Items in the News
MRSA, a drug-resistant germ, lurks in Washington hospitals, carried by patients and staff and fueled by inconsistent infection control. This stubborn germ is spreading here at an alarming rate, but no one has tracked these cases — until now.
By Michael J. Berens and Ken Armstrong
Seattle Times staff reporters
Year after year, the number of victims climbed. But even as casualties mounted — as the germ grew stronger and spread inside hospitals — the toll remained hidden from the public, and hospitals ignored simple steps to control the threat.
Over the past decade, the number of Washington hospital patients infected with a frightening, antibiotic-resistant germ called MRSA has skyrocketed from 141 a year to 4,723.
These numbers don't appear in public documents. Washington regulators don't track the germ or its victims, and Washington hospitals do not have to reveal infection rates.
The Seattle Times analyzed millions of computerized hospital records, death certificates and other documents to track the swath of one of the nation's most widespread, and preventable, epidemics.
In its investigation — the first comprehensive accounting of MRSA cases in Washington hospitals — The Times gained access to state files that revealed 672 previously undisclosed deaths attributable to the infection.
MRSA, methicillin-resistant Staphylococcus aureus, is spread by touch or contact. It can slip into breaks in the skin as tiny as a mosquito bite.
Six out of seven people infected with MRSA contract it at a health-care facility.
Many people first learned about the germ last fall when the federal Centers for Disease Control and Prevention set off a media frenzy with its announcement that invasive MRSA infections claim at least 18,000 lives a year, more than AIDS.
But MRSA has been quietly killing for decades. And all along, there has been a simple diagnostic test that could have saved countless lives. This quick and painless test, which costs about $20, lets hospitals know who's infected or a carrier. Once identified, people with the germ can be isolated from other patients and treated.
Federal veterans hospitals screen all patients for MRSA, which has reduced their cases to near zero. Yet not a single community hospital in Washington screens every patient for the pathogen.
Many hospital officials say widespread screening is unnecessary and too burdensome. They say broad infection-control measures, such as washing hands and wearing protective garments, can thwart MRSA's spread.
But Washington hospitals violate these fundamental safety measures time and again, state and federal inspection reports reveal, from the Tacoma surgeon who refused to wear a mask during surgery to a Spokane blood technician who carelessly brushed her contaminated hands against supplies destined for other patients.
At Harborview Medical Center in the early 1980s, 17 people died during a MRSA outbreak fueled by the failure of the state's premier trauma center to isolate all infected patients immediately. But to this day, according to confidential records obtained by The Times, Harborview still rooms some MRSA patients with those who don't have the germ.
Meanwhile, MRSA is infecting and killing more people this year than ever before.
Crippled for life
In October 2005, Joyce Allen went in for open-heart surgery at St. Joseph Medical Center in Tacoma. Doctors told her to expect a quick recovery. But during the operation, MRSA slipped into her chest.
Doctors had cut through her sternum, a flat bone that binds the rib cage and protects the heart. When they fused the sternum back together, the contagion was entombed inside.
The blood-rich bone marrow was a perfect hiding spot. Within a week, the germ pushed into her arteries and crept into vital organs.
Physicians resorted to their most powerful antibiotic — vancomycin — known as the "drug of last resort." For six weeks, twice a day, Allen received intravenous infusions. A suction system sealed her chest and drained away toxic fluid.
"The pain was excruciating. I wanted to die, it hurt so bad," Allen says.
Antibiotics failed to conquer the infection. By April 2006, as Allen hovered near death, surgeons made the decision they had dreaded: Cut out the sternum.
They sheared away 6 inches of bone with a diamond-coated blade. Then they severed her abdominal muscles near the groin, and stretched the flaps tight across her chest, to shield her heart.
Allen, 57, is crippled for life. She measures each day by the level of pain. On her worst days, she's unable to pick up her small grandson.
"This germ destroyed my life," she says.
Disabled, she gave up her customer-service job at a Tacoma cabinet company. She now lives in a trailer in Spanaway, surviving on $877 a month in government benefits.
Nobody knows how the germ got into St. Joseph's operating room.
Allen says her surgeon was devastated by the infection. Hospital officials suggested that she might have carried the pathogen into the facility, on her skin.
If that were so, screening likely would have detected the germ and allowed doctors to eradicate it beforehand.
Cardiac patients like Allen are among the most vulnerable to MRSA infections and often face prolonged and expensive recoveries, medical research shows.
But St. Joseph didn't test her for MRSA, according to medical records. When it comes to most cardiac patients, the hospital still doesn't. On Friday, it said that policy is under review.
Most aren't tested
Who gets tested for MRSA, and who does not, is a medical game of chance.
Washington hospitals make their own rules. There are no federal or state mandates for screening.
The result is a haphazard array of infection-control policies that often fail to protect the most vulnerable patients, according to a Times survey of the state's 25 largest hospitals.
MRSA infections often strike critically ill patients or those with weakened immune systems — patients typically treated in a hospital's intensive-care unit.
But Swedish Medical Center in Seattle doesn't routinely screen patients in its ICU. Instead, it screens patients having elective surgery.
Sacred Heart Hospital in Spokane does test ICU patients — but not those seeking elective surgery.
The University of Washington Medical Center tests only premature babies.
Valley Medical Center in Renton doesn't routinely screen any patient group.
The bottom line is that most Washington patients don't get tested.
Whether to test, and whom to test, are at the core of a bitter national debate within the U.S. health care system.
Those who oppose testing all patients often argue that it undermines patient safety to dedicate limited resources to just one germ.
The reality, they say, is that hospitals often lack the staff, lab resources or space to ramp up existing testing programs or isolate large numbers of patients.
Swedish Medical Center would be hard-pressed to screen its 41,000-plus admissions each year, officials said. Harborview Medical Center, the state's most crowded hospital, doesn't have enough private rooms to isolate every patient, officials said.
Some hospitals fear lawsuits. If they screened every patient, results would show who already had the germ upon admission — and who picked it up while in the hospital. Patients could then blame the hospital for their infections.
Federally funded researchers called MRSA a possible epidemic in the early 1980s, following a series of outbreaks in large hospitals nationally. Yet most Washington hospitals began limited screening only within the past three years, The Times found.
"Many hospitals have ignored MRSA for decades," said Dr. William Jarvis, who retired in 2003 from the federal Centers for Disease Control and Prevention, where he was once acting director.
MRSA can cause painful and treatable skin lesions or slip into the blood. About 1 percent of infections prove fatal, while many others result in crippling injuries.
No one knows how many people carry the germ on their skin. Nationally, medical researchers have estimated that it's 1 or 2 percent of the general population. Washington hospitals that have initiated selective screening have discovered significantly higher levels — up to 11 percent.
Some surgeons around Seattle so dread the pathogen that they order tests when hospitals won't.
MRSA cases hidden
To control an infection, health officials need to know where it's been. They need counts, patterns, examples. But in Washington, MRSA's tracks have largely been obscured.
The state Department of Health asks physicians or medical examiners filling out death-certificate forms to give not only the primary cause of death, but the "chain of events" — the "diseases, injuries, or complications" — that contributed. Without such detail, these forms, when compiled in a database, may miss signs of emerging threats to public health.
But omissions undercut these certificates' value.
In 2005, Brenda L. Smith, 47, of Puyallup, died at Swedish Medical Center/Providence in Seattle. For "final anatomical diagnosis," her autopsy lists, at the top, MRSA pneumonia. But her death certificate — which relied on the autopsy report — says only pneumonia, with no mention of MRSA.
That same year, Willie Pompey, of Everett, died at age 58. His death certificate lists kidney failure, but does not account for an underlying reason. Pompey received a kidney transplant in 2002 at Virginia Mason Medical Center, but, because of a post-surgical MRSA infection, his body rejected the new organ. On his death certificate, MRSA is nowhere to be found.
How many examples are there like this? It's impossible to say. Finding them requires working backward — as The Times had to do — scouring lawsuits or other documents for indications of someone with MRSA, then comparing them against the public health records to see what, if anything, is missing.
A Bainbridge Island plaintiffs' lawyer, Christopher Otorowski, believes doctors may sometimes omit MRSA from death certificates because the infection is typically picked up in a hospital.
"Unless MRSA is the primary, explanatory cause of the death, I would think the physicians are going to be reluctant to put MRSA on the death certificate because it might implicate the hospital," he says.
For years, the state health department released a database of death certificates that is used by academics, journalists and others to report on public-health issues. But the state excluded a key component, a field that included doctors' notes that expanded on factors contributing to the person's death. The Times discovered the omission this year and insisted upon a complete database.
This new database links 672 deaths to MRSA between 2003 and 2006. The old database didn't attribute a single death to the germ. It couldn't have. The state relies on a standardized coding system, used internationally, that has more than 13,000 diagnosis codes — but not a single one for MRSA.
To gauge the prevalence of MRSA, The Times also analyzed a second database, which compiles diagnoses and billing records for patients discharged from Washington hospitals. The state uses this data, which has no individual names, to identify health trends and to analyze costs.
But as with the death certificates, this data set proved incomplete. The Times found dozens of examples where alternative records showed a patient had been treated for MRSA, while the billing database made no mention of it.
Because of these holes, the number of MRSA cases and deaths generated by the newspaper's analysis amounts to a minimum count, not a complete one.
Nationally, exact numbers are not available either, leaving public-health officials to estimate or extrapolate the scope of the epidemic.
Repeat offenders
To impede MRSA and other infectious germs, Washington hospitals typically rely on basic strategies — washing hands, isolating patients, sterilizing equipment.
But most of the state's 25 largest hospitals have been cited for unsanitary conditions or failure to adhere to fundamental safety standards, state and federal regulatory reports since 2005 show.
Last year, at Spokane's Holy Family Hospital, state Department of Health inspectors discovered the following:
A nurse entered Room 520 and dropped two packets of pills on the floor. Instead of throwing them out, she scooped up the packets and put them in a paper medication cup. She then pried the pills from the packets, dumped them into the contaminated cup and handed it to the patient.
An hour later, in a different room with an infectious patient, a staff member began to leave without washing hands. A second staffer tried to leave without discarding a contaminated gown. Both were headed for public areas of the hospital before state inspectors stopped them.
That afternoon, inspectors watched a phlebotomist draw blood from an infectious patient. Afterward, she brushed her gloved hands against items in a nearby supply cart — supplies destined for other patients.
In all, the four-day inspection cited seven staff members for violating basic infection-control standards, state records show.
Physicians can be the most lackadaisical about infection control.
In April 2006, doctors at the UW Medical Center carried personal items from home into sterile operating rooms and dropped them on the floor. These items included backpacks and satchels, made of porous materials friendly to germs. Hospital administrators told inspectors this was "common practice."
In November 2006, a physician at St. Joseph Medical Center in Tacoma removed his surgical mask during an operation. He had complained it was uncomfortable. Hospital officials told inspectors the physician was a "repeat" violator and had been warned before to keep his mouth and nose covered.
In hospitals, the most common violation is the failure to wash hands upon entering or leaving a patient's room.
In the worst cases, as few as 40 percent of staff members comply with hand-washing standards. Doctors are the worst offenders, according to confidential hospital records reviewed by The Times.
Even the best hospitals typically boast no better than 90 percent compliance — which means one out of 10 practitioners may have contaminated hands.
Hospitals remedied all violations spotted during the inspections, records show.
But these violations were all the more brazen because hospital officials — benefiting from a new law — knew the exact day that state inspectors were coming.
No surprise inspections
In the past, the state health department conducted surprise inspections to ensure that hospitals adhered to health and safety codes, from patient care to building maintenance.
But in 2002, the Washington State Hospital Association issued a 28-page report: "How Regulations are Overwhelming Washington Hospitals." In it, hospital administrators claimed surprise inspections disrupted patient care.
In Olympia, lawmakers voted unanimously to eliminate surprise inspections starting in July 2004. Today, the Department of Health must provide four weeks' notice — even the exact hour of arrival.
Hospital officials also had complained that some state inspectors were abrupt and unfriendly.
Lawmakers approved a Band-Aid: Hospital officials now can anonymously evaluate state regulators on whether they were polite enough.
The Legislature receives an annual compilation of these critiques. One hospital official wrote that state inspectors could "do a better job of highlighting the positive," instead of just looking for problems.
Washington is the only state that legally empowers hospitals to rate the conduct of regulators, according to the Consumers Union, a nonprofit organization that monitors hospital-related legislation.
"What kind of message does that send?" said Lisa McGiffert, who directs the organization's Stop Hospital Infections project.
Federally commissioned hospital inspectors began surprise inspections in 2004 — the same year Washington eliminated them.
The Joint Commission on Accreditation of Healthcare Organizations sets health-care standards and certifies hospitals to receive federal funding, such as Medicare. For decades, the commission had provided at least a month's notice before inspections.
But dozens of hospitals exploited the advance notice to temporarily hire more staff, cart in rental medical equipment — which was returned when inspectors left — and conduct dramatic makeovers with fresh sheets and pillows, according to inspector general reports at the U.S. Department of Health and Human Services.
Responding to public criticism, the commission stopped giving notice.
In some Washington hospitals, makeovers now take place just before state inspections, three registered nurses told The Times. The hospitals beef up staffs during planned inspections and, in some cases, have hired extra cleaners to disinfect beds and equipment, the nurses said.
The state hospital association recognizes "more needs to be done" to combat MRSA and is pushing to standardize patient-isolation procedures and increase hand-hygiene compliance, association president Leo Greenawalt said.
"My doctor was stunned"
When Chuck Velte first saw the woman at a flower show — sitting in a wheelchair, her right leg missing at the knee — he tried not to stare.
It was the spring of 2006, and Velte had knee surgery pending. He couldn't help but wonder: What happened to the woman's leg?
So he asked.
"She said that her knee was infected after routine surgery. She called the germ MRSA. I'd never heard of it," says Velte, who's now 64.
"I looked at her missing leg and was scared: This could be me."
Velte asked medical practitioners at Valley Orthopedic Associates in Renton about the germ's threat. He says they told him: Don't worry. This infection targets people with weak immune systems, and you're healthy.
Velte was unconvinced. A former senior analyst at Boeing, he launched into research. He learned patients could infect themselves if dormant MRSA germs were on their skin. The bacterium could drop into a wound during surgery and touch off numerous complications, even death.
Velte didn't know it, but at least 66 patients who underwent joint surgery the year before suffered amputation of legs, arms or fingers after contracting MRSA, a Times analysis of Washington hospital-billing records shows. For the past decade, the number of such patients stands at 512.
But Velte's research also turned up a simple safeguard: a nasal swab test that can detect if someone's a carrier.
Velte demanded to be screened. Doctors questioned its need, but sent him to a laboratory at Valley Medical Center in Renton, where the surgery was scheduled.
"I get there, and my knees are killing me, and the lab guys said they don't do a MRSA test. They told me to go home," Velte says.
Velte hobbled to the hospital's executive offices and plopped in a chair. "I want to see the highest-ranking person here," he recalls saying. "I'm not leaving here until I get a MRSA test."
An apologetic administrator arranged for a test. Results arrived four days later.
"I tested positive for MRSA," Velte says. "My doctor was stunned. He said that if he had operated, it could have been catastrophic."
To get rid of the germ, Velte scrubbed himself with over-the-counter soap containing chlorhexidine, an antibacterial chemical. He also wiped his house down with bacteria-killing bleach.
He was screened for MRSA again, was cleared and underwent surgery. It was successful.
A year later, MRSA invaded Velte's life again.
His 92-year-old mother, Rita, lived at a nursing home in Eau Claire, Wis. Last fall, Velte learned she had a festering wound, resembling a giant boil, on her buttocks. He demanded a MRSA test.
"After what I'd been through, I knew it was a possibility," he says.
A lab report confirmed his suspicions. His mother was infected with invasive MRSA, the worst kind. Within two days, she was gripped by pneumonia, followed by sepsis — blood poisoning — which reached into every vital organ, medical records show.
She suffered a fatal heart attack on Nov. 1 — less than two weeks after she was diagnosed with the germ.
Yet, MRSA did not appear on her death certificate. The official causes of death were heart attack, pneumonia and sepsis.
Velte says he demanded a correction — the truth. After reviewing medical records, the certifying doctor added MRSA.
"I wonder," Velte says, "how many people die of MRSA and nobody ever knows."
By Michael J. Berens and Ken Armstrong
Seattle Times staff reporters
In the spring of 1980, when he was wheeled into Harborview Medical Center, Norman Hurst already had the bug. It was in his blood, his saliva, on his skin, in his burns.
Harborview, atop Seattle's First Hill, was the city's safety net, a public hospital that embraced the poor and scrambled to save people hurt the worst. But Harborview was also a contagion's land of dreams — 300 beds, with a burn unit and bustling intensive-care ward, a concentration of patients with weakened immune systems and open wounds.
At the time, the public had no idea what MRSA was, much less how virulent it could be. But Harborview's doctors knew. The hospital's first case had appeared in 1968. A year after that, an outbreak killed two patients. Doctors wrote up the lessons learned — the need for heightened hygiene among doctors and nurses, the need to identify infected patients and to isolate them.
Hurst was 72. A retired truck driver from Aurora, Ore., he had been driving his motor home through southeast Texas when a flatbed lumber truck blew a tire and hit him. The motor home rolled and caught fire. Hurst's wife, Viola, escaped. But Hurst was pinned, and suffered burns to a third of his body.
For three months he was treated at a hospital in Houston. From what doctors could later tell, this is where he picked up MRSA — or methicillin-resistant Staphylococcus aureus — a germ that spreads by contact.
To be closer to home, Hurst was flown by medical transport to Seattle in mid-June. From culture samples taken upon admission, Harborview learned that Hurst had MRSA.
Discovering the bug so soon could have helped Harborview contain it. But that didn't happen. Hurst died 12 days after being admitted, but the pathogen had already escaped. How? No one can say for sure. A doctor's coat, brushing skin, can pick the germ up and pass it on. So can a stethoscope, or a blood-pressure cuff, or a nurse's unwashed hands.
In August, September and October, eight other patients in the burn unit became infected or colonized, meaning the germ settled on their skin, turning them into carriers.
To help trace the outbreak, each would later receive a number, corresponding to the order in which they tested positive. Hurst was patient No. 1. The others became patients 2 through 9.
For centuries, doctors have used isolation to combat infections. But in October, Harborview moved patient No. 9 from the burn unit into the surgical intensive-care unit. There, the germ skipped to the patient in an adjacent bed — the outbreak's patient No. 10.
Only in November — five months after Hurst's arrival — did Harborview begin systematically isolating patients.
By then, it was too late. From No. 10, the contagion exploded in the surgical ICU, then swept into the rehabilitation ward. By March 1981, the germ infected or colonized 19 more patients, all linked, by molecular fingerprint, to patient 10.
Nine months after Hurst's arrival, the germ's spread seemed to stop. April passed with no new cases. But in May and June 1981, the pathogen resurfaced — and in an unexpected place: a new burn unit full of patients who had no known contact with the outbreak's previous victims.
Doctors have known since the 1800s that hospital personnel can exacerbate infections by carrying germs from bed to bed and ward to ward. But only now — one year after Hurst's arrival — did Harborview test 182 doctors, nurses and therapists for MRSA.
These tests turned up a carrier: a nurse, with a chronic skin condition, who had MRSA all over, in her ears, her nose, her armpits. She worked in the new burn unit. She had worked in the old burn unit. She had worked in the surgical ICU.
She was removed from the burn unit and treated, and the outbreak petered out.
In the end, the outbreak lasted 15 months. Thirty-five patients became infected or colonized. Seventeen died. The youngest victim was 19, the oldest 82. Thirteen of the deaths were blamed on MRSA, making this outbreak one of the country's deadliest.
At the time, the public knew nothing. But a year later, doctors described the outbreak in a medical journal. They wrote up the lessons learned, noting again how important it was to identify carriers and to isolate them.
Whether those lessons would be put into practice was another matter.
One hospital hunts germ
While Harborview struggled with its MRSA outbreak, a hospital in Virginia suffered through one even worse.
Methicillin, the "M" in MRSA, was introduced in 1959 to attack staph germs resistant to penicillin. But only two years later, germs resistant to the new drug emerged. This threat, called MRSA, took hold in Europe before surfacing in the U.S.
