How Safe is Your Hospital?
by Jennifer Pirtle
Kathy McCabe, 31, had already seen two doctors about the stabbing pain in her stomach. But when it worsened, she headed to the ER near her home in Washington, D.C. After lying on the hospital floor in anguish for more than 2 hours, McCabe was given a CAT scan so doctors could see 3-D images of her organs. The radiologist said the CAT scan showed nothing unusual, so the ER staff gave McCabe two things. A prescription: More painkillers. And directions: Go home.
The next day McCabe visited three more doctors. One internist referred her to a surgeon, who wanted her to undergo exploratory surgery. The third doctor, an internist who specialized in geriatric issues, questioned McCabe thoroughly and then urged her to retrieve her CAT scan from the hospital. He took one look at the film and told McCabe that she had advanced diverticulitis, a serious infection of her digestive tract. Worse, her bloodstream was overwhelmed by the resulting bacteria.
"He couldn't believe how sick I was," McCabe says. "He said my colon was in danger of bursting."
The doctor put McCabe on antibiotics for 2 months. Although McCabe says she didn't suffer any lasting health complications from the "nothing's un-usual" diagnosis at the ER, the experience has shaken her confidence in the healthcare system and made her apprehensive of hospitals.
"I now know I can't take what a doctor says as 100 percent true," she says.
150,000 - Shortage of Nurses Nationally
More than ever, medical mix-ups, errors, and misjudgments have turned safe havens into potentially dangerous ones. Just consider the stats:
As many as 98,000 people die each year in U.S. hospitals from medical errors, according to the Institute of Medicine of the National Academy of Sciences. That's more than from car accidents, breast cancer, or AIDS.
Nearly 2 million people pick up infections in hospitals each year — largely due to preventable errors — and 90,000 people die from them.
While it's tempting to blame a staff's ineptitude, ignorance, or irreverence, experts say the problem is simply 21st century health care. "It's safe to make the assumption that every person who goes to work in a hospital is there to help. Unfortunately they quite often end up doing the opposite," says Thomas Sharon, R.N., M.P.H., author of Protect Yourself in the Hospital.
The rise of HMOs during the past two decades, coupled with lower reimbursements by Medicare and Medicaid, has created a financial climate that has led hospitals and clinics to cut staff and attempt to do more with less. The result: Poor communication among staff, a faulty system of checks and balances, and overworked or minimally trained workers. The hardest hit has been the nursing profession. The United States has a shortage of nearly 150,000 nurses (the shortage is attributed, in part, to early retirements caused by the physical and emotional demands of the job). That shortage is expected to climb to more than 800,000 in 15 years, according to a report from the U.S. Department of Health and Human Services.
"The general public doesn't know how much of an impact the nurse has on the safety of their care," says Ronda Hughes, Ph.D., senior health science administrator at the Agency for Healthcare Research and Quality in Maryland. It's the nurse, for example, who administers medication and ensures that unsterile devices or products aren't used.
Simply, fewer nurses means more mistakes. In 2002 the Joint Commission on Accreditation of Healthcare Organizations examined more than 1,600 hospital reports of patient deaths and injuries since 1996. It found that low nursing staff levels were a contributing factor in 24 percent of the cases. And adding just one additional patient over four already in a nurse's care has been shown to raise a surgical patient's risk of death by 7 percent.
"Nurses are trying to meet the needs of the patients, but they're stressed, angry, and frustrated because they know there aren't enough of themselves on staff," Dr. Hughes says. With the average age of nurses at 45 and most nurses retiring in their late 50s, it's becoming especially challenging to find enough new recruits. Why? Nationally, there simply aren't enough good instructors to train them. "Schools are looking for doctor-trained faculty, but these people have to take huge salary cuts to teach," says Dr. Hughes, who estimates that most nursing institutions are missing an average of five full-time instructors. "Most just aren't willing to do that."
235,000 - Number of Medication Errors Hospitals Make Every Year
Julie Botteri, 34, of Marathon, Florida, was visiting a nearby hospital 4 years ago for an inflamed cat bite on her left hand. The attending physician looked at her index finger — which had swelled to twice its normal size — and immediately ordered an intravenous antibiotic drip. Because a cat's needle-like fangs inject bacteria deep into a wound, the resulting infection could enter the bloodstream and make its way into tissues and organs, causing life-threatening complications like pneumonia, heart infection, or the loss of a limb. "He warned that if the bite didn't improve quickly, he'd need to slice open my finger to release some of the infection," Botteri says.
