with disinfectant and water. Additionally, frequent washing causes the skin to dry out and crack. Consequently, most hospitals have begun to use a waterless disinfectant that kills germs and instantly dries on hands. Nurses can squeeze the solution on their hands from wall dispensers and continue to the next patient as their hands are cleaned. Studies show the waterless system kills germs as effectively as soap and water. However, many nurses fail to adopt even this simple measure, hospital inspection reports show. The sanitary condition of a hospital also depends on the diligence of its housekeeping staff, but in many facilities those staffs are poorly trained and overburdened.

Since 1995, federal inspectors have cited 31 Chicago hospitals for failure to properly sanitize rooms between patients, mirroring problems found in half of hospitals nationally. "Hospitals hire people and say just go in there and clean," said Pia Davis, president of a Chicago health-care chapter for the Service Employees International Union. "They don't show them what chemicals to use or not to use. We have report after report showing that rooms are not cleaned every day." Still, in some hospitals, there is a growing awareness that germs need to be fought with more than the latest drugs--that hospital sanitation, patient monitoring and infection tracking are key to saving lives in a never-ending battle. "What is needed is not more antibiotics," said Dr. Gary Noskin, chief of infection control for Northwestern Memorial Hospital, which has some of the nation's lowest infection rates. He attributes the hospital's success to rapid detection of germs and aggressive treatment of infections. "These bugs are so smart," he said. "They have been here a million years before we were here and they'll be here a million years after we're gone." ---------The series Sunday: Thousands of hospital patients die from avoidable infections they picked up while under care. Monday: Following simple procedures could have helped save the lives of thousands of sick children. Tuesday: Dangerous antibiotic-resistant germs are spreading from hospitals to the community at large. Copyright 2002, Chicago Tribune

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Virus attacked Chicago children in outbreak kept under wraps

By Michael J. Berens Tribune staff reporter July 21, 2002 The germ raced through the Misericordia Home for handicapped children in Chicago, masquerading as a cold-weather flu as it moved from bed to bed. Each child already was ill; most had been born with severe physical and mental impairments. The rare strain of adenovirus pounced on their weakened immune systems, enveloping victims with blistering fevers while attacking the brain, lungs or heart. Over several weeks starting in October 1998, 31 children contracted flulike infections and eight died as the microscopic invader snaked through the 93-bed long-term care center, which is operated by the Sisters of Mercy with the support of the Catholic Church. The outbreak on the Southwest Side was one of several nationally linked to the rare virus. But these incidents went largely unreported in the media, and in Chicago the Department of Public Health still is not releasing public records on the outbreak--an example of how health-care facilities and public agencies are able to keep damaging information about infections under wraps. Though the virus' origins remain a mystery, federal and city health-care investigators believe they know how it was spread: The germ hitched rides on health-care workers. Doctors and nurses at Misericordia and Rush-Presbyterian-St. Luke's Medical Center-one of the hospitals that later treated the children--also were infected by the germ, but they continued to work among the children. The lapse meant that every cough, sniffle and touch could result in death to another child, health-care investigators concluded. The Chicago deaths highlight what many epidemiologists warn are escalating rates of infections inside the nation's secondary tier of health care--specialized long-term care centers like Misericordia, nursing homes and outpatient clinics. Though the federal surveillance of germ outbreaks is centered almost exclusively on hospitals, unsanitary conditions inside the nation's growing network of specialized facilities remain largely undocumented. "There are a lot of infections that occur outside hospitals that we know nothing about,"

said Dr. Donald Graham, a former infection-control investigator for the federal Centers for Disease Control and Prevention and professor at Southern Illinois University School of Medicine. "If we don't count our infections, we won't know about them and we won't be able to intervene." The Chicago outbreak also reveals how the Chicago Department of Public Health undermined its trust as public guardian to protect the private interests of health-care facilities. City officials decided not to alert the public about the lethal outbreak. Even though health department officials acknowledge investigating it, they say they can't locate a single record. "I know how embarrassing this looks for us," health department spokesman Tim Hadac said. Sources connected to the investigation, however, provided the Tribune with city files on the Misericordia outbreak. City health commissioner John Wilhelm defended the secrecy. The city has a fragile, voluntary relationship with health-care facilities, and if the city warned the public about every outbreak, health-care facilities might stop sharing information, he said. During a recent tour of Misericordia, officials said that visitors are now asked to wash their hands or stay home if they have symptoms of any illness, such as the flu. Though it is a medical facility, the home is run differently in many ways from a hospital. Children are bused to special-education classes, for instance, and visitors are welcomed at all hours, presenting opportunities for children to be exposed to germs. "We give these children a quality of life. This is not a lockdown facility. The parents know that infection is an everyday risk, but an acceptable one," said Betty Flynn, a registered nurse and home administrator at Misericordia. The deadliest strain At the time of the outbreak, Misericordia and hospital officials were unaware that they were dealing with the most deadly strain of adenovirus. Drawing upon a biological archive of germ samples collected worldwide, CDC scientists determined that the Chicago outbreak involved a strain known as Ad7d2. As a result, the CDC launched a national hunt for the Ad7d2 germ, first documented by medical investigators in Beijing in 1981.