By the early 1980s, more than 100 U.S. hospitals reported MRSA infections; federally funded researchers wrote that MRSA may be "reaching epidemic proportions." But descriptions of outbreaks — 61 infected or colonized patients in the Houston hospital where Hurst first stayed, 66 in two Portland hospitals, 245 in Jackson, Miss. — were relegated mostly to medical journals, all but escaping public notice.
The University of Virginia Hospital saw its first MRSA case in 1978. But within two years, the contagion accounted for nearly half the hospital's staph infections — a shocking spread that presaged what many other hospitals would confront in decades to come.
"Very quickly, we knew we had an explosive epidemic," says Dr. Richard Wenzel, the hospital's epidemiologist at the time. "We knew it was something new. We knew it was going from bed to bed."
In December 1980, the hospital tried something new. Rather than react — case to case, outbreak to outbreak — the Virginia hospital opted to anticipate, to go and find patients with MRSA, symptoms or no symptoms, and to neutralize them before they endangered others. This approach became known as Active Detection and Isolation, or ADI, and what made it different was the first word: Active.
The hospital began hunting the germ, screening patients at high risk of getting MRSA — trauma patients, burn patients, any patients with wounds on their skin. Colonized or infected, anyone with the germ was isolated.
Right away, the hospital's MRSA cases dropped, from 33 a month, to 25, 21, 19. Within a year, it was down to six cases a month. And a half year after that — "it was gone," says Dr. Barry Farr, who was a resident physician at the hospital during most of the outbreak.
Farr, an infection-control specialist, saw how well ADI worked. He became the hospital's epidemiologist in 1986 — and emerged, in time, as the country's leading proponent for using such aggressive control measures.
Even in the absence of an outbreak, the Virginia hospital kept using the detection-and-isolation method.
In 1991, the hospital saw its MRSA rate climb again, and, by tracking patients, discovered why. Patients were contracting MRSA in surrounding hospitals — ones not using ADI — and, when transferred, bringing in the germ.
"Infection control is a shared problem," Farr says. "What goes around comes around, and it comes in our front door."
Farr lobbied other Virginia hospitals to use active detection but found few takers. He created the Problem Pathogen Partnership in Virginia and North Carolina, but only a fraction of hospitals joined up.
"It was clear to me that it would work," he says of ADI. "The frustrating thing was that people didn't even want to try."
CDC's "cop out"
ADI, also known as "active surveillance" and "search and destroy," has split the medical community.
Here and there, hospitals would adopt active detection — with stunning results. In the late 1980s, Shadyside Hospital in Pittsburgh eliminated MRSA's spread within five months; its entire screening program cost about as much as treating a single MRSA victim.
In the 1990s, dozens of other U.S. hospitals reduced their MRSA rates using screening.
Success stories also rolled in from Denmark, Finland, Western Australia.
To Farr, the mounting evidence proved that active detection worked. But most hospitals balked. Some doctors questioned the costs, the scientific validity of all those studies, the wisdom of concentrating so much attention on a single contagion. They advocated broad measures — for example, reinforcing the need for doctors and nurses to wash their hands — that could reduce hospital infections overall.
Some doctors also cited a handful of research reports that disputed screening's effectiveness.
The Centers for Disease Control and Prevention (CDC), a federal agency in Atlanta, stands as the nation's health-care sentinel, studying infectious diseases and recommending ways to stop their spread. CDC guidelines don't bind hospitals, but often become the standard of practice. With MRSA, the CDC could have helped settle the screening debate. Instead, the agency dodged it.
Since the 1980s, the CDC has issued at least 14 sets of infection-control guidelines for hospitals. Added up, they provide 1,333 recommendations — a bewildering, sometimes inconsistent thicket of alternatives: try this, then that, or if not that, maybe the other thing.
ADI has been relegated to maybe the other thing — not dismissed out of hand, nor urged as a matter of routine.
The CDC prizes flexibility, loathe to assume that what works in an urban medical center will also work in a rural hospital.
One of Farr's staunchest allies has been Dr. William Jarvis, who retired from the CDC in 2003 after leading the investigation of more than 150 outbreaks of infectious disease in health-care settings. While at the CDC, Jarvis urged the agency to champion MRSA screening, to no avail.
In 2004, Jarvis reviewed new infection-control guidelines that were being drafted by the agency. He fired off a 33-page critique, calling the proposals "biased," "illogical" and "a cop out," according to a copy obtained by The Times.
The CDC guidelines, Jarvis wrote, devoted inordinate attention to rare pathogens — for example, monkeypox, which can be picked up from pet prairie dogs — while glossing over MRSA, "the most prevalent and problematic organism" in hospitals "throughout the world." His letter said "an enormous amount of data" supports ADI, yet the draft guidelines gave screening less support and prominence than a recommendation that health-care workers avoid wearing false fingernails.
In 2006, the final version of these guidelines was finally released. To Farr and Jarvis, they amounted to more of the same, with active detection accorded second-tier status, something hospitals might consider if other measures failed.
Last year, Farr wrote in a medical journal that such caution may have been defensible in the early 1980s. But now, more than 140 studies supported the merits of active detection, he wrote. Fourteen studies showed ADI saved more money than it cost.
Harborview struggles
While the CDC deliberated, MRSA escalated.
The CDC's 2006 recommendations had followed six years of meetings, drafts and revisions. In those same six years, the number of Washington hospital patients with MRSA jumped from 815 a year to 4,643, patient discharge data shows. The number of deaths in the state attributed to MRSA also climbed, going from 58 a year to 190.
No Washington hospital has treated more patients with MRSA than Harborview — 1,651 cases since 1997. To some extent, that's a function of patient population.
When medical helicopters pick up accident victims clinging to life, they fly them to Harborview, the Pacific Northwest's premier trauma center. Harborview also helps the down and out — prisoners, the mentally ill, people with substance-abuse problems — providing more than $100 million a year in charity care.
With all the hustle and crowds, Harborview struggles to maintain a sterile environment. Homeless people — who are more likely to be MRSA carriers — often sleep in the hospital's main-floor lobbies, curled up in armchairs or crashed out on sofas. Patients walk outside to grab a smoke, then stroll back in, carrying whatever germs they happened to pick up. On one recent day, four employees — three in blue scrubs, one in a white coat — ate lunch outside. They sat around a large planter and, at times, put their feet in the soil, which is fertile ground for germs.
Many Harborview patients — chronically or desperately ill, with weakened immune systems — are particularly susceptible to MRSA. But that vulnerability also provides reason for Harborview to take extra care in guarding against infection.
That's what makes the hospital's sluggish response to the threat so baffling.
At this decade's start, the number of Harborview patients with MRSA kept going up, year after year. In 2000, 60 inpatients were treated, according to discharge data. By 2004, the number was 316 — a figure that eclipsed other Washington hospitals, none of which had even 200.
MRSA continued to kill Harborview patients, like Rosetta Craig, a Pierce County woman who died in 2003 at age 63.
Her son, Teddy Craig, visited her in Harborview every day. He and a family friend didn't wear gloves or gowns, or take other precautions.
"We'd hug mom goodbye and walk out of the room," he says. "Nobody told us she had an infection. I had no idea she had MRSA. Nobody warned us to be extra careful when we were in her room or to wash our hands before we left the room. The germ could have been all over us."
It wasn't until 2005 that Harborview began to incorporate some of the lessons offered by the University of Virginia Hospital.
In June of that year, Harborview began screening patients in the intensive-care unit for MRSA — a form of active detection. Three months later, Harborview expanded screening to patients getting elective surgery.
The results would have come as no surprise to Farr, the advocate of active surveillance. While the state's MRSA numbers as a whole continued upward, Harborview's annual totals started to fall — to 292, to 224, to 207.
"I'm quite happy with it," says Dr. Timothy Dellit, Harborview's director of infection control. "That's why we still do it. It shows benefit."
With each MRSA patient costing maybe $20,000 extra to treat, the program has paid for itself. "You don't have to prevent many cases of MRSA to reap the savings," Dellit says.
But while Harborview made advances in screening, it would continue to ignore other infection-control measures.
Public can't track MRSA
With infections, knowledge is power. Where's the bug been? How many people did it infect? What steps were taken to stop it? But at Harborview, as with many Washington hospitals, information about MRSA can be elusive.
In Harborview's deadly outbreak in the early '80s, Norman Hurst was the "index patient," medical-speak for trigger. But his death certificate — a crucial public-health tool that can expose emerging threats — says nothing about his infection. It lists sepsis, kidney failure, liver failure, burns to 35 percent of his body. But there's not a word about MRSA, not even in the box for "other significant conditions."
Hurst's son, Allen, lives in Shoreline. He helped get his dad transferred to Harborview 28 years ago. He says the Harborview doctors didn't tell him anything about MRSA. Like most folks at the time, he didn't even know what it was.
Hurst had to piece the story together himself.
In 1982, doctors described the Harborview outbreak in a medical journal. The Associated Press summarized their account. Hurst read the AP story and thought he recognized his father in the clues — the transfer from Texas, the severity of the burns. He took the article to Harborview, and a doctor there confirmed his hunch.
"Otherwise, I wouldn't have gotten any other information about it," Hurst says.
The Seattle Times identified Norman Hurst in much the same way, running clues from the medical journal through a database of death certificates. Even with the omission of MRSA, enough details fit.
The state Department of Health also keeps another database, information collected from hospitals about each admitted patient, with the patients' names stripped out. But holes riddle this data set, which regulators use to spot health trends and analyze costs.
Take Rosetta Craig, the Harborview patient who died in 2003. With the help of Craig's family, The Times was able to determine that while she appears in this database, there's no mention of MRSA. The newspaper identified her as a victim of the germ only by obtaining a death-certificate database from the state that includes expanded doctors' notes.
In 1982, a retired shipyard worker sued Harborview, alleging the hospital had used unsterilized medical equipment while implanting a pacemaker, triggering a staph infection that settled in his spinal column. His lawyer asked Harborview how many of its patients had developed staph infections since 1976, a question that would have swept up the 1980-81 MRSA outbreak, since MRSA is also a staph germ.
But Harborview refused to answer. Under the law, it didn't have to.
Although Harborview is a public entity — a teaching hospital, affiliated with the University of Washington — the law has protected it from having to disclose infection rates, as well as the steps it takes to keep infections down.
CDC issues scary news
On Oct. 16, 2007, the CDC issued a press release that hit like a thunderclap, touching off fear and uncertainty.
The agency's experts revealed, for the first time, that MRSA was now killing more people than AIDS.
Without a mandatory reporting system to draw upon, the CDC reached its numbers by extrapolating from nine sites — cities and counties mostly. It estimated that in 2005, MRSA killed nearly 19,000 people in the United States.
Newscasters alerted viewers. Anderson Cooper: "This is scary stuff." Katie Couric: "This is really scary." Hannah Storm: "Very, very scary stuff."
The CDC estimated that 85 percent of the MRSA cases were picked up in hospitals or other health-care settings. But it was the other cases — those where MRSA was acquired in the community — that captured the country's attention. People had been dying from MRSA for decades, in dramatic numbers, with little notice paid. Now individual deaths received exhaustive coverage. A 12-year-old in Brooklyn. A 17-year-old in Virginia.
Soon after the CDC announcement, Seattle media spotlighted John Jones, a 46-year-old Federal Way man who died of MRSA at Harborview.
But he was hardly an isolated example.
In 2006, nine MRSA victims died at Harborview, a Seattle Times analysis shows. They included a 44-year-old construction worker, a 65-year-old pharmacist and a 76-year-old longshoreman, all from Seattle. In 2005, 10 MRSA victims died at Harborview. They included a landscaper from SeaTac, a human-resources assistant from Sumner and a nurse from Renton. In 2004, the number was seven. The year before that, 11. One of the 11 was Rosetta Craig.
After the CDC announcement, elementary schools shuttered over a single student infection. Friday night football games went dark to disinfect locker rooms. Playgrounds, health clubs, even the backyard swing set — no place seemed safe.
Some media called MRSA an emerging threat, although it appeared to have reached epidemic proportions a quarter-century before. The CDC called its numbers a "call to action" for hospitals to do all they can to control MRSA. But Farr had been sounding the same alarm for two decades.
"We don't want to do it"
On Oct. 15, 2007, the day before the CDC's announcement, Harborview issued a new set of internal policies for infection control. These guidelines, obtained by The Times, exempted MRSA from at least two crucial safeguards.
When dealing with most infectious patients — for example, those with pneumonia or diphtheria — Harborview's doctors and nurses were told to put on fresh gloves and gowns and dispose of them afterward. But not with MRSA patients. With that germ, such contact precautions weren't required.
What's more, the hospital's guidelines allowed patients with MRSA to share a room with those not already infected. Harborview "does not routinely isolate patients with MRSA colonization or infection at this time," the guidelines say.
When it comes to ADI, Harborview had taken steps on the front end, "Active Detection," adopting screening procedures that rank among the state's most rigorous. But Harborview doesn't strictly adhere to the back end: "Isolation." To work best, the two must go together, Farr says.
In 1980, it was Harborview's failure to isolate that allowed the germ to spread from patient No. 9 to patient No. 10, and to explode from there. What also fanned the outbreak was the nurse who had become a carrier, her body littered with MRSA germs.
Since taking over infection control at Harborview in 2006, Dr. Timothy Dellit has pushed for reform.
With its stepped-up screening program, Harborview managed to knock its MRSA numbers down by 30 to 40 percent. But to Dellit, they were still too high. So this year, he finally ordered everyone to wear gloves and protective clothing while caring for MRSA patients.
"Going from a hospital that hadn't done that, that was a big deal," Dellit says.
"This was a huge culture change for us."
But Harborview still lacks the space needed to isolate every MRSA patient, Dellit says. Its beds — now, 400-plus — fill up most every day. If Harborview can't find a MRSA patient a private room, it pairs MRSA patients. Failing that, the hospital will room a MRSA patient with someone who isn't infected or colonized.
That happens maybe twice a day, Dellit acknowledged.
"We don't want to do it," he says. "We'd prefer not to do it."
A Times survey of the state's 25 largest hospitals turned up only one other — Harrison Medical Center, in Bremerton — that will also room MRSA patients with non-MRSA patients.
"We would never do that," says the head of infection control at Sacred Heart Medical Center in Spokane. "NEVER," wrote an infection-control nurse at Stevens Hospital in Edmonds.
But Harborview's mission — to accept all patients, at all times — remains paramount. The hope is that pairing such patients poses minimal risk, Dellit says.
In 1980, doctors clung to that same hope.
By Michael J. Berens and Ken Armstrong Seattle Times staff reporters
A night-shift nurse slipped into Jeanine Thomas' hospital room and whispered, "I don't know how you're taking this so well. If I were you, I'd be curled up in a ball crying."
The remark mystified Thomas. She'd had ankle surgery, and yes, there had been complications. But she thought she was recovering. Was there something she didn't know?
In November 2000, Thomas, then a 45-year-old antiques dealer, had slipped on ice and shattered her left ankle outside her suburban Chicago home. But days after surgery at her local hospital, the skin surrounding the incisions turned black, and her body swelled. Doctors wanted to amputate, but Thomas, an avid tennis player, refused to let them.
Then, a friend told Thomas about her mother's battle with MRSA, an antibiotic-resistant germ. Their symptoms matched. Thomas confronted a doctor and learned the truth: She, too, had MRSA. Only now did the nurse's comment make sense.
Thomas asked doctors how many people get MRSA. She was met by silence.
"That's when I knew — a light bulb went on in my head," she says. "They don't want anyone to know about this."
Today, Thomas is exposing MRSA's staggering toll as one of the nation's most influential patient advocates. Because of her persistence, Illinois hospitals now must disclose MRSA infection rates and screen for the germ. She's also pushing for federal legislation that could enhance patient safety in Washington and every other state.
Thomas epitomizes a revolt in health care. A growing number of consumer advocates — many bound by ordeals with MRSA, or methicillin-resistant Staphylococcus aureus — have vowed that if the U.S. hospital system will not heal itself, they will do it.
Five years ago, not a single state forced hospitals to reveal how many patients contracted infections while under their care. Now 25 states have some form of "report card" disclosure that can make hospitals more accountable.
Washington has a report card; it tracks three kinds of infections — but not MRSA.
MRSA rates in Washington have increased 33-fold in the past decade, a Seattle Times analysis shows. Last year, 4,723 hospital patients were diagnosed with the infection.
With fanfare, the state launched two initiatives last year to combat the epidemic. But in the end, neither made much difference.
Advocates gain ground
Across the country, consumer advocates have embraced two tools — MRSA screening and hospital report cards — to make hospitals more transparent and aggressive when dealing with infections.
The more popular has been report cards, often a byproduct of patient frustration with hospital secrecy and inadequate infection control.
Chris Cahill, a consumer advocate, worked with legislators to pass a report-card law this year in California.
Before retiring in 2006, Cahill worked for 12 years as a hospital surveyor for the California Department of Health Services. She inspected dozens of hospitals and saw how they could become easy targets for contagion. Some hospitals are "so filthy and dirty it's just incredible," she says.
Many infection-control departments, a cornerstone of patient safety, have so little staff and equipment that it's impossible to track every germ or consistently enforce standards, she says. Even large hospitals often put infection control in the hands of just one or two nurses.
"Many hospitals see infection control as a necessary evil. All they see is the bottom line," Cahill says.
That so many states have recently adopted hospital report cards shows how influential consumer advocates have become. But the hospital industry has often pushed back.
Some hospital officials believe consumers will draw unfair comparisons from report cards, without considering how each hospital has different patient populations. A hospital with a trauma center will have more patients who are vulnerable than one that focuses on elective surgeries.
Lawmakers in some states have passed report cards that provide little information to the public.
In Nevada and Nebraska, hospitals now must report infections to state health officials. But to the public, the numbers remain locked away.
Arkansas encourages hospitals to report infection rates — if they want to. Most don't.
"Not essential right now"
Washington passed its own report-card act in spring 2007. But hospitals have to report only one kind of infection this year: bloodstream maladies in patients who receive a central-line intravenous hookup. The report card will add a second type of infection next year, and a third by 2010. But MRSA is not among them.
Twice before, report-card legislation had died in Washington, after drawing fierce opposition from the hospital industry. The current measure represents a compromise or a first step, said state Rep. Tom Campbell, R-Roy, who sponsored the bill.
In Washington, MRSA has been linked to 1,217 deaths in the past decade, a Seattle Times analysis of hospital records shows. At least 23,707 hospital patients have been diagnosed with MRSA infections.
One Seattle hospital estimates that it costs $20,000 to treat a MRSA infection. Using that figure, MRSA's financial toll in Washington exceeds $474 million.
In the report-card bill, Washington lawmakers had included $240,000 for state health officials to investigate MRSA outbreaks, establish surveillance programs and educate health-care workers and the public about stopping the germ's spread.
The Washington Hospital Association supported the measure, which would have allotted public money to address MRSA.
But Gov. Christine Gregoire stripped the provision out, along with all kinds of other spending items. Her veto notes called the measure "valuable" but "not essential to do right now."
The Illinois fight begins
While hospital report cards have been enacted in much of the country, legislation requiring hospitals to screen patients for MRSA has been difficult to pass.
When Jeanine Thomas contracted MRSA in 2000, no state had even considered such a law. Her success in changing the culture has become a strategic blueprint for consumers in other states, where hospital resistance to mandated screening remains steadfast.
After her ankle healed enough that she could walk, Thomas cobbled together bits and pieces of information about a germ that few seemed to know about.
In 2003, she helped muster support for a bill requiring Illinois hospitals to disclose infection rates. A state senator named Barack Obama co-sponsored the legislation, which passed that year.
The experience inspired Thomas. She began campaigning for a law that would require hospitals to screen patients for MRSA. The screening test, which costs about $20, allows hospitals to identify who has the germ and to isolate them, to protect other patients.
Thomas wrote letters to state legislators and spoke out at health-care meetings. She said doctors undecided about screening had adopted a "compromise of doing nothing."
To combat the medical establishment, she received help from two of the nation's leading infection-control experts. One was Dr. Barry Farr, who was retired from the University of Virginia. Farr had urged hospitals since the 1980s to adopt aggressive screening programs, but he often met with resistance.
