"Just the required exposure for my pathology residency," Laurie said.

"We have definitely considered a carrier to be the source of the problem. In fact, so much so that we have repeatedly cultured everyone: medical staff, service personnel, and particularly those individuals who regularly visit all three of our hospitals. One of the ways that our CEO founder conceived of keeping expenses down was to have centralized services like laundry, engineering, laboratory, nursing, and food service. Each service has a department head whose office is at Angels Healthcare's central office but who travels on a regular schedule to all three hospitals. These people have been tested repeatedly for the exact reason you've suggested."

"Has anybody tested positive?"

"Absolutely About twenty percent positive, which is what one would expect in the normal population. In fact, slightly more on the medical staff. And everybody who tested positive has been treated with mupirocin until they tested negative."

"Did any of them test positive for the community-acquired MRSA?"

"Oh, yeah. Quite a few."

"Do you know if the subtype was the same as what killed your patients?"

"Our subtyping was by a VITEK system and only for antibiotic resistance, and yes, some were the same."

"Antibiotic resistance is not particularly sensitive in terms of differentiating substrains."

"I'm aware of that, but since we treated anyone positive for staph, we didn't think it mattered."

"Maybe so," Laurie said. "Did you have any of the isolates typed by the CDC?"

"No, we didn't."

"Why?"

"That was a decision made by the home office. I suppose because we were treating everyone who was positive, as I said, so that characterizing it more served no purpose. Also, we were already instituting every known infection-control procedure."

"Did you let the CDC know you were experiencing this MRSA outbreak?"

"We did not."

"How about the Joint Commission on Accreditation of Healthcare Organizations? Did you notify them?"

"No, we didn't. The JCAHO only needs to be notified if our overall infection rate goes above four percent over our designated surveillance period."

"Which is what?"

Laurie watched Loraine hesitate as if Laurie had asked a state secret. "You don't have to tell me if you feel uncomfortable," Laurie added. "I don't even know why I'm asking."

"And I don't know why I'm hesitating. Anyway it is a year interval."

"But your rate could be above four percent if you considered the last three months."

"It's possible," Loraine agreed. "But I've not stopped to figure it out."

"How about the New York City Board of Health?" Laurie asked. "I presume you let them know."

"Of course," Loraine said. "And the city epidemiologist, Dr. Clint Abelard, has made several site visits. He was impressed with everything we were doing and didn't have any suggestions, which is not surprising, since we had tried everything."

"Very interesting," Laurie commented. She felt better about coming for her visit, since Loraine hadn't ridiculed her about any of her thoughts. At the same time, she was reluctant to mention any of her more outlandish ideas. "How about a tour. Your hospital is truly elegant, and not like any other I've ever seen."

"Sure," Loraine said without hesitation. "We all are quite proud of it, especially since we are all owners."

"Really?" Laurie questioned. "How so?"

"Our CEO, Dr. Dawson, gave all the employees a little stock when we signed on. It's not much, but there is a certain symbolic value. Actually, that might change for the better in the near future. The company is scheduled to go public in a few weeks. If all goes well, our tiny amounts of stock could actually be worth something."

"Well, I'll say a little prayer for the IPO."

"Thanks," Loraine said. "The rumor is that it is going to do very well."

"Can we do the tour now?" Laurie asked.

"Certainly," Loraine said. She stood and opened the door leading to the area occupied by the secretaries. Laurie followed.

"What is it you'd like to see?" Loraine questioned as they left the admin area and emerged into the main lounge. "It's fancier than other hospitals but otherwise basically the same."

"But no emergency room."

"Right, no emergency room. We're a surgical hospital. We don't want beds taken up with medical patients."

"How about an intensive-care unit?"

"Not an intensive-care unit per se. If that kind of care is needed, we can isolate part of the PACU, or post-anesthesia unit. If the PACU is too full, we send patients to the University Hospital. It saves a lot of money."

"I'm sure it does," Laurie agreed, but the idea of a surgical hospital not having a full-fledged ICU bothered her.

They paused out in the main lobby area, standing in front of the elevators.

"I cannot help but notice how quiet it seems to be," Laurie said. "There are so few people."

"That's because our census is very low, which has been progressive since the MRSA problem began. Of course, the worst was when the ORs were completely shut down. During that period we had the entire hospital staff, including the president, disinfecting everything."

"But the ORs are open now?"

"Yes, they are open now except for the OR where Mr. Jeffries was operated on."

"Was he the only case done in the room yesterday?"

"No, he wasn't. There were two others after Mr. Jeffries."

"And they are well."

"Perfectly fine," Loraine said. "I know what you are thinking. It has us baffled as well."

"Since your census is low, does that mean some of your staff doctors are choosing to do their surgery elsewhere?"

"I'm afraid so."

"What about Dr. Wendell Anderson?"

"He's one of the brave ones, or should I say loyal. He's still operating here on a regular basis."

Laurie nodded while fantasizing about tying Jack to the bed during his sleep Wednesday night. More than ever, she did not want him to have his operation.

"What is it you'd like to see?" Loraine repeated.

"How about starting out with your HVAC system?"

Loraine did the equivalent of a double take. "Are you joking?"

"I'm serious," Laurie said. "Are the operating rooms and the PACU on a separate system from the main part of the hospital?"

"Absolutely," Loraine said. "This is a state-of-the-art facility. The HVAC for the operating rooms is designed to change each OR's air every six minutes. There would be no need to do that for the whole hospital. Even the laboratory area has its own system, although not with that kind of flow."

"I'd still like to see it," Laurie said. "Particularly the OR system."

"Well, I don't see why not." They boarded a waiting elevator. Loraine pressed the button for the fourth floor. She explained that the second floor was for outpatient services, the third was the OR and PACU as well as central supply, and the fourth was for the laboratory and engineering. Engineering included HVAC and the supply of various gases for the ORs and bedside. All the floors higher than the fourth were for patient rooms. The very top floor was a special VIP section, which had slightly larger rooms and more expensive decor. The service, she insisted, was the same.

"Are all the Angels Healthcare hospitals similar?" Laurie asked.

"Essentially identical, as will be the six hospitals slated soon to be constructed: three each in Miami and Los Angeles."

"My word," Laurie said simply. She was impressed with the edifice but bemoaned that its luxury represented the enormous amount of money essentially being stolen on an ongoing basis from full-service hospitals like University or even General, which were already struggling to make ends meet. Angels Healthcare, like other specialty hospitals, was interested only in the paying patients with acute problems, not the uninsured or the chronically ill. Not only that, the fortunes being made by the businessmen owners were also being sucked out of the healthcare system and unavailable for patient care.