As word spread in the medical community about the deadly germ, a New Orleans doctor filed a report detailing a previously undisclosed June 1996 outbreak in a Houma, La., pediatric facility for long-term care that killed seven children and infected six others, according to CDC records. In October 1999, seven patients were killed and 26 others infected by adenovirus that swept through a New York City chronic-care facility for the mentally ill, those records show. A year later, four children died and 16 other patients were infected after the germ invaded a pediatric long-term care facility in Des Moines. Iowa public health epidemiologist Dr. Patricia Quinlisk said investigators could not determine how the adenovirus entered the pediatric center but said that germs were cultured from the hands of a health-care worker and that several staff members also became ill from the virus. The germ, investigators theorize, may have gained a foothold in the pediatric center after infecting a child who left the facility for special-education classes. In all three cases, the CDC records do not name the facilities, only the cities where they are located. CDC investigators now believe the Ad7d2 germ is more rooted in the United States than previously known. The first Chicago children stricken four years ago at Misericordia had not been bused to outside classes, leading investigators to believe that a visitor, a health-care worker or another child carried the germ into the facility. From Misericordia, many of the fever-ridden children were sent for treatment to RushPresbyterian-St. Luke's Medical Center. A registered nurse assigned to track germs in the intensive care unit was the first to suspect a pattern. Based on the nurse's report and laboratory findings, Dr. John Segreti, chief of the infectious disease department at Rush, said he immediately recognized that the hospital, and potentially the city, was dealing with a deadly germ. Three days after the children were admitted to the hospital, laboratory tests confirmed the presence of adenovirus. During this time, the germ spread inside Rush, infecting a 5month-old boy who later recovered, Segreti said. Infected children were isolated and health-care workers were ordered to adhere to strict infection-control procedures. "We think it was spread on the hands of a health-care worker," Segreti said.

No vaccine available There are more than 50 strains of adenovirus, but there was no way to eradicate the germ. The nation's sole vaccine was discontinued in 1996 by pharmaceutical giant WyethAyerst. At the time, company officials said demand was too low for the $1-a-pill medicine. Healthy people typically fend off the virus, which might cause fever or other flulike symptoms. But critically ill patients, particularly children whose immune systems are paper thin, can face life-or-death struggles. Segreti said he immediately notified the city health department, which later requested CDC investigators. Segreti and other health-care officials believe the hospital's quick discovery of the germ may have prevented a wider, more devastating outbreak. But Rush administrators say they also learned an important lesson about problems inside their own hospital. Through staff surveys and laboratory tests, Segreti discovered that 36 Rush-Presbyterian health-care workers were confirmed or suspected carriers of the infection, probably picking up germs from the Misericordia children. At least 30 doctors, nurses and technicians had fevers and other symptoms but continued to work among young patients throughout the hospital, Segreti said. At least 26 employees failed to follow strict infection-control procedures, such as wearing gloves or washing hands. "It's not uncommon for people in health care to think they are not part of the problem," Segreti said. Infected workers were sent home for up to two weeks. The staff was retrained on the importance of infection control. At Misericordia, once the outbreak was apparent, ill children were moved together in the same rooms to limit exposure to healthy children, and family visits were temporarily restricted. "We were certainly battening down the hatches," said Deb Ryan, director of nursing at Misericordia. Although nobody located the source of the germ, Misericordia employees received training on hand-washing procedures and wearing gloves and masks.

Like the nurses at Rush, at least one Misericordia employee contracted adenovirus, and some employees may have continued to work while ill, Ryan said. Since the outbreak, the staff of 180 has been told to stay home if suffering any symptom of illness, but the message is tough to enforce. "As nurses, we've always been taught to drag yourself to work," Ryan said. "It's been the culture for 30 years. If we don't show up to work, who will take care of the children?" Copyright 2002, Chicago Tribune