The other was Dr. William Jarvis, former acting director of the Centers for Disease Control and Prevention (CDC). Jarvis also supported screening, and sparred with its opponents at infection-control conferences.
"The public is tired of waiting for us to decide this debate and move into action," he says.
By late 2005, Thomas had forged an alliance with Illinois state Sen. Christine Radogno, who agreed to sponsor legislation that would mandate MRSA screening. If passed, the law would be the nation's first.
Thomas later wrote a note about her meeting with Radogno: "She told me tell no one."
They agreed that stealth was necessary because a war was about to begin.
Maryland bill fails
In Maryland, a home contractor from Baltimore had already started a similar war.
Michael Bennett created the Coalition for Patients' Rights after his 88-year-old father, Mark, contracted MRSA at a local hospital. A week after getting MRSA, his father picked up two more antibiotic-resistant germs. Those infections touched off necrotizing fasciitis — also called flesh-eating disease — and his leg was amputated.
Bennett's father was transferred to a series of rehabilitation centers. There he picked up three more infections, which destroyed his kidneys and poisoned his blood before killing him in June 2004.
While his father was in the hospital, Bennett says, doctors let two months pass before revealing the MRSA diagnosis. During that time, he says, dozens of staffers could have spread the germ. They only occasionally wore gloves or gowns or washed their hands after caring for his father.
In 2005, Bennett helped get legislation introduced to mandate MRSA screening in Maryland.
"Hospital infections have been killing too many for far too long," he says.
But the bill received what Bennett calls a "barrage of criticism" from hospital-industry officials, and it went down to defeat. Bennett tried again in 2006 and 2007, but with the same result.
The first breakthrough
When the Illinois MRSA legislation was introduced in January 2006, a firestorm erupted.
National medical groups attacked the bill, challenging screening's benefits and costs while touting existing infection-control measures, such as hand hygiene. The bill died in a House committee.
But Thomas tried again.
The first public hearing was held in February 2007 in downtown Chicago, during a fierce snowstorm. Many opponents showed up; Thomas was the lone supporter.
The Illinois Hospital Association originally opposed Thomas, fearing her proposal would force hospitals to test every patient. Later, when assured the scope was limited to critically ill patients and others at high risk of contracting MRSA, the association supported the measure.
The association had conducted research of patient-discharge data — the same kind of analysis The Seattle Times did in Washington — and was stunned at how many MRSA cases it found, Thomas says.
In May 2007, the bill passed the Illinois Legislature. The House vote was 106-0.
Thomas immediately called Farr: "He was overcome. He said he had waited so long for this."
But in August, an aide to Gov. Rod Blagojevich called and told Thomas the governor intended to veto the bill. His office issued a news release saying as much. Thomas, crying, began working the phones, rallying legislators to flood the governor with calls.
A few hours later, the governor changed his mind and signed the bill.
Three other states — Pennsylvania, New Jersey and California — have since passed similar screening laws.
"Impractical or extreme"
Washington, like the rest of the country, was rattled last October by the highly publicized announcement of the federal Centers for Disease Control and Prevention that MRSA now kills more people than AIDS.
Some schools closed temporarily over a single MRSA infection, or canceled football games so locker rooms could be disinfected.
In November, Gregoire wrote to the state Health Department, saying: "We need to do more." She ordered the agency to collect MRSA test results from medical laboratories statewide, and to create a panel of experts to recommend ways to curb MRSA's spread.
"Gregoire takes on superbug," a Seattle Times headline said.
But a year later, these two unfunded initiatives have had little effect.
The reporting of test results was voluntary, so some labs did not submit them. In other cases, the information was so sketchy that state officials couldn't tell where people caught the germ.
"We didn't find a whole lot of meaningful data," says Judith May, the Health Department's acting director of epidemiology.
As for the expert panel, it was stacked with hospital representatives, without a single consumer advocate. In January, the 18-member panel published its MRSA report — an 82-page rehash of existing medical literature.
The panel opposed screening all patients for MRSA, calling it "impractical or extreme ... with little added value."
Instead, it recommended that hospitals use infection-control guidelines from the CDC. But those guidelines have been widely criticized by congressional investigators, who call them confusing and conflicting.
In Washington, most community hospitals make these guidelines the core of their infection-control programs. None tests every patient for MRSA.
Last month, a representative of the Illinois Hospital Association met with a few dozen Washington hospital officials and touted the benefits of widespread MRSA screening.
For the first time, Illinois is getting a true picture of MRSA's toll, the representative told them.
Last year, the Illinois hospital group found approximately 11,300 MRSA cases. But this year, with screening in full force, the group estimates the number could be close to 30,000.
The fight continues
Today, Jeanine Thomas runs the MRSA Survivors Network.
She's haunted by memories of her time in the hospital, when she rolled up and down the corridors in a wheelchair, or grabbed coffee in the cafeteria, or used the drinking fountains.
"For two months I didn't know I had this infectious germ. The hospital let me go wherever I wanted.
"How many people did I infect?"
These days, she is campaigning for a federal law to mandate hospital MRSA screening in every state.
She criticizes Washington's refusal to embrace widespread screening, saying many of its hospitals are endangering patients.
Her Web page links to survivor stories, from a mother who lost her 7-week-old daughter to MRSA to a 58-year-old man who lost much of his left leg.
Thomas points to these survivors when confronting critics of MRSA screening.
"I'm trying to save lives," she tells them. "What are you trying to save?"
24 plaintiffs seek more than $30K per count
By Deborah Gates
Staff Writer
SALISBURY -- Patients and their family members are suing Dr. John McLean, claiming the Salisbury cardiologist over a span of five years needlessly performed cardiac catheterization and stent placement surgeries, an attorney for the plaintiffs said Friday.
The lawsuit also names the doctor's practice, John R. McLean, MD & Associates; Peninsula Regional Medical Center, where he performed procedures; and the hospital's governing agency, Peninsula Regional Health System Inc.
The two-count lawsuit filed last week in Wicomico County Circuit Court charges negligence of patients as individuals and of patients jointly with their spouses or estate representatives. Plaintiffs -- 13 patients scattered throughout the Delmarva Peninsula along with representatives of a patient's estate or their spouses -- seek damages in excess of the jurisdictional limit of $30,000 for each count together with all costs of the legal action, the lawsuit reads.
"The medical records evidence a pattern of negligent behavior," according to the lawsuit filed last week by E. Dale Adkins III and four other attorneys representing 24 plaintiffs including patients or their spouses. "Dr. McLean dramatically overstated findings from cardiac stress tests and diagnostic imaging and, based upon these findings, convinced people to undergo heart surgeries they did not need."
In March 2007, PRMC accused the then 55-year-old cardiology veteran of 20 years of conducting 25 unnecessary heart stent procedures, saying that alternative and less costly methods to treat blood clots could have been used. A federal investigation into McLean was under way in conjunction with the U.S. Department of Health and Human Services that runs Medicare.
"Dr. McLean had misread and misinterpreted his or her imaging studies and other diagnostic data," the lawsuit alleges the hospital said.
In December 2006, McLean voluntarily forfeited his catheterization laboratory credentials, which prevented him from using the key procedure to diagnose coronary artery disease. At the time, he cited a recently diagnosed vision problem as a factor that could have led to the controversy.
While McLean has said he is now retired, his medical license is in an "active status" with an expiration date of Sept. 30, 2009, according to the Maryland Board of Physicians.
The state physician watch organization took no disciplinary action against McLean, said Karen Wulff, a board policy analyst, adding that fear that a physician could do patient harm would be the condition by which the group would attempt to suspend a doctor's license.
In a separate case in Wicomico County, Corentha Savage of Fruitland in February filed a medical malpractice lawsuit against McLean that is scheduled for a civil jury trial in mid-2009.
Roger Follebout, a spokesman at PRMC, was not available to comment about the civil lawsuit case.
One claimant, Harry Baublitz of Delmar, died last year. He underwent a cardiac catheterization Jan. 20, 2006.
Another patient underwent the procedure twice in 13 days: Joseph Croce of Bridgeville, who received cardiac catheterization Sept. 20, 2005, and Oct. 3, 2005. At least two claimants underwent the ordeal three times: Frank Merrill of Greenbackville underwent the procedure July 25, 2003, Sept. 9, 2005 and June 26, 2006, the lawsuit states; for Donald Milligan of Seaford, procedures were June 15, 2004, Jan. 5 2006, and Dec. 4 2006, according to the document.
"Prior to each of these catheterizations, Dr. McLean convinced each claimant that he or she needed to undergo catheterization and have stents inserted into his or hear arteries because significant blockages were affecting his or her cardiac health," the lawsuit reads.
Plaintiffs also accuses nurses and technicians who assisted McLean in the PRMC cardiac catheterization laboratory of being aware of the alleged wrongdoing "and failed to prevent or report his actions."
Meanwhile, in a separate case in Wicomico County, Corentha Savage of Fruitland in February filed a medical malpractice lawsuit against McLean that is scheduled for a civil jury trial in mid-2009.
dgates@dmg.gannett.com
410-845-4641
Doctors hurt doctors, too
The author's quest to find out what went wrong with a "routine' needle biopsy was met by a stony wall of silence.
Jul 4, 2008
By: Janice M. Scully, MD
Medical Economics
As I write this, it's been almost three-and-a-half years since my medical procedure, and I'm still haunted by it.
Physically, I've recovered as completely as possible, thanks to the doctors who treated me afterward. But it's the lingering emotional injury that still wakes me up at night―and this I owe to my profession, as well. Indeed, doctors can be miraculous healers, but they can also cause needless, avoidable suffering.
One morning in February 2005, my husband, Bart, and I drove to the hospital where we'd been medical interns 20 years before. At age 52, I'd discovered a hard mass the size of a fist in my abdomen. As we drove, I imagined chemotherapy and premature death.
At the hospital, I was seen by my internist, then underwent a CT scan and was scheduled for a biopsy of what was most likely lymphoma. At the time, I was worried about the cancer, not the abdominal needle biopsy.
Every day, physicians perform thousands of diagnostic needle biopsies on patients suspected of having cancer. I assumed there was nothing to worry about. And because my platelet count was normal, any bleeding from the biopsy site was almost certain to stop on its own, according to an article by an interventional radiologist that I'd read recently.
In the minutes before he began, the radiologist who'd be performing the procedure explained what would happen. To reach what were suspected to be abnormal lymph nodes, he'd place a needle through the skin of my abdomen, while being directed by a CT scan. The small piece of tissue he'd remove would be analyzed, and that analysis would guide the course of my treatment. Complications―mostly bleeding―were rare, he said. Except for mild sedation, I'd be given no medications or blood products. In all likelihood, I'd be heading home in several hours.
I signed the consent, thinking that I'd be able to see my boys get off the school bus later that day.
I experience the worst pain of my life
After receiving mild sedation, I underwent the procedure. Minutes later, I awakened, while Bart sat in the waiting room.
The radiologist came to check on me. There had been bleeding from the biopsy needle deep in my abdomen, he informed me. To staunch it, he'd injected D-Stat. In his pre-surgical talk, he'd never mentioned D-Stat to me, nor did I know much about it.
Eventually, I learned that D-Stat is liquid thrombin, a protein extracted from pig's blood that serves as a powerful clotting agent. Typically, it's used to stop bleeding from open wounds of the kind seen during surgery. It's also used to stop any oozing blood that may occur in the arm or groin after cardiac catheterization. In my case, instead of waiting for the bleeding to stop on its own, as it might well have given my normal platelet count, the radiologist had immediately turned to D-Stat. In so doing, he'd turned my low-risk procedure into a high-risk one.
Soon, I began experiencing the worst pain of my life. In a panic, I remember trying to climb from the stretcher. In my chart for that day, the radiology nurse recorded this note, a half hour after the injection: "Patient writhing in 5/5 pain." I was also hypertensive and tachycardic, both consistent with severe pain.
It was only much later that I was able to deduce―through research and by examining my own records―what had happened. The radiologist had inadvertently injected the potent blood-clotting agent into an artery, thereby halting the blood flow to six feet of my small intestine and causing me sudden, excruciating pain. No one knew this at the time, including the radiologist, who failed to appreciate the causal link between his coagulant injection and my sudden severe pain. Instead, he attributed my postop problem to simple peritoneal irritation. I was given morphine and wheeled to the floor to recover. The expectation was that I'd be going home in several hours.
By the afternoon, neither my internist nor my oncologist knew that I'd been injected with D-Stat. Certainly, the progress notes never mentioned it. My husband knew, however, and he suspected that it might be the root of my problem. "Could it have been the D-Stat?" he asked the technician later that day.
"No, we use it all the time," the technician responded.
But my pain continued. And despite the morphine drip that had been ordered, I had more pain and vomiting the next day.
With every hour that passed under the radiologist's care, my husband became more perplexed and more afraid. Finally, he asked for a surgical consult.
A full two days after my needle biopsy procedure, it was discovered during exploratory surgery that I had an infarcted bowel. The surgeon resected six feet of my small intestine, which the pathologist's report later described as "ischemic, gangrenous but structurally normal."
I recovered in the hospital for a week, during which I remained on morphine and hyperalimentation. The good news was that my talented surgeon had saved me from a colostomy. The bad news was that there was no adequate biopsy material left.
Plaintiffs' attorneys reject the case
Why am I writing about this incident three-and-a-half years later? Why don't I just forget about it?
For one, it was terrifying to find myself lying night and day in a morphine fog. During this surreal time in the hospital, I fantasized that I was in a third-world country.
But I'm compelled to recall this incident for another, equally disturbing reason: Saying he didn't understand what had happened, the radiologist assumed no responsibility and offered no apology. As for my surgeon, he wrote in my discharge summary that Ihad a dead bowel, but he never ventured a guess as to its etiology. The oncologist who was covering for my regular one refused to talk about it.
Try as I might, my questions prompted vague responses. Someone, I forget who, even quipped that bad things always seemed to happen to doctor-patients. Did that mean I was somehow at fault?
When I returned home, I wrote a series of letters. One, to the chief of radiology, elicited this response: "I'm sorry you weren't happy with your care." Pending an interdepartmental investigation, assuming he even thought one necessary, he couldn't discuss details of my case. Through a doctor friend, I learned that following my injury, the hospital's radiology department no longer used D-Stat. At least some good has come of my ordeal, I thought at the time.
But further comfort was hard to come by. The hospital's CEO, a former professor from my internship, met with my husband and me and promised a formal explanation. I deserved one, he said. But I never got a formal explanation.
Frustrated, I consulted plaintiffs' attorneys. All of their consulting radiologists said that the radiologist who'd performed the needle biopsy on me had acted within the acceptable standard of care, including his use of D-Stat. The small-bowel infarction that had resulted, though unfortunate, didn't negate this. And since I wasn't permanently disabled, and my status as a physician might make juries less than sympathetic to me, I couldn't find an attorney to take my case.
Could these hired guns, the radiology consultants, be right? Nagged by this question, I contacted the academic radiologist who'd written the review article on needle biopsies. What, I asked, are the guidelines for the use of D-Stat during abdominal needle biopsy? His reply surprised me, given what I'd been told: "There are none," he said. "I know no one who uses it."
How, then, could the use of D-Stat be standard if a leading authority on needle biopsies says no one uses it?
I explored further, asking an interventional radiologist at an academic institution in North Carolina for his thoughts on the subject. His hospital didn't use D-Stat during abdominal needle biopsies either, he informed me.
All doctors will be patients someday
I was convinced: Injecting thrombin directly into an abdomen through a needle with blood emerging from it was a bad idea. Competent doctors didn't do it, it seemed clear. And the drug label itself confirmed the danger: "Injecting D-Stat into a blood vessel can cause injury and death."
I'd sought this simple explanation from my caregivers and others. What I'd encountered, instead, was the wall of silence that victims of medical error too often run up against. Forced to search for months for answers that could have been communicated to me in minutes, I felt humiliated.
My own medical mishap was terrible, both physically and emotionally. Now and again, physicians should remind themselves that some day they, too, will be patients.
AMA apologizes for past racism
By Liz F. Kay and David Kohn ,Sun Reporters
July 11, 2008
news
...admitting privileges at hospitals, financial support such as loans to open practices, leases for office space and even medical malpractice insurance, said Dr. Matthew Wynia, director of the AMA's Institute of Ethics. Continuing education was also difficult...
Sacramento Bee
Troubled drug program for doctors shuts down
By Aurelio Rojas - arojas@sacbee.com
Published 12:00 am PDT Saturday, July 5, 2008
Story appeared in MAIN NEWS section, Page A11
Dismissed as ineffective even by the state board that ran it, California's drug and alcohol diversion program for doctors has quietly ceased operation after 27 years.
On Tuesday, the program's final day, the plastic surgeon who operated on rapper Kanye West's mother just before she died pleaded not guilty in Solano County to drunken driving charges.
The surgeon, Jan Adams, was driving with a license that had been suspended because of a 2006 DUI conviction. He pleaded no contest in 2003 to another DUI charge.
When Donda West died last November, the California Medical Board was investigating Adams and considering revoking his medical license.
A Los Angeles County Coroner's Office probe did not fault surgical errors for West's death. But state Sen. Mark Ridley-Thomas said the case underscores why California needs an effective program to monitor doctors with drug and alcohol problems.
"(Adams) was in and out of the diversion program, which is an indication of its ineffectiveness – and the enforcement that, perhaps, should have taken place did not," said Ridley-Thomas.
The Los Angeles Democrat heads the panel that oversees licensing of health professionals in California. He is also the author of Senate Bill 1441, which would set uniform standards by January 2010 to monitor health professionals in treatment programs. The bill has cleared the Senate and is scheduled for a hearing in the Assembly Appropriations Committee this month.
The boards that license nurses, dentists, pharmacists, physical therapists, veterinarians, osteopaths and physician assistants set their own standards and contract with a private company, Maximus Inc., to run their programs.
The now-defunct program for physicians was operated by the California Medical Board, one of only three nationwide run by employees of a state medical licensing board.
While its demise leaves the state without a current alternative, Ridley-Thomas and other critics contend it largely failed to protect the public.
Of about 127,000 doctors licensed in California, experts estimate that up to 14,000 suffer from substance abuse during their career, according to Dr. Richard Fantozzi, a San Diego surgeon who is the medical board's president.
But only about 250 physicians were in the state program at any time, and more than 80 percent entered rather than have the board take enforcement action.
Experts say most doctors who seek treatment do so privately, without informing the medical board, because they fear losing their licenses.
And because of the state program's confidentiality, patients – including Donda West – had no way of knowing whether their doctor was in the program.
Candis Cohen, a spokeswoman for the medical board, said she could not comment on the board's probe of Adams because his case is pending.
But she conceded the board's program – which failed five audits – had not fulfilled its responsibility to protect the public.
"The board voted a year ago to allow its diversion program to sunset because it believed that, after failing repeated audits, the program was not consistent with its mission," Cohen said.
Because of the program's shortcomings, including inadequate staffing and resources, its funding was expected to end.
The final blow was a report, released a year ago by the California state auditor, finding that the medical board did not always require doctors to stop practicing immediately after testing positive for alcohol or drugs.
Participants agreed to a five-year monitoring period that included random testing for drugs and alcohol. But the audit found the program inconsistently monitored participants, with more than one in four urine tests not performed as randomly scheduled.
"Given the history of the problems with medical board's supervision – and oversight of the diversion program – it was high time we did something about it," Ridley-Thomas said.
The decision to end the program pitted the medical board against the 35,000-member California Medical Association, which argued the program could be strengthened.
"We believe in the underlying objective of the program, which was providing a pathway for physicians to get help," said Ned Wigglesworth, a spokesman for the association.
Julianne D'Angelo Fellmeth, who published an independent report in 2004 calling for major improvements in the program, said the medical board made the right decision.
"I would rather have no program than a fundamentally flawed program that does not work," said Fellmeth, administrative director of the Center for Public Interest Law based at the University of San Diego.
The CMA has not taken a position on SB 1441. The association is sponsoring a competing measure.
Assembly Bill 214 by Assemblyman Felipe Fuentes, D-Sylmar, would establish a program run by the Department of Public Health that would allow doctors to see patients while undergoing treatment.
If doctors voluntarily entered the program, their identities would not be disclosed to the public or medical board.