Botteri estimates she received four or five bags of the antibiotic solution before a nurse changed the IV. "For the 30 minutes it took the new bag to drain, it felt like ice-cold water was flowing down my arm and across my chest," she says. "I pressed the nurse call button several times, but no one came until the shift change. The nurses seemed overworked and exhausted."
Although the cool sensation Botteri felt was likely because one liquid was colder than another, the temperature disparity was enough to make Botteri ask questions. At Botteri's urging, the new nurse checked her charts and discovered that her predecessor had mistakenly given saline instead of the crucial antibiotic. Botteri resumed antibiotics, the infection cleared, and she returned home within 3 days.
The most common type of medical error now is a medication mistake. In 2003, 570 hospitals and health-care facilities reported more than 235,000 medication errors to the database of the U.S. Pharmacopeia, a nonprofit watchdog group that works with the FDA. There were 13 different kinds of slipups, including vague or unreadable prescriptions, right medications given to the wrong patient, and mix-ups of similarly named medications, such as giving Zantac, an acid-reflux drug, instead of Zyrtec, an allergy drug.
Much of the problem circles back to the shortage. A 2004 study from the University of Pennsylvania found that the risk of making an error increased when hospital nurses worked more than 12 hours per shift, worked overtime, or worked more than 40 hours per week. (Several states are now banning or limiting mandatory overtime.)
"In hospitals you have the best people who are sometimes at their worst," says Sharon, who has more than 20 years of experience in the health-care field. "You can't expect 100 percent performance of them every time they go to work."
40 - Percentage of Doctors Who Don't Wash Hands Enough
Ann Eide, 37, from Columbus, Mississippi, had a small biopsy on her leg to test for mitochondrial myopathy, a rare offshoot of muscular dystrophy. The resulting incision was just 1-inch long and sutured with seven stitches, yet Eide says that when she returned home from the hospital, the wound "looked really red and was oozing pretty badly."
She immediately called the hospital and was told over the telephone not to worry, that the redness was "normal." The next day, same thing. With the infection worsening, Eide became concerned and went to an ER at another hospital.
"The doctor who looked at my leg was shocked," Eide says. "He called the wound 'horrific' and asked who had done this to me. He told me that if the stitches had been left in my leg much longer, the infection could have become very serious." Antibiotics cleared the infection within 1 week, but the wound remained tender for nearly 4 months. "To this day it still throbs from time to time," Eide says.
Hospital-acquired infections account for $4.5 billion in excess health-care costs annually, the Centers for Disease Control and Prevention says. Infections, which can be caused by bacteria, fungi, viruses, or parasites, might already be in your body, or they can come from the environment, contaminated hospital equipment, health-care workers, or other patients.
The most common:
Urinary tract infections. While a healthy bladder is sterile, the bacteria that march up the rubber or plastic tube can cause infection if the insertion site is not properly cared for. A study at the University of Michigan's Department of Internal Medicine found that more than 1-quarter of catheter patients develop urinary tract infections within 2 days of having a catheter inserted. (They're relatively minor and go away with antibiotics, but they add an average of 1 extra hospital day to a patient's visit.)
Pneumonia. It often arises when intensive-care patients are put on ventilators to help them breathe easier. Patients who have had tubes inserted are 20 times more likely to develop pneumonia than ones who haven't, mainly because the ventilators make it easier for bacteria or vomit to get into the lungs, according to the Association for Professionals in Infection Control and Epidemiology.
Surgical infections. "Surgery increases a patient's risk of getting an infection in the hospital, as broken skin gives bacteria a way to enter into normally sterile parts of the body," says Lance R. Peterson, M.D., director of clinical microbiology and infectious disease research at Evanston Northwestern Healthcare in Illinois. So-called surgical site infections can originate with contaminated equipment, with health-care workers, or anything in between. The CDC estimates that 500,000 such infections occur annually in the United States. A single infection resulting from cardiac surgery can cost a hospital as much as $42,000 to treat.