From the Los Angeles Times
Report raises red flag on infection control at Burbank's Providence hospital
An inspection last fall found 'serious deficiencies' that could threaten the federal funding for the medical center, which says it's aggressively addressing the issues.
By Rong-Gong Lin II
Los Angeles Times Staff Writer
July 13, 2008
Something was amiss last fall at Providence Saint Joseph Medical Center in Burbank.
On Nov. 27, one patient had a wound infection in her groin after an operation. Another patient, who was in the hospital because of a blocked bowel, had a drug-resistant form of staphylococcus bacteria detected in his urine.
Yet the hospital employee assigned to track and prevent the spread of infections and communicable diseases was unaware that the two patients were in the hospital, according to state inspectors working on behalf of the U.S. Centers for Medicare and Medicaid Services.
An inspection the next day revealed other problems. An anesthesiologist who should have been wearing sanitized scrubs was found wearing, in the operating room, a black fleece jacket that had visible stains and spots on the back. Visibly soiled cloth tape held up paper notices in a different operating room.
Citing such problems, the state inspectors said the hospital, the largest serving the San Fernando Valley, had "serious deficiencies," and federal officials said it did not meet Medicare's standards for infection control.
If it does not resolve those problems, the 431-bed nonprofit hospital could be stripped of federal funding.
It is common for complaints to be lodged against a hospital, which prompts an investigation by public health officials. Investigators determine whether the complaint is substantiated. If deficiencies are found, they usually do not rise to the level at which federal officials determine that the hospital fails to meet Medicare's standard.
"It has to be really egregious," said Chris Cahill, a retired hospital inspector for the California Department of Public Health.
Healthcare experts say that keeping a hospital clean is crucial for the prevention of hospital-acquired infections, and that reducing infections would save not only lives, but also money for the cash-strapped U.S. healthcare system.
In an interview last week, hospital officials said they did not believe the medical center had poor hygienic practices or an "infection problem." They pointed to its ranking on CalHospitalCompare.org, a website that tracks statewide hospital performance. The site ranks Providence Saint Joseph "above average" in "surgical infection prevention."
But the officials acknowledged opportunities for improvement and have launched new sanitation procedures and hired new staff.
"Everyone was mortified" at the inspectors' report, said Barry Wolfman, chief executive of the hospital. "We're not cavalier about it. We're not cocky about it."
"What we realized was our oversight wasn't at the level it needs to be," said Dr. Bernard Klein, the hospital's chief medical officer.
Steven Chickering, an associate regional administrator for the Centers for Medicare and Medicaid Services, said the hospital has been asked to demonstrate how it intends to resolve the deficiencies listed in the report.
The hospital has submitted a plan. If the federal agency accepts the report, the hospital will be subject to another inspection.
"Whatever they do, we want that correction to be sustained," Chickering said. "It's not just a one-time fix or Band-Aid approach."
The November inspection came a month after the hospital was cited by the Department of Public Health for failing to report a 2006 case in which a patient was diagnosed with so-called flesh-eating bacteria. The hospital was also cited for failing to implement its policy on monitoring, preventing and controlling hospital-acquired infections.
The 2006 incident involved actress Alicia Cole, who on Aug. 15 underwent routine surgery to remove noncancerous growths on her uterus. Ten days after the surgery, she was diagnosed with flesh-eating bacteria and had to undergo five surgeries to remove infected skin, according to a state citation. She is still recovering (see accompanying story). A friend's call to the Department of Public Health triggered the November 2007 inspection.
Among the findings of that inspection:
* On Nov. 27, 2007, the hospital's infection control practitioner was unaware of the two patients who had infections. She told inspectors at 2:40 p.m. that she was 24 hours behind schedule and had not reviewed the daily patient list. She also said "she was the only infection control officer and that she had to cover two hospitals."
* Inspectors found paper sheathed in plastic protectors inside the operating rooms; one of the sheet protectors on the main operating room door "was full of dust and dirt."
* Inspectors said hospital officials failed to provide evidence that they acted on an internal report that showed doctors had violated infection control practices in the operating room June 6, 2007.
That internal report said an epidemiology nurse saw a surgeon walk into the operating room wearing a white lab coat, while an anesthesiologist brought in a bag from the outside. Neither wore a hat, shoe covers or a mask. Such practices can track in germs.
Cahill found the problems listed in the report troubling.
"You don't allow anesthesiologists to wear their own fleece jackets in the operating room," he said. "We don't know where that jacket has been."
Anything brought from outside the operating room can carry in germs, said Cahill, who is supporting legislation in Sacramento that would require hospitals to report infection rates on certain procedures.
Wolfman said the hospital has taken aggressive steps in the last few months to respond to the report. Providence Saint Joseph has hired a second infection control practitioner and is looking to hire a third. Infection control practitioners are typically registered nurses.
The hospital has also instituted a policy stating that anyone wearing inappropriate attire in the operating room will be asked to leave. Officials say they welcome anonymous calls and e-mails from staff if they think violations are occurring.
"Could we have gotten a little lax? Perhaps," Wolfman said. "Do we need to remind people that this is a serious issue? Absolutely."
4-28-08
Medicare May Add to List of No-Pay Hospital Errors
4-26-08
The Junkie in the O.R.
Some doctors are addicted to the very drugs they prescribe. Find out why going under the knife could be more dangerous than you think
3-31-08
Monk | Hospital says doctors case bogus
3-21-08
Cares4Kayla. How the Louisiana Medical System Failed
Arrogance, Abuse, Fraud, and Medical Malpractice: How Some ...
Patients may or may not know a hospital is a teaching hospital; and the average patient does not know their physician will lie; we are not told the ...
3-18-08
About 1 in 200 Patients Suffered MRSA Infections After Facelift ...
ABC News
Facelift patients may be putting themselves at risk of a potentially deadly MRSA infection, new research suggests.
Study: Screening Hospital Patients Reduces MRSA Infections...NBC5.com, IL
Recently published results of that effort show a 70 percent reduction in MRSA infections at the facility. Another MRSA study published last week in ...
3-12-08
Cepheid Takes Hit on False MRSA Testing Claim
Seeking Alpha, NY
... been told by sources that this hospital used home brewed, home built tests -- not a standard test from Cepheid or competitor Becton Dickinson (BDX).
FBI Arrests Doctor Wanted in Australia
First New York, then Oregon, and now Australia. Dr. Jayant Patel is accused of leaving a bloody trail of mistakes as a surgeon, now resulting in manslaughter charges.
3-4-08
Germ warfare
Sun Publications Chicago, IL
Beth Reimer lost her 2-month-old daughter Madeline to an MRSA infection. Here Beth plays with her son Luke, Madeline's twin, in Madeline's bedroom. ...
3-2-08
Superbug defies antibiotics
Baltimore Sun, United States - 8 hours ago But what followed wasn't: a raging MRSA infection that cost
her both legs below the knee, a collapsed lung and four months in a hospital bed, ...
2-28-08
[CU-health-care-safety] The Morning Show: Tina Minasian: Addicted Doctors (video)
2-27-08
Stop That Patient! How Safe are America's Hospitals_
2-26-08
Doctors Who Do Harm
2-25-08
Why Wasn't He Stopped? Experts duped by pedophile endocrinologist
2-12-08
State investigates deaths at LI hospital
In July, a patient died from an infection due to a catheter. Another woman died after her neck was punctured, and a 19-year-old patient died from a ...
2-5-08
FAULTY FORECASTS
Baltimore Sun, United States - Feb 1, 2008
During 2003 and 2004, actuaries for Maryland's largest medical malpractice insurer, the Medical Mutual Liability
1-24-08
"Earlier this week, Brigham and Women's Hospital in Boston released a study showing cases of the deadly staph infection MRSA have tripled in the last decade."
Red Sox Coach Nearly Loses Leg To Staph Infection
LA Hospital Sued for Obscene Case of Patient Dumping
InjuryBoard.com, FL - Jan 18, 2008
The lawsuit, filed in Superior Court, charges the hospital did not investigate Olvera’s mental illness and failed to treat his urinary tract infection then ...
1-13-08
Did CDC make Andrew Speaker a test case?
Atlanta Journal Constitution, USA
Centers for Disease Control and Prevention Director Julie Gerberding alerted the public in May that a man with drug-resistant tuberculosis had traveled on ...
Clear results, disputed method
Baltimore Sun, United States -
... reported in the New England Journal of Medicine in 2006, a major step in efforts to reduce the estimated 90000 deaths from hospital infections each year ...
1-11-08
THE INFORMED PATIENT
By LAURA LANDRO
Learning to Ask
Tough Questions
Of Your Surgeon
While many Web savvy patients today can ask a doctor about minute details of their circulatory system or cancer treatment, when it comes to asking the really tough, personal questions, they often clam up. Even when going under the knife, patients are often too intimidated to ask how qualified a surgeon is, or what safety procedures are in place.
But as complications and errors dog some surgical procedures, experts say it is increasingly crucial for patients to vet their surgeons and take an active role in preventing mistakes.
To help patients be more pro-active, health-care groups, hospitals and medical specialty societies are offering new resources, including Web sites, books and checklists of questions to ask. The aim is to help patients select qualified surgeons, prepare for operations, and overcome the fear that often inhibits them from asking tough questions.
These new efforts are spurred in part by the sharp rise in surgeries performed in outpatient facilities; including doctor's offices and surgical centers, where patients aren't guaranteed the same access to care as in a hospital should something go wrong. A rash of recent news has highlighted the risks, such as the death of rap mogul Kanye West's mother after an office cosmetic procedure by a surgeon who was facing disciplinary action at the state medical board and two malpractice suits that ended in significant payouts.
Since patients can't prevent mishaps once they are under anesthesia, it is all the more important to question surgeons beforehand. "Patients should feel free to ask their surgeon anything they want answered about the operation or the surgeon's competency to perform it," says Thomas Russell, a surgeon and executive director of the American College of Surgeons. "There are no questions that should be off the table."
In a new book to be published this month, "I Need an Operation...Now What? A Patient's Guide to a Safe and Successful Outcome," Dr. Russell provides patients with lists of questions for surgeons, including their success rates, how many operations they perform in a year, and whether they have any health issues of their own that would interfere with their ability to do the procedure. While he suggests using a respectful and nonconfrontational tone, he also urges patients to "size up" the surgeon's communication skills -- and avoid those who are unresponsive, distracted or rushed.
Ronda Collier, a 43-year-old Ann Arbor, Mich., marketing professional, consulted several surgeons prior to having brain surgery a few years ago, but she recalls being too worried about seeming offensive to ask whether a doctor had a good safety record or used recreational drugs or alcohol. With a checklist such as that devised by Dr. Russell, "You can simply say I have this list of questions recommended to me and I'm just going down the list," she says. "It's not a personal attack."
Consumer Guides
Most major hospitals around the country have added to their Web sites checklists such as a 2005 brochure prepared by the federal Agency for Healthcare Research and Quality, "Having Surgery? What You Need to Know." And state medical boards have added consumer guides, such as the Massachusetts Medical Board's guide to asking questions during office-based procedures.
But by far the most useful information comes from medical specialty groups and nonprofit disease advocacy organizations that offer tips for specific surgeries. SpineUniverse.com, which is affiliated with spine-related medical societies, offers a list of questions specific to back surgery, while breastcancer.org provides a list of questions to ask the doctor before making decisions about mastectomies and lumpectomies.
The American Society for Dermatologic Surgery recently launched a patient-safety campaign urging consumers to check a practitioner's qualifications and credentials before undergoing any cosmetic surgery procedure, offering up some gruesome pictures on its Web site (asds.net) of complications that resulted from botched lasers, high-tech light devices and chemical peels.
And the American Board of Medical Specialties, whose 24 member boards certify about 85% of U.S. physicians, recently began airing a televised public-service announcement about the importance of board certification, a process that requires doctors to take continuing medical-education courses and periodic exams to demonstrate competency. Its abms.org Web site allows patients to search by name and specialty to verify a physician's certification. Consumers can also use state medical boards' Web sites to see whether a surgeon's license is current and whether there are any disciplinary actions pending; for a $9 fee, the Federation of State Medical Boards (www.fsmb.org) will also run a search.
To be sure, most of the estimated 40 million surgical procedures that Americans undergo every year are safe, and quality groups such as the Joint Commission, which accredits hospitals and other health-care providers, have in recent years pushed the adoption of new safety measures, such as the use of pre-surgery antibiotics to prevent infections, and post-surgical monitoring to prevent strokes or blood clots.
Resisting Change
Yet many of those safety measures aren't being universally followed, in part because of the frenetic pace of many hospitals but also because hospitals haven't done enough to improve the processes of care. Moreover, surgeons are often resistant to changes in the way they do things -- such as stopping a surgical procedure to do a safety check, says Peter Angood, a surgeon who is vice president and chief patient safety officer of the Joint Commission.
Though still infrequent, wrong-site surgeries -- a term that includes the wrong procedure, wrong site or wrong person -- continue to bedevil safety experts. The Joint Commission in 2004 issued a protocol for all hospitals that includes a final safety check and requires the marking of the procedure site with an indelible marker. But the number of reported cases of wrong-site surgery have actually increased, at a rate of about five to eight new cases per month -- for a total of nearly 550 since 1996.
Preventing Mistakes
A study of near-misses and wrong-site surgeries in Pennsylvania showed that correct information from patients or families was often key to preventing a mistake; Dr. Angood urges patients to participate in marking the site and ask whether surgeons are following the wrong-site prevention steps. The Joint Commission Web site (jointcommission.org) has more information on the wrong-site protocol; consumers can download a brochure, "Help Avoid Mistakes in Your Surgery" and check the safety record of the facility at qualitycheck.org.
Aside from complications and errors during surgery, patients should ask about issues that may affect recovery after an operation, and what types of post-operative complications may occur. Dr. Russell of the American College of Surgeons advises patients to speak up about any concerns such as a wound that doesn't heal or pain that isn't controlled, and includes a list of post-operative complications to watch out for such as swelling in the legs that could signal a blood clot. In addition to his $19.95 book -- proceeds will be used for safety and education research -- the college offers free consumer information about what to expect from a number of different surgeries on its www.facs.org Web site.
Email: informedpatient@wsj.com
12-31-07
A Lifesaving Checklist
Op-Ed Contributor
By ATUL GAWANDE
Published: December 30, 2007
Boston
IN Bethesda, Md., in a squat building off a suburban parkway, sits a small federal agency called the Office for Human Research Protections. Its aim is to protect people. But lately you have to wonder. Consider this recent case.
A year ago, researchers at Johns Hopkins University published the results of a program that instituted in nearly every intensive care unit in Michigan a simple five-step checklist designed to prevent certain hospital infections. It reminds doctors to make sure, for example, that before putting large intravenous lines into patients, they actually wash their hands and don a sterile gown and gloves.
The results were stunning. Within three months, the rate of bloodstream infections from these I.V. lines fell by two-thirds. The average I.C.U. cut its infection rate from 4 percent to zero. Over 18 months, the program saved more than 1,500 lives and nearly $200 million.
Yet this past month, the Office for Human Research Protections shut the program down. The agency issued notice to the researchers and the Michigan Health and Hospital Association that, by introducing a checklist and tracking the results without written, informed consent from each patient and health-care provider, they had violated scientific ethics regulations. Johns Hopkins had to halt not only the program in Michigan but also its plans to extend it to hospitals in New Jersey and Rhode Island.
The government’s decision was bizarre and dangerous. But there was a certain blinkered logic to it, which went like this: A checklist is an alteration in medical care no less than an experimental drug is. Studying an experimental drug in people without federal monitoring and explicit written permission from each patient is unethical and illegal. Therefore it is no less unethical and illegal to do the same with a checklist. Indeed, a checklist may require even more stringent oversight, the administration ruled, because the data gathered in testing it could put not only the patients but also the doctors at risk — by exposing how poorly some of them follow basic infection-prevention procedures.
The need for safeguards in medical experimentation has been evident since before the Nazi physician trials at Nuremberg. Testing a checklist for infection prevention, however, is not the same as testing an experimental drug — and neither are like-minded efforts now under way to reduce pneumonia in hospitals, improve the consistency of stroke and heart attack treatment and increase flu vaccination rates. Such organizational research work, new to medicine, aims to cement minimum standards and ensure they are followed, not to discover new therapies. This work is different from drug testing not merely because it poses lower risks, but because a failure to carry it out poses a vastly greater risk to people’s lives.
A large body of evidence gathered in recent years has revealed a profound failure by health-care professionals to follow basic steps proven to stop infection and other major complications. We now know that hundreds of thousands of Americans suffer serious complications or die as a result. It’s not for lack of effort. People in health care work long, hard hours. They are struggling, however, to provide increasingly complex care in the absence of effective systematization.
Excellent clinical care is no longer possible without doctors and nurses routinely using checklists and other organizational strategies and studying their results. There need to be as few barriers to such efforts as possible. Instead, the endeavor itself is treated as the danger.
If the government’s ruling were applied more widely, whole swaths of critical work to ensure safe and effective care would either halt or shrink: efforts by the Centers for Disease Control and Prevention to examine responses to outbreaks of infectious disease; the military’s program to track the care of wounded soldiers; the Five Million Lives campaign, by the nonprofit Institute for Healthcare Improvement, to reduce avoidable complications in 3,700 hospitals nationwide.
I work with the World Health Organization on a new effort to introduce surgical safety checklists worldwide. It aims to ensure that a dozen basic safety steps are actually followed in operating rooms here and abroad — that the operating team gives an antibiotic before making an incision, for example, and reviews how much blood loss to prepare for. A critical component of the program involves tracking successes and failures and learning from them. If each of the hundreds of hospitals we’re trying to draw into the program were required to obtain permissions for this, even just from research regulators, few could join.
Scientific research regulations had previously exempted efforts to improve medical quality and public health — because they hadn’t been scientific. Now that the work is becoming more systematic (and effective), the authorities have stepped in. And they’re in danger of putting ethics bureaucracy in the way of actual ethical medical care. The agency should allow this research to continue unencumbered. If it won’t, then Congress will have to.
Atul Gawande, a surgeon at Brigham and Women’s Hospital in Boston and a New Yorker staff writer, is the author of “Better.”
To write your US representative: http://www.house.gov/writerep/
To contact your US senator: http://www.senate.gov/general/contact_information/senators_cfm.cfm
Office for Human Research Protections correspondence regarding the infection checklist program:
http://www.hhs.gov/ohrp/detrm_letrs/YR07/jul07d.pdf
http://www.hhs.gov/ohrp/detrm_letrs/YR07/nov07c.pdf
12-30-07
St. Paul Pioneer Press
Hectic shifts have nurses worried
Nurses and patients alike say in a survey that low staffing jeopardizes quality care in Minnesota. The nurses' union is proposing legislation to address workloads.
BY SUZANNE SOBOTKA
Pioneer Press
Marcy McCracken, a pediatric nurse at Children's Hospital
in St. Paul, works with 3-year-old Jenna Molin and her mother,
Stephanie. Jenna, whose family lives in White Bear Township,
had her tonsils and adenoids removed.
(SCOTT TAKUSHI, Pioneer Press)
Marcy McCracken, a pediatric nurse at Children's Hospital in St. Paul, works with 3-year-old Jenna Molin and her mother, Stephanie. Jenna, whose family lives in White Bear Township, had her tonsils and adenoids removed. (SCOTT TAKUSHI, Pioneer Press)
Nurse Marcy McCracken had finished giving Jenna Molin an IV dose of steroids when the 3-year-old shot a familiar, pained look to her mother, Stephanie.
"She's about to get sick," her mother said.
On cue, Jenna threw up on herself and her bed. McCracken quickly hit a call bell, and two other nurses left their patients and rushed in.
They carried fresh bedding, pajamas and laundry bags. They changed the sheets, and dressed and comforted Jenna.
"This is why nurses need four hands," McCracken said as she cleaned Jenna's IV line with another nurse's help. "Six would be better."
Statewide, nurses worry they are being spread too thin.
A recent Minnesota Nurses Association survey of 400 nurses and 400 patients found both groups are concerned. More than 90 percent of respondents said they believe low staffing levels hurt patient safety.
Even at Children's Hospital in St. Paul, which was recently praised for its staffing in a U.S. News & World Report analysis, a typical shift for McCracken and other registered nurses can be hectic.
McCracken was having "a steady, good day" before checking on Jenna, who earlier in the morning had her tonsils and adenoids removed. McCracken soon had the girl from White Bear Township cleaned and calmed.
But there was no time for a break. Across the unit, McCracken met a new patient with a respiratory problem. She took vital signs, read the patient's chart and called for a social worker to inform the parents about medical assistance and insurance programs.
Next, it was back down the hall to check on Miranda Sangrene, 13, a diabetic vomiting blood. McCracken brought her lunch and then returned with a dose of insulin and another fruit cup.
McCracken quizzed Miranda as she prepared to inject her insulin.
"Your macaroni and cheese and fruit cup have 60 grams of carbs, so how much insulin would you need?" she asked, repeating the answer twice before injecting the medicine.
McCracken believes her role is to educate patients while caring for them.
"We really want to encourage our diabetes patients to be as independent as possible," she said.
Next, it was back to Jenna to give her a dose of anti-nausea medication before cycling through the rooms again.
McCracken said she felt fortunate. Her patient load was manageable. If any patients become very sick, her supervisor usually gives her the time to focus on them and passes other patients on to less busy nurses.
She doesn't think that's the case at other hospitals and for her Minnesota nursing peers, and the survey suggests she might be right. Of the nurses surveyed, 90 percent felt unable to adequately provide emotional support to patients and their families. And 85 percent felt they couldn't watch over patients in critical condition as closely as they should.
The burden of caring for the sickest patients has been a primary concern for the Minnesota Nurses Association, said Jan Rabbers, a spokeswoman for the union. The survey results suggest that shifts need to be reorganized so nurses can focus on these patients, she said.
Rabbers believes this kind of reform could save lives and reduce mistakes. The survey was motivated in part by a 1999 U.S. Institute of Medicine report that attributes as many as 98,000 deaths annually to medical errors.
Fatigue is a significant concern for nurses. McCracken walks at least two to five miles during her typical 12-hour shifts. Many nurses end up with 16-hour shifts, said Elaina Hane, a pediatric intensive care nurse at Children's and a chair of the nurses union.
Children's Hospital has taken steps to stop medical errors that could be blamed on fatigue. Hospital policy allows nurses to report fatigue without penalty or loss of pay and allows them to admit and learn from mistakes.
Most nurses make a medical error at some point, said Ginger Malone, chief nursing officer for Children's Hospitals and Clinics of Minnesota. "We're trying to establish a culture in which nurses are not blamed for these errors."
Hane gives Children's credit for its upcoming renovation, which will bring patient supplies closer to the bedside.
"We have to run all over the unit to get supplies," she said.
However, she criticized the hospital's cutbacks on nursing assistants and unit secretaries.
"Without them here, nurses have to do the work they do," she said. "It's not difficult, but it's just one more thing to do in addition to caring for patients."
The nurses union and its members are proposing state legislation to increase the number of nurses available to work with patients. Rabbers said similar legislation is being considered in California, Illinois, Washington and Oregon, but the Minnesota proposal is unique because it would incorporate how sick the patients are in determining nursing workloads.
McCracken hopes nurses will have a strong say in the solutions to staffing shortfalls.
"Nurses know best what they can handle and what they can do to give quality care," she said.
Suzanne Sobotka can be reached at ssobotka@pioneerpress.com.
12-2-07
Press Release: Doctors sue Texas Medical Board for Misconduct
AAPS
Association of American Physicans and Surgeons
1601 N. Tucson Blvd. Suite 9
Tucson, AZ 85716-3450
Phone: (800) 635-1196
DOCTORS SUE TEXAS MEDICAL BOARD FOR MISCONDUCT - Cites institutional culture of retaliation & intimidation
The entire Texas Medical Board (TMB) and its officials have been named in a lawsuit filed by the Association of American Physicians and Surgeons (AAPS). The complaint, filed this week in District Court in Texarkana, accuses the board of misconduct while performing its official duties, specifically:
- Manipulation of anonymous complaints;
- Conflicts of interest;
- Violation of due process;
- Breach of privacy; and
- Retaliation against those who speak out.
“The situation has reached the crisis point for patients and doctors,” said Jane M. Orient, M.D, Executive Director of AAPS. “Our members are too afraid of retaliation to sue the Board as individuals.”
The lawsuit specifically points out misconduct by Roberta Kalafut, the Board president. The law suit claims that Kalafut “arranged for her husband to file anonymous complaints again other physicians, including her competitors in Abilene…”
She then “…worked inside the TMB, with other defendants, to discipline doctors based on anonymous complaints filed by her physician husband.”
The lawsuit also charges that Kalafut and Donald Patrick, Executive Director, knew about the conflict of interest of Keith Miller while he was Chair of the Disciplinary Process Review Committee. Miller served as plaintiffs’ witness in at least 50 cases brought before the Board without disclosing that to the disciplined doctors or the public.
During a marathon 11-and-a-half hour legislative hearing about the Texas Medical Board on October 23, 2007, Kalafut and Patrick admitted under oath that they were aware of the conflicts of interest.
“It seems clear from the sworn testimony before the legislative committee that they knew about the problems and had done what they could to hide them,” said Dr. Orient.
The lawsuit demands that the Court put an immediate stop to abuses by the Board, and that previous disciplinary actions tainted by the Board’s violations be re-opened.
“Doctors in Texas should not be forced to practice in this atmosphere of fear and intimidation,” said Dr. Orient. “Complaints from our members have identified the TMB as probably the worst in the country. It’s bad for patients when their doctors are afraid that doing the right thing could result in licensure action.”
--------------------------------------------------------------------------------
COMPLAINT AVAILABLE: A copy of the complaint is available at www.aapsonline.org.
NOTE: AAPS is a non-profit, professional association of physicians in all specialties, dedicated since 1943 to protection of the patient-physician relationship. It accepts no corporate or government funding, and its board members and officers serve without compensation.
12-2-07
Malpractice insurer, Md. reach deal
Baltimore Sun, United States - Dec 14, 2007
Since then, nationally and in Maryland, the number of malpractice claims filed has been falling back. After peaking in 2003 and 2004, Med Mutual's payouts ...
12-2-07
As Medical Costs Soar, The Insured Face Huge Tab
AMA to lobby for the right to bill patients for amounts denied by Medicare.
RFF NEWS RELEASE
NEW STUDY: HOSPITALIZATIONS RELATED TO SUPERBUG INFECTIONS DOUBLE OVER SIX YEARS
Antibiotic Resistance Reaches Epidemic Proportions; Researchers Say
Infection Control Should Be “National Priority”
For Immediate Release: November 29, 2007
Contacts: Resources for the Future Office of Communications, 202-328-5026
Caroline Broder or Todd Kutyla, Burness Communications 301-652-1558
WASHINGTON – Hospitalizations related to methicillin-resistant Staphylococcus aureus (MRSA) infections more than doubled, from 127,000 to nearly 280,000, between 1999 and 2005, according to a new study in the December issue of the journal Emerging Infectious Diseases. During that same period, hospitalizations of patients with general staph infections increased 62 percent across the country.
Staph, or Staphylococcus aureus, are a kind of bacteria that attack wounds and cause life-threatening infections, such as blood poisoning and pneumonia. Methicillin-resistant S. aureus (MRSA) are “superbugs” that have evolved resistance to most commonly used antibiotics, so they are more difficult and expensive to treat.
The study, which is the first to examine the recent magnitude and trends related to staph and MRSA infections, found that such infections are now “endemic, and in some cases epidemic,” in many U.S. hospitals, long-term care facilities, and communities. Study researchers say that control of the infection should be made a “national priority.”
The study, conducted by researchers at Resources for the Future and the University of Florida, finds that the pattern of infection is changing. The researchers saw dramatic increases in the rate of minor skin and soft tissue infections caused by staph and MRSA that are commonly spread outside hospital walls. At the same time, there was no trend in the number of deaths from hospital-associated staph or MRSA infections.
“Taken together, these findings indicate a change in the ecology of the disease,” says senior study author Ramanan Laxminarayan, Ph.D., M.P.H., of Extending the Cure, a project of Resources for the Future. “Antibiotic-resistant infections are spreading more rapidly in the community while the epidemic of drug-resistant infections in hospitals continues unabated.”
In all likelihood, the researchers say, MRSA infections are spreading in both hospitals and communities, complicating efforts to prevent infections in hospital patients. Hospital-acquired infections from all causes result in an estimated 90,000 deaths per year, and are the sixth-leading cause of death nationally. They also increase patient suffering and the length of time patients spend in the hospital – in addition to direct health care costs, estimated to be more than $6 billion annually.
Antibiotic-resistant infections impose even greater costs. Several studies have estimated that antibiotic-resistant infections increase direct costs by 30 percent to 100 percent. MRSA-specific studies suggest that the additional cost of treating an antibiotic-resistant staph infection versus an antibiotic-sensitive infection range from a minimum of $3,000 to more than $35,000 per case. This suggests that such infections cost the health care system an extra $830 million to $9.7 billion in 2005, even without taking into account indirect costs related to patient pain, illness, and time spent in the hospital.
“At a national level, the rising tide of antibiotic resistance that we are seeing raises concerns about our ability to effectively treat serious bacterial infections,” says J. Glenn Morris, Jr., M.D., professor and director of the Emerging Pathogens Institute at the University of Florida and a renowned expert on hospital infections. “Research on antibiotic resistance, and on development of therapies to treat antibiotic-resistant infections, should clearly be a national priority.”
In addition, the researchers say that the rising incidence of MRSA will likely increase demand for vancomycin, a powerful antibiotic often used when other antibiotics fail. The emergence of infections that are resistant to vancomycin is already a serious problem in hospitals, the researchers contend. The MRSA epidemic is likely to make things worse.
The researchers offer several suggestions to address the spread of both staph and MRSA infections. These include national surveillance or reporting requirements for these infections, more research to explore the interaction between community-and hospital-associated infection, stepped-up efforts to control hospital infection, and increased investment in the development of a staph vaccine.
Funding for this research was provided by the Robert Wood Johnson Foundation’s Pioneer Portfolio, which supports innovative ideas that may lead to breakthroughs in the future of health and health care.
###
About Resources for the Future
RFF is a nonprofit and nonpartisan organization that conducts independent research - rooted primarily in economics and other social sciences - on environmental, energy, natural resources, and public health issues. RFF is headquartered in Washington, D.C., but its research scope comprises programs in nations around the world. Founded in 1952, RFF pioneered the application of economics as a tool to develop more effective policy for the use and conservation of natural resources. Its scholars employ social science methods to analyze critical issues concerning antibiotic and antimalarial resistance, pollution control, energy policy, land and water use, hazardous waste, climate change, and the environmental and health challenges of developing countries.
About the Robert Wood Johnson Foundation
The Robert Wood Johnson Foundation focuses on the pressing health and health care issues facing our country. As the nation's largest philanthropy devoted exclusively to improving the health and health care of all Americans, the Foundation works with a diverse group of organizations and individuals to identify solutions and achieve comprehensive, meaningful and timely change. The Foundation’s Pioneer Portfolio supports innovative ideas and projects that may trigger important breakthroughs in health and health care. Projects in the Pioneer Portfolio are future-oriented and look beyond conventional thinking to explore solutions at the cutting edge of health and health care.
For more than 35 years the Foundation has brought experience, commitment, and a rigorous, balanced approach to the problems that affect the health and health care of those it serves. When it comes to helping Americans lead healthier lives and get the care they need, the Foundation expects to make a difference in your lifetime. For more information, visit www.rwjf.org.
11-26-07
How To Protect Physician Whistleblower Patient Advocates from Retaliation, to Benefit Patients - a legal analysis regarding Summary Suspension, Retaliation, Peer Review and Remedies, by Dr. Gil Mileikowsky, MD and Bartholomew Lee, Attorney at Law.*
Correspondence is invited: blee@slksf.com. [V 2.1, 27 Aug 07] * Member of the California Bar, of counsel to Spiegel Liao & Kagay, San Francisco, California. Dr. Mileikowsky is a client of the firm. The views expressed herein are ours and not those of the firm, its partners or its counsel. We are grateful to Dr. Nick Yaqub, (MD, JD) also a client of the firm, for valuable insight and analysis but the views expressed herein are not necessarily his either. See: Yaqub v. Salinas Valley Memorial Healthcare System (2004) 122 Cal. App.4th 474, 18 Cal. Rptr.3d 780; Mileikowsky v. West Hills Hosp. Medical Center (2007) 154 Cal.App.4th 752, 64 Cal.Rptr.3d 888, review filed (Oct. 05, 2007).
Introduction -The Overriding Public Interest in Saving lives: More than half a million people have died in a recent three year period as a result of medical error and complications in the United States. The World Health Organization (WHO) and others say that American health care ranks low among the nations third-world care at twice the cost, in effect. The RAND Corporation finds: "all adults ...are at risk for receiving poor health care, no matter where they live; why, where and from whom they seek care; or what their race, gender or financial status is."
It is, however, unlikely that the situation will improve by itself. Physicians who try to diminish patient risk and improve patient care and safety are often targeted for retaliation. The integrity of the House of Medicine is thus at risk, as is health care itself. The following proposals to counter, limit and deter retaliation will decrease overall costs. It is a paradox of modern American medicine that patients don't get what is paid for, quality care. The Health Care Quality Improvement Act of 1986 and substituted state legislation has failed to protect patients and prejudices their safety.
The Problem: Patient Safety Advocacy Risks Immediate Professional Destruction: "A lie can travel halfway round the world while the truth is putting on its shoes," said Mark Twain. Physicians who speak out can suffer the irreversible defamation of a public report of accusation alone, in the context of hospital discipline of physicians. These physicians may or may not have done anything wrong, and may well have simply done too many things right for the comfort of some. Protecting physician patient-safety advocates from retaliatory discipline is essential to improve the quality of delivery of care. Physicians who advocate for patients' safety must be protected from institutional retaliation, for the sake of the patients as well as the physicians.
As Harvard Professor Alan Dershowitz stated: "Physicians who are entrusted with the care of their patients can see their professional careers destroyed if they dare to challenge a hospital's practices. When a 'whistleblowing' physician is retaliated against, it threatens not only the physician's livelihood, but the care of all patients. This ... affects every patient and potential patient in America."
The chilling effect on physicians resurrects the old Code of Silence that formerly frustrated so many meritorious medical malpractice cases.
Unfortunately for patients, the old proverb "the way to Hell is paved with good intentions" applies. This is so because the presumably good intentions behind laws regulating medical practice have been defeated by conflicting economic interests. According to extensive research by Harvard's Professor Lucian Leape, it is not in any hospital's best economic interest to reduce errors and complications He notes that there are no warrantees in medical care and he reports " perversely, under most forms of payment, healthcare professionals receive a premium for defective products, physicians and hospitals can bill for the additional services that are needed when patients are injured by their mistakes." Inasmuch as hospitals profit from high-cost, high-complication bad medicine they have every incentive to encourage it, making more than enough money to pay premiums for malpractice insurance, at most a nuisance.
Persistent bad medicine is encouraged all the more by retaliation against those who oppose it, especially because effective good faith peer review that reduces errors and complications would diminish hospital revenues. In the present environment, dollar signs trump patients' vital signs. "Retaliation" is wrongful in many ways, on many levels and on various legal grounds, including its violation of Equal Protection of the Laws and of Due Process of Law.
As one model of public protection by way of proscription of retaliation, the California Business and Professionals Code protects physicians against retaliation with respect to insurance companies, and medical groups. This does not yet apply to hospitals that suspend or revoke privileges of physicians who are not employees. It is both ironic and unjust that the members of the learned professions of medicine, who enjoy mere "privileges" at hospitals, have less protection as patient advocates than any employee including orderlies and night custodial staff, as valuable and necessary as their labors may be.
A summary suspension of a physician from practice in a hospital is just that: summary, without any process at all in which the physician can participate. A registered report of a summary suspension of a physician ends that physician's career. The physician is condemned before any hearing is even initiated. This is professional capital punishment before trial. Once a hospital reports a physician's summary suspension to a state medical board or agency, it creates an avalanche effect by mandatory reporting to the National Practitioners Data Bank, (NPDB). Other hospitals will then deny that physician's clinical privileges as well, followed by suspension of medical liability insurance coverage and preclusion of participation with medical insurance providers.
Moreover, there is no penalty for a false report and no private judicial redress available, unlike for example a private libel. Making the problem worse, there is no administrative remedy for a state Medical Board's continuing to post an accusation which that Board has itself found to be unfounded. The goal to be achieved, immediately lest it become meaningless, is "name-clearing" of the physician advocate, besmirched and tainted by suspension or worse. This is a matter of substantive and not procedural due process of law.
Unless a physician can prevent the professional libel of a public report of the summary suspension, other remedies for retaliation are for all practical purposes moot, too late and ineffective. "Substantive" due process in economic matters is much disfavored since about 1905. On the other hand, protection of many constitutional rights other than property rights amounts to substantive due process in disguise. The notion of a substantive right to protect one's good name is implemented by the procedure of a "name-clearing hearing."
It is well established in a leading California case that a professional has a liberty interest in his professional reputation (name) that is distinct and separate from property interest in his medical license. The California Supreme Court ruled with respect to the California Constitution: "It is clear that the due process clause of article I, section 7(a) is self-executing, and that even without any effectuating legislation, all branches of government are required to comply with its terms. Furthermore, it also is clear that, like many other constitutional provisions, this section supports an action, brought by a private plaintiff against a proper defendant, for declaratory relief or for injunction.... "
One's good name is a liberty interest and substantive interest, and the law protects liberty interests more than property interests. In this case, a professor of medicine at a University of California medical school and Chair of its Department of Radiology was investigated for alleged misappropriation of funds. At the conclusion of investigation the University announced that it initiated "appropriate personnel actions," but did not name any specific employee. The professor was then removed as the Chair, but remained tenured at the medical school and a staff physician at its medical center. The California Supreme Court held that "[a]lthough the department chairmanship was an at-will position, terminable without cause at the discretion of the chancellor of the ... campus (and hence plaintiff concedes that he had no due process property right to that position), it is well established that an at-will [public] employee's liberty interests are deprived when his discharge is accompanied by charges that might seriously damage his standing and associations in his community or impose[ ] on him a stigma or other disability that foreclose[s] his freedom to take advantage of other employment opportunities."
To establish the right to a name-clearing hearing a petitioner " ... must first establish that the due process clause applies by showing a protected liberty or property interest." A liberty interest is shown if "the accuracy of the charge is contested, there is some public disclosure of the charge, and it is made in connection with the [petitioner]." Thus the liberty interest a physician has in his or her good name justifies an immediate opportunity for at least a temporary restraining order, followed by injunctive relief, against at least registration or publication of a summary or otherwise unadjudicated suspension.
The Law Today Favors Bad Medicine: Once a hospital hearing to test a summary suspension commences, the administrative process controls the suspended physician. Due to the "doctrine of exhaustion of administrative remedies" no court will intervene to prevent administrative dissemination of the defamation of the report of the summary suspension, even though there has been no adverse finding or adjudication. "Exhaustion of administrative remedies" usually means exhaustion of physician resources, in litigation and its antecedents, especially inasmuch as the physician cannot (on interim suspension) practice medicine.
Furthermore, due to the abuse by hospitals of that doctrine, hospitals can prolong that administrative process with many delays, e.g., by an ostensibly favorable ruling of the hospital's appeal board granting yet another, new "hearing" to the still suspended physician. That is a most effective strategy, at worst malicious prosecution, at best "good intentions gone awry," to exhaust the physician as an adversary emotionally, financially and physically. Hence, the hospital wins by attrition before any litigation is even possible. In the end, the physician's "exhaustion of administrative remedies" may be futile. It all too often ends up with a final blow by the governing board of the hospital (even if members of that board may believe that this physician is innocent). This is so, because a ruling by the governing board in favor of the physician, would open the door to claims for monetary damages for the physician against the hospital. The board in its perceived fiduciary responsibility will wish to prevent such a financial loss.
The hospital simply must bury its mistake, and take advantage of the reluctance of judges to substitute judgment for medical professionals in staff matters.