Hypervigilant hygiene, including proper wound care, is crucial in preventing and combating infection. Staphylococcus aureus (also known simply as "staph") are bacteria that can live harmlessly on many skin surfaces, especially around the nose, mouth, and genitals. But when the skin is punctured or broken, as during surgery or when a catheter is inserted, the bacteria can enter the wound and make a person extremely sick. (Of mounting concern is a sometimes-fatal staph variant known as MRSA, which can be resistant to antibiotics.)
The most effective way to protect patients against bacterial infections is hand-washing. Scrubbing just 20 to 30 seconds with soap and water, or rubbing with an alcohol-based gel, helps health-care workers beat most bugs. Yet hand-washing compliance by doctors in hospitals is around 60 percent, mainly because of busy workloads and a heavy patient rotation, according to a recent report in the Annals of Internal Medicine.
"Health-care workers know they need to be doing it," Dr. Peterson says, "but they're not very good in practice."
Zero - Cases of Ventilator-Induced Pneumonia at One Hospital Using a New Protocol
Today more states and agencies are trying to make changes to improve safety. Illinois, Pennsylvania, Missouri, and Florida have passed laws requiring the publishing of hospital-acquired infection rates (15 others are considering legislation). And last year the FDA called for the inclusion of bar codes (think supermarket scanners) on prescription drugs and over-the-counter drugs commonly used in hospitals. New medications covered by the rule will have to include bar codes within 60 days of the medication's approval by the FDA; most previously approved medicines and all blood and blood products will have to comply with the new requirements by 2006. They're good changes in theory, but many states have shot down laws that would require hospitals to report infection data (many hospitals don't want data made public because of the bad press), and the FDA ruling doesn't require hospitals to install bar-coding systems. Another government-led initiative to create a national electronic health network to share clinical information will take at least a decade to create and implement.
"More often than not, the government will try to start some positive motion but will get bogged down in the details," says Jeffrey Goldstein, M.D., senior physician consultant for HealthGrades, an independent healthcare quality ratings company in Golden, Colorado. That's why change will likely come from other places. Dr. Goldstein points to the "100,000 Lives" program, which was launched in December 2004 by the Institute for Healthcare Improvement, a nonprofit organization in Cambridge, Massachusetts, which aims to show that 100,000 deaths can be avoided through simple interventions. One hospital that joined the campaign, Newark Beth Israel Medical Center in New Jersey, reduced cases of ventilator-induced pneumonia to zero just by weaning patients from ventilators more quickly.
Many others — from individual hospitals to larger grassroots groups — are making their own changes. For example:The Department of Veterans Affairs began using a proprietary bar-code system in its 1,300 care facilities more than 5 years ago. Under the system all units of medication leave the pharmacy with a bar-coded label that can be scanned to correspond with a bar code on the patient's hospital wristband, providing a way to track missed doses and pinpoint errors in dispensing. Now the VA reports a significant reduction in problems caused by medication mistakes.
This year Evanston Northwestern Healthcare began using a presurgical nasal swab screen to identify staph DNA in 2 hours, as opposed to 4 days with older techniques. This has helped the company's hospitals cut postsurgical staph infection rates among patients fivefold.
The Leapfrog Group, a collection of more than 170 companies and organizations that buy health care for more than 35 million employees nationwide, is rewarding hospitals with perks like bonus payments and increased reimbursement rates. For a hospital to benefit, it must pass recommended quality and safety practices. These "leaps" include the use of a computerized system to order tests and medication, assurance that patients with high-risk conditions are cared for using procedures shown to improve outcomes, and an intensive care unit supervised by specialists in critical care medicine.
In 2003 Leapfrog's first three quality and safety practices were estimated to have the potential to save over 65,000 lives, prevent as many as 907,000 medication errors each year, and save $41.5 billion.
Ideally, hospitals, agencies, and the government will look to provide optimal care and make patient safety a priority, but these decisions may be tempered by financial constraints, Dr. Goldstein says. "The patient doesn't care about cost or similar factors that play into clinical decision-making," he says. "The only thing that matters is that he or she receives the best and safest care possible."