Moreover, a physician who can get to court generally at most wins a remand to the administering hospital, for yet another round of hearings.
When it is understood that hospitals' attorneys drafted the amended federal Health Care Quality Improvement Act (HCQIA 1989), the insertion of a quasi-judicial immunity provision can also be explained. The effect if not the object was not so much protection of physician participants in good faith peer review; rather it was the perhaps unintended consequence of protection of hospitals that sponsor bad faith peer review. Hence, only very few injured physicians in the last 20 years have been able to get past the twin peaks of judicial deference to medical prosecutors and administrators and immunity for the complicit as well as the innocent.
As if this were not enough, the HCQIA also provides that a peer review body's failure to meet the conditions described in the law does not constitute failure to meet the applicable standards. In other words, failure to comply with this particular law is not a violation of this particular law. Such a caveat sacrifices the health care quality improvement spirit of the law by gutting the letter of the law. In effect, the hospitals' lawyers' lobbying has loaded the dice. The public cannot expect this process to be either fair or reasonable. An objective observer could join advocates in concluding that at this time, the "peer review" disciplinary hearing process is rigged to a point way beyond any "stacked deck" of cards. Even without malicious intent, physicians from the same hospital are frequently too close to the personalities to avoid bias one way or the other (unlike, for example, a jury of one's peers in court, who are strangers to the parties). Hospital administrators face economic incentives to maximize income, but not to minimize complications.
Ironically, bad physicians are rarely subject to such malicious prosecution. This is so because they are often significant income providers to the hospital and thus enjoy the protection of a hospital more concerned with revenues than patient well-being. This was the case in Redding, California for two heart doctors who did hundreds of sometimes fatal heart procedures, utterly unneeded, and full of risk. All monitoring and inspection by several agencies failed to detect this enormity. When hospital managements, closest to the problems, are compensated only in proportion to revenue growth, patient safety suffers. Often bad physicians, without the leverage of big revenue, simply agree to leave the hospital, provided the hospital does not report them to the state medical board, thereby minimizing its own exposures. They thus evade the "radar screen" of mandatory reporting.
The public is not protected. The reporting system tells of summary suspensions of even outstanding physicians without adjudications, but cannot report cover-ups.
Thus, the goals of the Health Care Quality Improvement Act are undercut by hospitals' economic conflicts of interest. Even motivated patients cannot get undistorted information about physicians. Policy-makers, law-makers, courts, legislative staffs, federal and state agencies, employers, unions, and experts responsible for drafting public healthcare law appear not to grasp Professor Leape's point. The healthcare costs explosion will continue to erode the quality of delivery of medical care in America as long as bad medicine is lucrative.
It is thus all the more important, as a counter-force, to provide effective protection for all physicians and healthcare providers who show that they care about patient safety by standing up for it. Advocacy for patient safety is to be encouraged, not punished. These health care professionals are "whistleblowers," a legal term that well describes them as the people who call attention to wrongdoing. They are to be protected from the often inevitable retaliation against them. That retaliation, usually beginning with a summary suspension, destroys them professionally and compromises patient care deeply. Such protection is in the best interest of patients, the economy, and ultimately it is to the benefit of the many excellent physicians and the "House of Medicine" itself.
Remedies Proposed: Although private redress can provide deterrents to retaliation, as discussed below, it is often too little, too late. An immediate resort to the judicial process of the ex-parte temporary restraining order to review a summary suspension would be more effective, followed by substantive litigation if need be. One model appears from administrative practice: in California, its Medical Board may summarily suspend a physician from all medical practice. The device is an Interim Order of Suspension (IOS). Such an order may, however, be challenged immediately in court, and a stay obtained. Inasmuch as a summary suspension by a hospital quickly results in equivalently draconian effects on a physician's practice, an equivalently swift and sure remedy is only fair.
An amendment to HCQIA or California's governing statute could provide for such an immediate resort to court upon summary suspension, without res judicata effect either way. Thus, statute could and should provide for a way for a summarily suspended physician to obtain the judicial redress of an immediate stay of the suspension, or at least any report to the medical board of it, and a stay of the medical board making any report of the suspension until after a final and adverse adjudication. This is the necessary procedural vehicle to prevent effective retaliation. The courts may be relied upon to deny such immediate relief to any physician who, by reason of impairment or otherwise, does present any danger to the public. The career-ending report of a summary suspension should not be the unreviewable decision of an adversary hospital, but rather follow only a neutral adjudication.
Further Proposed Statutory Amendments To Deter Hospital Retaliation: Two initial ways to protect physicians whistleblowers could harness existing means of redress, to facilitate immediate judicial relief as well as ultimate remedy. One is to deny wrongdoers a shield under Health Care Quality Improvement Act HCQIA. The second is to provide physician advocates a sword under the Civil Rights Act (1872).
1) The shield is removed by two amendments to the HCQIA: First: "Retaliation against a physician or other health-care provider for advocacy for health care quality improvement, including testimony, is not immune, under this Act or any state law, to private judicial redress by way of damages and injunctive relief, and attorneys' fees." Immunity is the doctrine that precludes private redress irrespective of wrongdoing; judges for example, enjoy civil immunity, although they can be prosecuted criminally, impeached, or disciplined. Physicians on peer review disciplinary panels enjoy civil immunity under the Health Care Quality Improvement Act (HCQIA). Secondly, inasmuch as defective peer review is the cause of so much harm and error, rethinking the immunity that derives from the mere presence of some peer review process is appropriate. HCQIA, 42 U.S.C. 11112(b)(3) provides the loophole that a retaliation-minded hospital can work a way through: "A professional review body's failure to meet the [peer review] conditions described in this subsection shall not, in itself, constitute failure to meet the standards of subsection (a)(3) of this section." Meeting those standards provides the wide immunity of HCQIA. The way to fix the problem this section causes is to amend this section thus: "A professional review body's failure to meet the conditions described in this subsection shall, in itself, constitute failure to meet the standards of subsection (a)(3) of this section." That is, take out the "not."
A hospital tempted to run a kangaroo court should not get to take advantage of its own wrongdoing. Each and every National Practitioner Data Bank report that results from a peer review body that fails to meet the specified conditions should not be privileged, should be enjoin-able in equity in state or federal court, and should give rise to a damages action including attorneys' fees. A kangaroo court "peer review" should not enjoy immunity from any damages causes of action including antitrust treble damages upon a showing of violation and impact.
All of this may well drive some physicians out of the business of judging other physicians, as do many other factors. The hospitals have pretty much taken that over anyway, once the process gets out of departmental whitewashes and into "discipline." If it is going to be a legal rather than a medical process, it must be fair, afford due process of law and implement adequate legal remedies for those who are injured by wrongdoing, including attorneys' fees for intentionally or negligently injured or wronged physicians.
2) The sword is provided by an amendment to the Civil Rights Act, 1983: "Retaliation, against a physician or other health-care provider for advocacy, including testimony, for health care quality improvement or patient safety, by or in any institution that is governed by HCQIA or related state law, or funded directly or indirectly by the United States, is a denial of due process of law and equal protection of the laws, for which private judicial redress by way of monetary damages for all injury, and injunctive relief, and attorneys' fees, shall be available under this Act, notwithstanding any post-deprivation administrative remedy or any requirement of exhaustion of remedies." This amendment provides judicial redress for deprivation of the substantive right to speak out, testify and act in the pubic interest free of retaliation. This is the Right to Petition for Redress of Grievances guaranteed by the First Amendment.
3) In California, amendment to the Unruh Civil Rights Act, Civil Code 51, can also provide a sword: "Retaliation by any person, organization, healthcare institution or the like, that is governed California law such as the Business and Professions Code, the Health and Safety Code, and the like, or funded in whole or in part, directly or indirectly, by the State of California or any of its subdivisions, districts or the like, against a physician-advocate or any other health care professional for advocacy, including testimony, for health care quality improvement or patient safety, is a denial of equality before the law and due process of law, as they are guaranteed by the Constitution of this state, for which private judicial redress by way of monetary damages for all injury, and injunctive relief, and attorneys' fees, shall be available under this Act, notwithstanding any post-deprivation administrative remedy or any requirement of exhaustion of remedies and without application of any provision of law respecting strategic litigation against public participation." This amendment also provides judicial redress, under California law, for deprivation of the substantive right to speak out, testify and act in the pubic interest free of retaliation.
4) Another avenue may effect better health care by means of deterrence. Enforcement of the criminal law has as one of its primary purposes deterrence, but it fails for it apparent near- random impact, compromised by implicit political considerations, delay, and leniency for the white-collared. Private enforcement, on the other hand, is distributed widely, not centralized, promoted by private incentives such as treble damages, and highly effective. An example is the treble damage action of the Clayton Antitrust Act for violations of the earlier Sherman Antitrust Act. Inasmuch as so much of the revenue of the hospital industry comes from the federal government (e.g., Medicare, Medicaid), systemic improvements in such federally funded care will also benefit all others receiving care from the industry. An amendment to the False Claims Act could provide private incentives to litigation for large amounts of money. This in turn could effect the deterrence needed to protect physician-advocates (and others) from retaliation. Such an amendment could provide: "Violations of statutory or regulatory conditions of participation in federally funded programs, by a recipient of direct or indirect federal funding, coupled with certification of compliance therewith, shall be fraud on the United States notwithstanding apparent compliance with any other regulation, or accreditation." Use of the False Claims Act with respect to Medicare Conditions of Participation (COP) requiring good faith, as opposed to retaliatory, "peer review" may provide some deterrence to bad faith peer review, almost always retaliatory, or anti-competitive.
It may be noted that Medicare affects only people over 65 years of age. In practical terms, the effect of enforcement of law such that institutions must enable only good faith peer review because of Medicare constraints, protects all by protecting the favored. In other words, what the economists call "positive externalities" make for equitable results assuming effective enforcement of Medicare Conditions of Participation.
Denial of good faith peer review to the treatment of younger patients, at least as effective as that as required by law for treatment of older patients, is a denial of equal protection of the laws. To obviate this inequality, acceptance of any federal funding for any aspect of hospital care should by legislation be subject to explicit acceptance of Medicare-equivalent COP with respect to peer review. Violation of such extended COP should be subject to FCA enforcement. Patients are best equally protected by physician peer review only when the incentives to do it right are equal for younger and older patients. Moreover, all hospital care as affected by peer review is protected and promoted by "official proceedings." These proceedings cannot equitably be different for patients simply by reason of the patients' age. Any such invidious difference should be actionable under the Civil Rights Act.
Questions of jurisdictional standing may arise, but FCA claims for relief could be accompanied by Civil Rights Act Equal Protection claims for relief as well.
For the False Claims Act to provide deterrence, the private complainants, denominated "relators," need the encouragement of the monetary reward. Now, only the "original source" of the information about the false claim proven qualifies to participate in the recovery. An amendment is appropriate to enable all sources of the non-public information leading to the prosecution to share in the reward.
A related disincentive to the consequences of bad faith peer review could be civil forfeiture of the "ill-gotten gains" from the revenues generated in the absence of effective peer review that minimizes complications. The Tenet Redding, California hospital case cries out for such a remedy. Forfeiture could reach the parent corporations and the company executives who personally prosper from failing to prevent predatory and malicious medicine.
6) Another way to protect such physicians is to interpose a neutral evaluator unconnected to the hospital industry to process possibly retaliatory claims against physicians to determine merit. This would require creation by statute of a dedicated adjudicatory mechanism, not unlike the administrative courts system in the federal and many state governments. Awaiting such a development, an existing system for air industry safety could be adopted: The National Aeronautics and Space Administration (NASA) operates two anonymous safety-advocate reporting systems, one in healthcare for the Veterans Administration, which could be adapted to physician-advocate reports of inadequate health care practices and instances. By this means, the physician-advocate avoids retaliation by means of officially sponsored anonymity.
Conclusion: Public Safety Merits new Statutory Protections for Whistleblowers: The health of the public is at stake here. Physicians are closest to their patients and best able to advocate for better health care for them. Present healthcare industry structure and unintended consequences of regulatory legislation lend themselves to punitive legal proceedings against whistleblower patient safety advocates. A modest set of statutory amendments, prophylactic and remedial, especially to prevent premature reporting of summary suspensions, can counteract these inequities and rebalance the House of Medicine so it may Do No Harm.
11-26-07
DOC'S 'GAY SEX' SHOCK
Lloyd charged that she was also asked to lie to state officials investigating Grundfast in an unrelated malpractice suit. Lloyd said that when she refused ...
11-06-07
Maryland Malpractice Insurer Told Its $69 Million Dividend Belongs ...Insurance Journal, CA.
Maryland's largest medical malpractice insurer should return its entire $68.6 million dividend to the state, instead of the $32.5 million it has proposed as ...
Family seeks $45 million in King-Harbor death Los Angeles Times, CA ... King Jr.-Harbor Hospital, filed a $45-million lawsuit against Los Angeles County on Monday, alleging negligence, medical malpractice and wrongful death. ...
"The Emotional Toll Of Medical Mistakes" New York Times October 26, 2007
11-02-07
City's staph infection rate highest in the nation
Johns Hopkins News-Letter, MD - 1 hour ago
Methicillin-resistant Staphylococcus aureus (MRSA) manifests itself as a severe respiratory infection. Unlike average staph infections, MRSA is resistant to ...
7-30-07
A Miami heart surgeon has been suspended from Cedars Medical Center while under investigation for “numerous patient deaths” and after being charged with fraud and perjury. Troubled Miami surgeon is still on the job
A New York Times cover article details the successful infection control efforts of a Pittsburgh Veterans Affairs hospital. Swabs in Hand, Hospital Cuts Deadly Infections
In a whistle-blower lawsuit filed by a Miami anesthesiologist, a neurosurgeon and the hospital where she worked have agreed to reimburse the government for unnecessary spinal surgeries performed on Medicare patients. Neurosurgeon, hospital settle whistle-blower case
The American Society of Anesthesiologists will issue its first ever guidelines aimed at preventing surgical fires. Group to issue surgery fires guidelines
07-15-07
When a hospital or doctor makes a mistake, shouldn’t they pay to fix the mistake? The Leapfrog Group, formed to use employer purchasing power to improve hospital care, is pushing for hospitals to agree to waive all costs directly related to mistakes. The unfortunate result of this is that this does nothing to help victims
with other expenses that are the result of negligence, such as loss of
income, or pain and suffering.
No Minor Mistake: Doctor's Error, Your Expense
Utah, bucking the national trend of public reporting of adverse events, considers many such events to be privileged information. Protecting patients: Hospitals wrestle with reporting and fixing medical mistakes.
Despite a California man’s horrific ordeal caused by a medical mistake, due to California’s cap on medical malpractice awards for pain and suffering, he received only $150,000 at trial. Other victims of medical malpractice have received absurdly low awards due to the cap. California is often pointed to as a model for state and federal tort “reform” legislation. Man wins malpractice suit with Harbor-UCLA
A California doctor builds an empire by buying up hospitals, canceling insurance contracts and eliminating unprofitable services such as chemotherapy treatments and mental health care. The doctor’s hospitals are also being accused of turning away uninsured patients.
Hospital group rejects system and cashes in
06-25-07
A new study from the Association for Professionals in Infection Control and Epidemiology (APIC), authored by Dr. William Jarvis, shows as many as 1.2 million hospital patients are infected with MRSA, almost 10 times more than had been thought previously. Michael Bennett, President of Coalition for Patients’ Rights, is quoted in the article.
Staph infections rampant
06-25-07 A California physician who was forced from his position at Encino Medical Center for testifying in court about a mistake made at his hospital, has recommended that hospitals use “black boxes”, similar to their use in the aviation industry, to create a safer medical system. PHYSICIANS: A "black box" for docs
06-25-07 The Texas Medical Board’s efforts to protect consumers from incompetent doctors is inconsistent. Who's looking out for patients in Texas?
06-25-07 A report issued by Senator Tom Coburn says that the CDC wastes millions of dollars on a “Hollywood consultant, a lavish visitors center and a 70-foot-by-25 foot wall of plasma televisions.” Health Agency Wastes Cash on Consultants, Screens, Report Finds
06-25-07 The Maryland Board of Physicians ranks in the bottom ten in disciplinary action against doctors. Public Citizen’s Health Research Group Ranking of the Rate of State Medical Boards’ Serious Disciplinary Actions, 2004-2006
06-25-07 The New Jersey Senate has passed a bill to implement infection control guidelines in hospitals. These guidelines are identical to those outlined in a Maryland bill introduced in, but rejected by, the Maryland legislature. Senate Approves Buono Measure to Knock Out Drug-Resistant Germs
06-17-07
A Readers Digest article illuminates the increased risk for patients during night time and week-end hours. Night Shift Nightmare
In California, a former respiratory therapist pleads guilty to molesting brain-damaged children. Respiratory Therapist Admits Molestation
6-07-07
County officials express dismay at the events surrounding the recent controversial death at King-Harbor hospital. One nurse has resigned.
Tale of last 90 minutes of woman's life
A son recounts his mothers haunting final hours.
My Mother's Haunting End
The death rate from cardiac bypass surgery has declined in New Jersey hospitals during the years in which the state has reported outcome of surgeries in hospitals.
Deaths in NJ after bypass surgery drops
A West Virginia hospital has been fined for misconduct in a medical malpractice case.
Hospital sanctioned $1.3 million over lawsuit
A group home and the city of Washington, D.C. have been sued over occupant’s death.
Group Home Provider, City Sued Over Fatality
A tragic and devastating account of MRSA.
Adventures in the American Healthcare System.
5-20-07
Three California doctors have been arrested, accused o f performing unnecessary surgeries to collect insurance money. 3 doctors held in health insurance scam
5-06-07
Illinois Legislature Takes Up Where Maryland Lawmakers Have Failed.
CPR's legislation aimed at controlling MRSA and VRE in all of Maryland hospitals has been defeated two years running (2006, 2007) under strong opposition from the Maryland Hospital Association and others. Since the introduction of the Maryland bill, six states have introduced similar legislation and other states are poised to do so as well. Illinois stands to be the first state to pass this lifesaving measure.
Illinois considers program to fight drug-resistant bacteria
05-06-07
Overcrowded hospitals that are pushing to cut costs are placing patients at risk.
A concerned consumer discusses finding a compassionate doctor. http://www.drcomplaints.com
The Florida House approved a special bill that would compel payment of the full jury award against a state entity.
http://www.bradenton.com/331/story/31414.html
SoCal woman sues after husband dies during hair transplant
4-22-07
Results of a study conducted at Johns Hopkins University regarding MRSA and VRE have led to the decision by Hopkins to use the SHEA guidelines to screen for and prevent the spread of these deadly infections for all children admitted to the pediatric intensive care unit. The Coalition for Patients Rights has relentlessly pushed for the SHEA guidelines to be implemented nationwide, starting with Maryland where legislation has twice been introduced that would require this.
Source: Johns Hopkins Medical Institutions
Embargoed until: Mon 16-Apr-2007, 14:45 ET
Johns Hopkins Begins Aggressive Screening for "Superbugs in Children"
Infection control and critical care experts at The Johns Hopkins Hospital have ordered testing for the two most common hospital superbugs for every child admitted to its pediatric intensive care unit.
The more stringent admission screening methods for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) go well beyond standard hospital practices, where tests are only ordered after symptoms or early signs of infection appear.
The new hospital practice was introduced March 1 after a study conducted at Hopkins last year showed that more frequent screening detected many more carriers of the germs before their presence led to infection or the germs spread to others.
Admission screening is already standard at Hopkins for adults admitted to intensive care units.
Health experts fear spread of these particular bacteria because they have developed resistance to the antibiotic drugs most commonly used to combat them. Though infections caused by these bacteria are rarely fatal, carriers of either bug are at greater risk for more dangerous infections.
Results from the study, to be presented April 16 at the annual meeting of the Society of Health Care Epidemiology of America (SHEA) in Baltimore, are believed among the first to make a case for better screening in efforts to slow spread of the germs in hospitalized children.
The study compared the effectiveness of weekly screening to current practices for ordering tests and found the weekly model to be many times more effective than standard risk monitoring, in which the highly contagious bacteria are looked for after patients develop skin rash, fever or pain.
Weekly swab testing and bacterial growth cultures were done on nearly 330 patients in the hospital‚s pediatric intensive care unit for four months. Results were compared to findings of cultures obtained from patients showing possible signs or symptoms of infection. All patients were under age 18
The weekly testing for MRSA, the most common superbug, detected more than half of young patients who were carrying the germ (54 percent, or one and a half times as many) than were detected through routine testing, which missed 35 percent of those with MRSA. Results for detecting VRE, a lesser known but still common superbug, were six times higher with weekly testing than with routine testing, which missed 82 percent of those with VRE. Like most bacteria, hospital superbugs are picked up through direct contact, by touching someone or a surface with it.
„The results were quite clear to us: Aggressive patient safety programs should consider testing on admission as standard practice,‰ says study senior author and hospital epidemiologist Trish Perl, M.D. Perl and her team, however, will wait for evidence of improved patient safety before making any national recommendations to government agencies and other hospitals.
Perl is past president of SHEA and will be presenting at the four-day conference, expected to attract 1,200 infectious disease specialists, epidemiologists, nurses and hospital administrators to the city.
„We need to find patients who have these bacteria on them and who, as such, are not only at risk of personal infection, but also pose a serious threat of infection to other patients and hospital staff,‰ she says.
According to Perl, a professor of medicine and pathology at The Johns Hopkins University School of Medicine, patients found to be infected or to be a carrier before infection has set in are placed in isolation for the remainder of their stay. Wound care is done only in designated, confined treatment spaces or separate rooms, and hospital staff must take special precautions between treatments, such as cleaning equipment and furniture with strong disinfectants and wearing disposable gloves, masks and gowns.
„Children are more vulnerable to the problem of antibiotic resistance because their bodies are not fully developed to fight off illness and because fewer drugs are FDA approved for use in children,‰ says Aaron Milstone, M.D., a pediatric infectious diseases research fellow at Hopkins who led the study.
Vancomycin (Vancocin) is currently the only FDA-approved drug for MRSA in children, and only one drug, linezolid (Zyvox), is approved in pediatrics for VRE.
Milstone says children admitted to Hopkins are increasingly identified as harboring MRSA or VRE, with recent reports from the intensive care unit showing four times as many children with MRSA and twice as many with VRE than five years ago. These reports and others led the Hopkins team to conduct the study In 2006, the Joint Commission on Accreditation of Healthcare Organizations (now known only as the Joint Commission) estimated that 70 percent of the bacteria that cause infections for 2 million hospitalized Americans each year are resistant to at least one of the drugs most commonly used to treat them.
Funding for the study, conducted solely at Hopkins between June and September 2006, was provided by the Pediatric Infectious Diseases Society of America and The Johns Hopkins Hospital. Besides Perl and Milstone, other members of the Hopkins team involved in this investigation and study were Alex Shangraw; Xiaoyan Song, M.D., M.S.; Ivor Berkowitz, M.D.; and Claire Beers, R.N.
Contact Information
Johns Hopkins Medicine
Media Relations and Public Affairs
Media contact: David March
410-955-1534; dmarch1@jhmi.edu
4-22-07 “For the first time, Ontario hospitals will be forced to publicly disclose safety records. Hospital secrecy to end
4-22-07 Many of New York City’s most frequently sued doctors still practice medicine.
Johns Hopkins University Hospital will begin testing all patients who have spent time in nursing homes for MRSA and VRE. ( This patient group was also a focus of the SHEA guidelines and the Coalition for Patients Rights.) Most-at-risk Nursing Home Residents to be Tested for “Superbugs”
A new Consumers Report poll finds that consumers want the government to do whatever is necessary to ensure safe prescription drugs.
“Biotech firms make healthy profits from (body) tissue sales”
A study published in The Journal of the American Medical Association found that “large, for-profit dialysis chains administered significantly more of … anti-anemia drug Epogen than did not-for-profit … centers.” Dosing for Dollars
A Philidelphia Inquirer report reveals that adverse drug events in Pennsylvania are far too frequent.
4-13-07
A report, “Extending the Cure: Policy Responses to the Growing Threat of Antibiotic Resistance,” has recently been released by Resources for the Future, an organization that researches public health issues. Extending the Cure: Policy Research to Extend Antibiotic Effectiveness
4-13-07
A hospital’s new chief executive officer disciplines staff for failure to follow hospital policy. Discipline sent 'shock wave' through hospital
The Deleware Board of Medicines allows a doctor to practice psychiatry dispite past sex offense convictions. Farm sale leaves memories
The Illinois legislature passes a bill requiring hospitals to screen intensive care unit patients for MRSA. State targets staph in hospitals
“By discouraging lawsuits and capping damages, Indiana’s system either controls costs – or it makes the injured suffer even more.” Monitoring malpractice
In its fourth annual Patient Safety in American Hospitals Study, HealthGrades Inc. finds that nearly 250,000 hospitalized medicare patients’ deaths were preventable.
Hospital mistakes increase
Consumers want and need more information on hospital and physician quality.
Wanted: More information on healthcare
The Maryland Board of Physicians suspends the medical license of a doctor who admitted to “inappropriate sexual contact”” with a patient. Doctor admits to sex with patient
A common gallbladder surgery risk may be avoidable.
Colorado Governor Bill Ritter signs a bill protecting medical whistle-blowers.
A Colorado mother campaigns for a bill that would require all doctors to report final malpractice judgments against them. Mother campaigns for malpractice disclosure
Graduating classmates remember sixth grade classmate who died of a medical error.
Lost classmate will still help friends
Senator Charles E. Grassley, ranking member of the Senate Finance Committee, responds to Dr. Gerberding’s (Director of the CDC) refusal to allow the new CDC Ombudsman to brief the committee.
http://alt.coxnewsweb.com/ajc/pdf/cdc/grassleyletter.pdf
An expert on serotonin, depression and the brain is profiled in this account of his expert witness testimony against Pfizer Pharmaceuticals. Putting Science in the Dock
3-26-07
Majority of Medical Malpractice Claims in Seven States Closed ... without compensation.
3-14-07
A Virginia woman whose face caught fire during thyroid surgery has filed suit against her doctors and Inova Alexandria Hospital. Suit filed over surgery flash fire
3-14-07 This article chronicles the cozy relationship between local television news and local hospitals. What Couldn't Get Worse On the News Just Did
The CDC reports that dialysis patients are at a 100 times higher risk for MRSA infections than the general public. Medical 'dirty secret' out in open
A skydiver, injured in a fall, dies from a hospital acquired infection. It Wasn’t the Fall That Killed Him – Safe Care Campaign
A doctor’s vision problems may have led to unnecessary surgeries. Doctor with vision problem may have done unneeded surgeries
3-7-07
The response of two Canadian hospitals to SARS infected patients demonstrates the critical need to have infection control guidelines in place. Outbreak response: A tale of two cities
3-2-07
A Boston Globe correspondent entreats the FDA to sever its unseemly connections to drug companies. Taking back the FDA
3-2-07 Yet another patient dies from MRSA.
Hospitals' hidden danger
3-2-07 A commentator writes about the Notre Dame football coach, who is suing his doctors for malpractice. Weis' stout man with stout principles
3-2-07 Washington state lawmakers consider extending wrongful death suits to adult children. Grieving parents want greater legal rights
3-2-07 A North Carolina lawsuit “seeks to compel the state’s regulatory board to open up the selection process of its physician members.” Suit claims conflict of interest by state board; Doctor takes on Medical Society.
2-24-07
An Omaha doctor has been suspended from practicing medicine after two of his patients died from a drug overdose of oxycodone.
2-14-07
A group of 200 California hospitals will be strickly enforcing the main components of the SHEA guidelines, including screening of incoming patients for MRSA and isolating carriers. Health & Wellness
2-7-07
A mesh hernia repair patch has been recalled by the FDA. Hernia Mesh Patch Recall - FDA Warns of Death and Serious Health ...
2-7-07 A Colorado state legislative committee has passed a bill that would attempt to give health-care workers whistle blower protection.
What ails hospitals is silence
2-7-07 The Harvard School of Public Health reports that 34% of people say they or their families have experienced medical errors. Patient, protect thyself
Medical Malpractice
From the Baltimore Sun
Dialysis deaths prompt warning
24 patients in Md. died from bleeding; precautions urged
By Jonathan Bor
sun reporter
January 25, 2007
The Maryland medical examiner's office has called attention to the cases of 24 kidney dialysis patients who bled to death, usually at home alone, prompting health agencies to alert dialysis centers and patients to take precautions.
Dr. David Fowler, the state's chief medical examiner, said the cases of 22 people who died at home and two others who died at dialysis centers since 2000 came to light after he noticed a cluster and asked his staff to review records. A regional coalition of kidney programs said it is aware of 38 deaths over the six-year period.
In dialysis, a lifesaving treatment for kidney disease, a patient's blood is cycled through a machine that removes impurities and waste products. In most cases, doctors tap a vein in the arm or leg, creating a "vascular access site" or portal that can be used for years.
Most of the people died after their access sites weakened from repeated use and finally leaked.
"Most of these people seemed to be alone at the time the bleeding occurred," Fowler said in an interview. "Nobody was there to assist them."
The patients were as young as 28 and as old as 85. Almost two-thirds were men, and three-quarters were African-Americans. Kidney disease disproportionately affects blacks, who account for a third of people with kidney failure, according to the National Institutes of Health.
It remains unclear whether the number of deaths in Maryland was unusual. Fowler said he was hoping to invite discussion and possibly some answers when a research fellow, Dr. Donna Vincenti, presents the data next month at a national forensics conference. They also plan to submit an article to a national medical journal for publication.
Fowler, who declined to make public the names of patients who died or their dialysis centers, said the cases were scattered across the state.
Three agencies joined last month in issuing advisories to dialysis centers that treat up to 20,000 Marylanders.
"Some deaths from vascular access hemorrhage may have been preventable," the advisory reads. Patients should have "repeated educational sessions" about the proper care of their access sites and the signs of trouble.
A flier intended for distribution to patients lists warning signs such as redness, swelling, fever, chills and the loss of vibration - called "thrill" - when fingers are placed on the skin over the access site. Patients are advised to contact their dialysis centers if anything appears wrong, and to apply firm pressure and call 911 if they start bleeding.
Issuing the alerts were the Baltimore and state health departments and the Maryland Kidney Commission, which certifies and sets standards for dialysis centers and handles patient complaints. Fowler presented his findings to the commission last month.
The state health department found no evidence of insufficient care, a top official said.
"It wasn't a fault issue," said Wendy Kronmiller, director of the state Office of Health Care Quality. "It's just such a gruesome outcome, we wanted to make sure the message got out."
The Mid-Atlantic Renal Coalition, which oversees kidney programs in three states and the District of Columbia, knew of more cases than Fowler did. But the medical examiner said some cases might not have been referred for autopsy if the cause of death was obvious.
Nancy Armistead, director of the coalition, said she did not agree that the number was high enough to justify the health alerts.
"It's over a fairly long time period, and it's a relatively small number of deaths," she said. But she said, "I agree that some of these might be preventable."
Putting the deaths in context, she said, almost 12,000 dialysis patients have died in Maryland since 2000.
Armistead said the bleeding deaths represented about three-tenths of 1 percent of all dialysis deaths in Maryland - slightly higher than in West Virginia, and slightly less than in Virginia or Washington. Nationally, the leading causes of deaths among dialysis patients are cardiovascular disease and a patient's decision to discontinue dialysis treatments.
"Every death is significant, but statistically we didn't think it was anything that warranted the kind of attention the medical examiner is giving it," she said, adding that the coalition doesn't have the resources to pursue the issue.
Dr. Joshua Sharfstein, Baltimore's health commissioner, said the numbers were "striking" enough to justify a public health alert. "If there's something simple we could be doing to reduce the chance of a catastrophic outcome, then we should be doing that."
Patients usually get three dialysis treatments a week and may continue for years. In the dialysis center, a staffer inserts a needle into an access site in the patient's forearm or leg. The patient's blood is then diverted through plastic tubing to a filter before being returned to the body.
"It's a site where every couple of days, somebody inserts a needle to extract blood from the body," Fowler said. "There is this constant mild or minor trauma from these needles. Normally, these sites will last several years without a problem."
But if the vessel breaks down, the consequences can be fatal, especially if a patient is alone.
"The patients would be found with a good amount of blood around them," Vincenti said.
The two most common types of access sites are fistulas and grafts, both of which lie below the skin and are punctured during each dialysis treatment. A fistula is the joining of an artery to a vein, while a graft is a synthetic or natural vessel that is joined to a vein.
A third type is a venous catheter, a plastic tube that's inserted into a blood vessel but protrudes above the skin surface.
The deaths were not linked to one type. Seven of the people who bled to death had fistulas, while 10 had grafts, Vincenti said. Most of the 17 hemorrhaged after the veins had gradually eroded from repeated use.
Four patients had venous catheters that became dislodged. There was incomplete data on the remaining three.
"Right now, what we want to do is increase the amount of education that's going on. ... When you have someone in a hemodialysis chair, you have a captive audience," Vincenti said. "It may be a good time to re-educate them, review some warning signs."
Dr. Jeffrey Fink, the former chairman of the Maryland Kidney Commission, said hemorrhaging is a known risk of dialysis - but it's uncommon and hasn't, to his knowledge, been extensively researched.
"It does happen, it's unfortunate, but it's never hit a point on the radar screen as something that's epidemic," said Fink, a nephrologist at the University of Maryland Medical Center.
Fink said he favored issuing the advisories, but doesn't necessarily agree that some of the deaths could have been prevented. He said he would need further information from the medical examiner's office to make that judgment.
Fink said he's never had a patient bleed to death though one recently woke up in time to get help.
"The patient had a hemorrhage and happened to wake up wet," he said. "Everybody I talked to has a few cases where this has happened."
jonathan.bor@baltsun.com
The number of dialysis patients who die every year in Maryland was misstated when this article was published in the print edition. The Sun regrets the error.
Bush's Health Care Conspiracy
by Marilyn Clement; TomPaine; January 27, 2007
As I thought about the president's speech Tuesday night, I imagined his handlers sitting together joking conspiratorially about how to twist the issues and help the president's plummeting popularity. How could his handlers sneak through more support for his primary agenda, and that of right-wing fiscal conservatives, to decrease entitlements to Social Security and Medicare and transfer more of the people's tax money into Wall Street-while couching this scheme in the language of 'health care for all?'
I thought of them saying to each other, 'Wow, now that the voters have made clear that a universal health care system is their number one domestic priority-why don't we grab that issue from the Democrats? Since the Democratic Congress hasn't gotten the message and isn't really creating a new health care system, let's make it work for us!'
The president got it. One obvious thing he realized was that the American people want a national health care system for themselves and their children as much as they want our troops out of the killing fields of Iraq. So he offered several unworkable and ridiculous suggestions: relief from payroll taxes and a tax credit to the uninsured. What is he thinking? That the uninsured have big salaries and are seeking some kind of tax shelter?
His proposed $15,000 income tax deduction for middle- class families would jeopardize both Medicare and Social Security while not providing enough money to purchase real health insurance, projected to cost $16,500 for a family of four by the year 2009. And employers would be encouraged to bail out of the health care system even faster than they are today.
His plan for fixing the health care system is more of the same-more big bucks for the insurance companies. He believes that government has a responsibility for the children, the elderly and the disabled-but for everybody else, 'private insurance is the best.' Then he offers several plans to provide more billions of federal dollars to the private insurers who have driven the cost of the health care system up 73 percent since 2000.
I guess he means the private insurance companies that use up 31 percent of every health care dollar for their own CEOs' salaries, payments to lobbyists, media campaigns and the multiple bureaucratic costs of thousands of insurance companies rather than a single payer such as Medicare. Those same private insurance companies provide no health care to anyone in this country. (Well, maybe they provide health care for their own employees, who number in the tens of thousands.)
He must mean those same private insurance companies whose highest-paid CEO (at United Health) gets $122.7 million dollars a year-enough to cover the health care costs of roughly 34,000 American citizens.
The president also gave a big plug for the idea of so- called federal/state partnerships. He said he will be urging the provision of federal funds to the states so that the poor and the sick can be covered to purchase insurance-with an 'affordable choice.' More money for these same insurance companies! In every one of these instances, the president is talking about reckless additional spending for health care 'insurance'-not a net savings such as that which we would get from a single-payer system. That's why his highly applauded promise to balance the budget rings false-and cold- hearted.
Of course, he wants expanded money to help develop health savings accounts that help the very rich. It's yet another tax break for them, since they can earn interest on all the money they save and continue to have their health care benefits provided from their employers-or they may even be the employers. Small business health pools, supplemented by government, for small businesses is another recycled idea. Both of these plans would provide yet more of our federal dollars to the insurance companies.
Other ideas, like new money for medical technology to decrease medical errors, sound like a good plan.
But 'junk lawsuits?' Give me a break! This whole line of argument has been fully discredited by the facts. Only about four-tenths of a percent of medical malpractice lawsuits succeed in the courts. It is a big bugaboo to try to stop the common people from being able to bring lawsuits against the monied interests when we are injured. And guess who has been fueling the fire? It's the insurance companies, who convince the doctors that they must spend millions of dollars by purchasing insurance to protect themselves from lawsuits.
A single-payer system would end a lot of the problems of medical mistakes and malpractice because the medical costs of the miniscule numbers of suits that win in the courts would be covered in a universal system that would cover all health care costs for an injured person for the rest of her/his life.
So the president and the other administration ideologues hammered together a cruel package that would continue to send billions to 'market-place' solutions rather than providing a less expensive, high-quality health care system for everybody in the country, a system more like those enjoyed by the 37 advanced nations of the world who have a better health care system than ours.
Let's hope the Democratic Congress gets the message. The voters did indeed vote for a national response to the health care crisis. They desperately need it. The Democrats must get over the chilling effect of the Newt Gingrich attack that left them trembling in their boots.
So much has changed, and the American people have made it clear through the polls and through their votes that they expect their new leaders to lead.
[Marilyn Clement is the national coordinator of Healthcare-NOW.]
Special Article
Published at www.nejm.org January 26, 2007 (10.1056/NEJMsa064964)
Public Reporting and Pay for Performance in Hospital Quality Improvement
Peter K. Lindenauer, M.D., M.Sc., Denise Remus, Ph.D., R.N., Sheila Roman, M.D., M.P.H., Michael B. Rothberg, M.D., M.P.H., Evan M. Benjamin, M.D., Allen Ma, Ph.D., and Dale W. Bratzler, D.O., M.P.H.
ABSTRACT
Background
Public reporting and pay for performance are intended to accelerate improvements in hospital care, yet little is known about the benefits of these methods of providing incentives for improving care.
Methods
We measured changes in adherence to 10 individual and 4 composite measures of quality over a period of 2 years at 613 hospitals that voluntarily reported information about the quality of care through a national public-reporting initiative, including 207 facilities that simultaneously participated in a pay-for-performance demonstration project funded by the Centers for Medicare and Medicaid Services; we then compared the pay-for-performance hospitals with the 406 hospitals with public reporting only (control hospitals). We used multivariable modeling to estimate the improvement attributable to financial incentives after adjusting for baseline performance and other hospital characteristics.
Results
As compared with the control group, pay-for-performance hospitals showed greater improvement in all composite measures of quality, including measures of care for heart failure, acute myocardial infarction, and pneumonia and a composite of 10 measures. Baseline performance was inversely associated with improvement; in pay-for-performance hospitals, the improvement in the composite of all 10 measures was 16.1% for hospitals in the lowest quintile of baseline performance and 1.9% for those in the highest quintile (P<0.001). After adjustments were made for differences in baseline performance and other hospital characteristics, pay for performance was associated with improvements ranging from 2.6 to 4.1% over the 2-year period.
Conclusions
Hospitals engaged in both public reporting and pay for performance achieved modestly greater improvements in quality than did hospitals engaged only in public reporting. Additional research is required to determine whether different incentives would stimulate more improvement and whether the benefits of these programs outweigh their costs.
1-24-07
Pennsylvania Governor Ed Rendell’s new health care reform plan includes provisions for insurers to stop reimbursements for hospital acquired infections. His visit to the University of Pittsburg Medical Center, where Dr. Carlene Muto’s efforts have reduced MRSA infection rates by 80%, was part of a campaign to raise support for his plan. Health : Medical Malpractice Lawsuits Not the Cause of Health Care ...
When Patients Are Hospitalized in Bunches, Mortality Rises
By Crystal Phend, Staff Writer, MedPage Today
Reviewed by Zalman S. Agus, MD; Emeritus Professor at the University of Pennsylvania School of Medicine.
January 10, 2007
LOS ANGELES, Jan. 10 -- Older patients admitted to a large academic medical center on busy shifts may have a greater mortality risk than those who come to the hospital on less frenetic days, suggested investigators here.
This was the bottom line of a study of admissions to the general medicine service of the University of California San Francisco's Moffitt-Long Hospital, a 525-bed tertiary care center, over three years.
"Our findings suggest that higher house staff workload on admitting days -- when fewer backup resources are available -- increases resource use and may increase inpatient mortality," reported Michael Ong, M.D., Ph.D., of UCLA, and UCSF colleagues, in the Jan. 8 Archives of Internal Medicine.
The finding emerged from a retrospective cohort analysis of 5,742 adults, a majority of Medicare age, admitted from July 1, 1998, to June 30, 2001.
The study included only patients admitted to the general medicine service and intensive care unit without cardiovascular, neurologic, or cancer-related primary diagnoses. Those hospitalized for short-stay procedures or elective chemotherapy were also excluded.
The house staff teams were composed of one attending, one resident, and one or two interns. Patients were admitted when one team was scheduled to admit patients in 41.7% of the cases and when two teams were admitting in 36.5% of the cases.
The investigators found that each additional admission by a team of house staffers on a patient's admission day increased that patient's length of stay by 3.09% (95% CI 2.22% to 3.96%) and total costs by 2.31% (95% CI 1.29% to 3.33%).
The teams averaged 5.8 admissions per call cycle with a daily census of 10.1 patients. The total daily census for the general medical service averaged 44.8 patients with a mean of 7.8 admissions and 7.8 discharges each day.
The mortality risk increased substantially when days with three or fewer admissions were compared with days of nine or more admissions. Whereas four to six admissions had about a 50% increased mortality risk, 10 to 12 admissions was associated with more than 100% increased mortality risk and 13 to 15 admissions was associated with more than a 250% increased risk.
During the study, 5.5% of the inpatients died and 7.6% were readmitted to the same hospital within 30 days of discharge. Their median length of stay was four days with a median total cost of $4,319.
With each additional admission on a patient's admission day, the researchers reported in the multivariate analysis:
Inpatient mortality increased 1.09-fold (95% CI 1.02 to 1.15),
Length of stay was 3.09% longer (2.22% to 3.96%),
Total costs were 2.31% higher (1.29% to 3.33%), and
30-day admission was not significantly affected (adjusted odds ratio 0.97, 95% CI 0.92 to 1.02).
Although 13 to 15 admissions was associated with more than a 250% increased risk, at the busiest -- 16 or more admissions -- the increased mortality risk was no longer significant (P>0.05). This may reflect the general medicine service's method of redistributing patients to less busy teams after the busiest admitting days, the authors suggested.
In the multivariate analysis, additional findings included:
Each extra admission on a patient's discharge day had a significant effect on total costs (difference 1.51%, 95% CI 0.70% to 2.32%) but not on length of stay (difference 0.09%, 95% CI -0.59% to 0.77%),
Each additional discharge on a patient's admission day significantly decreased the length of stay by 4.69% (95% CI -3.38% to -5.97%) and total costs by 3.63% (95% CI -2.08% to -5.16%), and
The number of discharges on a patient's discharge day had no significant impact on length of stay or total costs.
The significant effect from busier admission days but not discharge days for patients may have due to the importance of early, accurate diagnosis and workup, the researchers said.
"Admission workup activity is extensive," they wrote, "more admissions reduce the time spent by teams on any one admitted patient, potentially leading to inaccurate initial clinical assessment or pushing workup activity onto subsequent days, leading to longer lengths of stay and higher total costs."
However, each additional patient on the team's average census during the patient's hospitalization was associated with earlier discharge (difference -5.30%, 95% CI -4.54% to -6.07%) and lower total costs (difference -5.11%, 95% CI -4.20% to -6.00%).
Dr. Ong and colleagues said they believe this counterintuitive finding represents adaptation by teams or the entire inpatient service.
"Unlike admission volume, which cannot be modified by teams," they wrote, "team average census is a work measure that teams can control by adapting their daily tasks, such as skipping teaching conferences to perform patient care tasks, to meet workload demands."
They also found that each additional admission assigned to a house staff team increased inpatient mortality risk (odds ratio 1.09, 95% confidence interval 1.02 to 1.15).
While the study was not large enough to be powered to show a mortality difference, the results have important implications for residency training programs and hospital administrators, the investigators said.
"Balancing the clinical and economic outcomes with available resources and the educational impact of changes in the organization of house staff teams will be important tasks for training programs and teaching hospitals in coming years," they wrote.
"High workload may also increase pressure to discharge patients quickly or focus attention of social workers and discharge planners on teams with higher patient volumes," they added.
On the other hand, increases in the total number of team admissions in a patient's month of admission -- reflecting long-term workload -- did increase length of stay and costs slightly though significantly (0.53% and 0.40%, respectively).
"This finding suggests that internal efficiency can be increased in the short-term, but fatigue may accumulate within teams over time," the authors wrote.
Results were similar in analyses of patients who had been redistributed to other teams or those with intensive care unit stays.
Findings were adjusted for patient sociodemographic factors, diagnosis-related severity, intensive care unit stays, and diagnoses of HIV, cancer, and pneumonia, as well as changes over the academic year and discontinuities in care due to team personnel switches.
Because the study included only a single academic medical center, the findings may not be applicable to smaller institutions with limited resources or to those that include surgical or pediatric services or have different house staff training systems.
The study was partially supported by a Veterans Administration Ambulatory Care Fellowship to Dr. Ong and a grant from the Agency for Healthcare Research and Quality to one of the other authors, but none reported financial disclosures.
Primary source: Archives of Internal Medicine
Source reference:
Ong M, et al "House Staff Team Workload and Organization Effects on Patient Outcomes in an Academic General Internal Medicine Inpatient Service" Arch Intern Med. 2007; 167:47-52.
Battling the Superbug AARP Bulletin (January, 2007)
How to squelch the spread of a dangerous pathogen
Dirty Hospitals AARP Bulletin (January, 2007)
A growing number of hospitals are working harder to stop infections, but as more bugs become resistant to antibiotics, it's an uphill struggle.
12-30-06
A journalist reports on the personal stories recounted at the recent Institute for Healthcare Improvement conference in Orlando.
First Person: To really learn about
medical errors, turn off the PowerPoint
12-30-06 Piedmont Medical Center, in South Carolina, joins the battle against MRSA, requiring universal nasal swabs for incoming patients and contact isolation until results are received. PMC hits front lines in germ warfare
12-30-06 A study by the Harvard School of Public Health casts doubt on claims that the medical malpractice system is plagued by frivolous lawsuits.
12-30-06 Coalition for Patients Rights’ President Michael Bennett highlights issues to consider in the medical malpractice debate. Letters to the editor
With Infections on Rise, Hospital Tactics Vary
First published: Tuesday, December 26, 2006
REUTERS NEWS SERVICE
As infections that patients pick up in hospitals grow increasingly resistant to antibiotics, facilities are turning to more aggressive measures, including a "search and destroy" approach borrowed from Europe.
Each year staph infections and other powerful bugs that thrive in hospitals kill 90,000 people and result in $4.5 billion in excess costs, according to the Centers for Disease Control and Prevention. A study published earlier this month in the American Journal of Medical Quality found hospitals lost $27,000 for each patient who gets a preventable infection there. Insurers reimburse many hospital stays by the diagnosis rather than per day, and payment drops off the longer patients stay in the hospital.
"A lot of hospital administrators don't realize how expensive these infections are," said Lance Peterson, head of epidemiology at Evanston Northwestern Hospital, located outside Chicago.
The costs haven't escaped notice of the government and private insurers that
collectively fund most of the $2 trillion U.S. health-care tab. Antibiotic
resistant strains, or "super bugs," now account for about two-thirds of
infections associated with health care. Vancomycin is most often used to
treat the stubborn infections, but some have become resistant to the
antibiotic.
Betsy McCaughey, founder of the nonprofit Committee to Reduce Infection Deaths, said most evidence showed that three steps could dramatically cut infection deaths in hospitals. But she said most U.S. facilities weren't implementing the practices: meticulous hand-washing between procedures, cleaning equipment between patient use, and identifying infected people before they enter the hospital. "About 90% of patients treated in a hospital know well ahead of time they will be admitted, and can be tested in a doctor's office a week before," Ms. McCaughey said.
The CDC suggests that hospitals screen high-risk patients, such as those with weak immune systems, but doesn't recommend testing all patients for infection. That leaves hospitals to experiment with myriad approaches, resulting in a lack of consistency, experts said. In fact, big for-profit chains like Tenet Healthcare Corp. and Triad Hospitals Inc. leave policies on handling infections up to local administrators.
Evanston Northwestern, affiliated with Northwestern University and part of a small local network, is one of a handful of U.S. hospitals to implement "universal surveillance" -- testing every patient that walks in the door for an infection. When it gets a positive result, it isolates the patient, administers a powerful antibiotic and requires all people going into the room to wear gowns and gloves.
The hospital's search-and-destroy approach steals a page from some European
countries like the Netherlands, where hospital-acquired infections are rare.
A key component of Evanston's effort is Becton, Dickinson & Co.'s new gene-based test, which gives results in a few hours, compared with a few days with an older product. About 160 of the 5,000 U.S. hospitals use the test, up from 60 a few months ago.
But some experts question whether the rapid gene-based test is more cost-effective than the older, and much cheaper, culture-based version that takes a few days to interpret.
Fighting Infections
First published: Tuesday, December 26, 2006
New York used to lead the nation in health care. In many respects, it still does. But not in one critical area: fighting hospital infections. Instead, New York trails behind Illinois, Massachusetts, Maryland and other states, as well as France, Denmark, Finland and the Netherlands.
How so? All of the other states and foreign countries have taken steps to reduce the number of staph infections in hospitals. But New York lags behind.
The bacteria that can cause these infections are carried on the skin, where they are harmless. But once they get under the skin -- for example, through a catheter, an IV or incision -- they can cause serious infections that are often resistant to common antibiotics. Indeed, hospital infections have been linked to the deaths of more than 100,000 patients every year, or five times more than those who die of AIDS.
And all because some simple, inexpensive procedures weren't taken.
Betsy McCaughey, who was George Pataki's first lieutenant governor, is rightly raising the alarm over these statistics, and urging the state Health Department to adopt guidelines for hospitals. The Committee to Reduce Infection Deaths, which Ms. McCaughey chairs, is providing information that should be helpful -- and in some cases, eye-opening -- for hospital administrators and patients alike.
The surest way to reduce the rate of staph infections, according to the committee, is to test everyone who is admitted to the hospital. That would involve a simple nasal or skin swab. Without a mandated test, doctors and nurses who come in contact with an infected patient often unknowingly carry the bacteria throughout the hospital, exposing other patients to infections through the use of blood pressure cuffs, bed rails, wheelchairs, stethoscopes and other equipment.
Regrettably, there are no federal guidelines for screening for staph bacteria, and the Centers for Disease Control claim more research is needed before promulgating them. But the experience at some major hospitals -- Boston's New England Baptist; Baltimore's Johns Hopkins; Evanston Northwestern in Illinois -- shows that when precautions are taken, there's a significant decline in infections. Similar results have been recorded in other countries where precautions are mandatory.
Ms. McCaughey estimates the cost of preventive measures at about $35,000 a year for hospitals, while the savings, as measured in the costs of treating infections, would amount to $800,000 a year. The math is compelling. It adds up to an urgent need for New York to mandate testing.
12-15-06
A medical student discovers the kind of doctor she does not want to be – a doctor who looks after their own interests before the interests of their patients.
The kind of doctor I'm NOT going to be
12-15-06 “Three years after the [Florida] legislature capped medical malpractice payouts, insurance company payouts have decreased dramatically, but not their rates.” Malpractice payouts dropping
12-15-06 The Institute for Healthcare Improvement, building on the success of its 100,000 Lives Campaign, announced a new 5 Million Lives Campaign.
IHI Launches National Campaign to Reduce Medical Harm in US ...
12-15-06 In Washington state, the sealing of court documents prevented the Department of Health from knowing crucial information in a disciplinary hearing.
What the state didn't know about doctor, malpractice suit
12-15-06 A new antibiotic – Ketek - has dangerous consequences for some.
Doctor: FDA-Approved Antibiotic A 'Time Bomb'
12-03-06
Tort “reform” in Georgia makes it “almost impossible for medical malpractice victims to pursue justice in a courtroom.”
Can We Survive Healthcare in an Accountability-Free Zone?
In an effort to prevent a tragic misdiagnosis, two of the largest health care providers, the Veterans Administration and Kaiser Permanente, “are leading new efforts to improve diagnostic accuracy”, including a web based diagnostic program.
Preventing the tragedy of misdiagnosis
A family in Florida says a DNR (Do Not Resuscitate) order was forged and their father died as a result.
Family Says Loved One's Life Signed Away at Local Hospital Without Authorization
11-28-06
Patients in out-patient dialysis care complain of poor care ranging from filthy conditions to inadequate staffing. The Association of Dialysis Advocates “believes that outpatient centers… are under-regulated and allowed by the federal government to focus too much on profits and not enough on patients.” After repeated complaints from a patient, a Birmingham facility is inspected and cited for numerous violations.
Patients seek better treatment
11-28-06 Geriatricians warn that seniors receive too many drugs and caution that more than four medications should serve as a red flag to doctors.
Some seniors get too many drugs
11-28-06 Health insurance CEOs receive “a cornucopia of compensation.”
Health insurance CEOs feast on exec pay
11-28-06 A suture needle is left inside a woman and she suffers the consequences. MEDICAL MISHAP: One Woman's Nightmare
11-28-06 This article points out the failed logic behind legislation limiting medical malpractice claims.
Why This Election Makes A Difference to Your Healthcare
11-20-06
Pennsylvania becomes the first state to track infection data for individual hospitals, citing the increased death rate and expense for those with hospital acquired infections. Pennsylvania pioneers with hospital infection data;
11-20-06 Some of the nation’s largest businesses called on U.S. hospitals to waive costs related to egregious medical errors. Hospitals urged to waive bill, apologize for 'never events'
To Catch a Deadly Germ
By BETSY McCAUGHEY
Published: November 14, 2006
WHAT kills more than five times as many Americans as AIDS? Hospital infections, which account for an estimated 100,000 deaths every year.
Yet the Centers for Disease Control and Prevention, which are calling for voluntary blood testing of all patients to stem the spread of AIDS, have chosen not to recommend a test that is essential to stop the spread of another killer sweeping through our nation’s hospitals: M.R.S.A., or methicillin-resistant Staphylococcus aureus. The C.D.C. guidelines to prevent hospital infections, released last month, conspicuously omit universal testing of patients for M.R.S.A.
That’s unfortunate. Research shows that the only way to prevent M.R.S.A. infections is to identify which patients bring the bacteria into the hospital. The M.R.S.A. test costs no more than the H.I.V. test and is less invasive, a simple nasal or skin swab.
Staph bacteria are the most prevalent infection-causing germs in most hospitals, and increasingly these infections cannot be cured with ordinary antibiotics. Sixty percent of staph infections are now drug resistant (that is, M.R.S.A.), up from 2 percent in 1974.
Some people carry M.R.S.A. germs in their noses or on their skin without realizing it. The bacteria do not cause infection unless they get inside the body — usually via a catheter, a ventilator, or an incision or other open wound. Once admitted to a hospital, these patients shed the germs on bedrails, wheelchairs, stethoscopes and other surfaces, where M.R.S.A. can live for many hours.
Doctors and other caregivers who lean over an M.R.S.A.-positive patient often pick up the germ on their hands, gloves or lab coats and carry it along to their next patient.
The blood-pressure cuffs that nurses wrap around patients’ bare arms frequently carry live bacteria, including M.R.S.A. In a recent study at a French teaching hospital, 77 percent of blood-pressure cuffs wheeled from room to room were contaminated. Another study linked contaminated blood-pressure cuffs to several infected infants in the nursery at the University of Iowa hospital.
Among developed nations, the United States has one of the worst records of curbing drug-resistant infections, according to the Sentry Antimicrobial Surveillance Program, an international effort to monitor drug-resistant germs. In this country, M.R.S.A. hospital infections increased 32-fold from 1976 to 2003, according to the C.D.C.
In the 1980s, Denmark, Finland and the Netherlands faced similarly soaring rates of M.R.S.A., but nearly eradicated it. How? By screening patients and requiring health care workers treating patients with M.R.S.A. to wear gowns and gloves and use dedicated equipment to prevent the spread. The Dutch called their strategy “search and destroy.”
A growing number of hospitals in the United States have proved that such precautions work here, too. Recently, a pilot program using screening at Presbyterian University Hospital, in Pittsburgh, reduced M.R.S.A. infections by 90 percent. At a Yale-affiliated hospital in New Haven, screening reduced M.R.S.A. infections in intensive care by two-thirds.
And a recently completed nine-year study at the Brigham and Women’s Hospital, in Boston, found that screening led to a 75 percent drop in M.R.S.A. bloodstream infections among intensive-care patients and a 67 percent decline throughout the hospital. Earlier efforts to stop these infections by installing many more dispensers of hand cleanser and conducting a yearlong educational campaign on hand hygiene had no effect.
Some public health advocates recommend screening only “high-risk” patients — those who recently have been hospitalized, live in nursing homes or have kidney disease. Partial screening is somewhat effective, but universal screening prevents the most infections.
Can hospitals afford to screen for M.R.S.A.? They cannot afford not to. Infections wipe out hospital profits. When a patient develops an infection and has to spend many additional weeks hospitalized, Medicare does not pay for most of that additional care.
Treating hospital infections costs an estimated $30.5 billion a year in the United States. Prevention, on the other hand, is inexpensive and requires no capital outlays. A pilot program at the University of Pittsburgh found that screening tests, gowns and other precautions cost only $35,000 a year, and saved more than $800,000 a year in infection costs. A review of similar cost analyses, published in The Lancet in September, concluded that M.R.S.A. screening increases hospital profits — as it saves lives.
Yet, for a decade, the C.D.C. has rebuffed calls for screening, most recently from a committee of the Society for Healthcare Epidemiologists of America. C.D.C. officials claim that more research is needed to prove the benefits of screening. More research cannot hurt, but we know enough already to move ahead.
Some hospitals are leading the way, including Evanston Northwestern, in Illinois; the Veterans Affairs medical centers; New England Baptist Hospital, in Boston; and Johns Hopkins Hospital, in Baltimore.
The C.D.C.’s lax guidelines give many other hospitals an excuse to do too little. Every year of delay costs thousands of lives and billions of dollars.
Betsy McCaughey, a former lieutenant governor of New York, is the founder of the Committee to Reduce Infection Deaths.
11-14-06
Republican Senator Grassley’s investigation of not-for-profit hospitals may have prompted a political action committee funded by a not-for-profit hospital to give tens of thousands in campaign contributions to try to regain a Democratic majority in the Senate, and thus oust Senator Grassley from the chairmanship.
Hospital Leaders Help Fund Effort to Aid Democrats
11-14-06 A book by Janet Lyn Mitchell titled Taking a Stand discusses how she recovered from her doctors’ egregious mistakes to become an advocate for patients rights. Book Chronicles Woman's Effort to Forgive Surgical Cover-Up
11-14-06 Betsey McCaughey’s op-ed castigates the CDC for once again refusing to recommend a simple, life-saving nasal or skin swab to prevent hospital acquired infections.
11-01-06
In an excellent article whose title says it all – “Europe is killing off hospital infections. Why isn’t the United States following suit?” – the author points out that “[i]f you are an American admitted to a hospital in Amsterdam, Toronto or Copenhagen these days, you’ll be considered a biohazard.”
Why isn't the US killing off more hospital infections?
11-01-06 The CDC issues new guidelines to control hospital acquired infections. Incredibly, despite the huge mortality rate, there continues to be resistance in American hospitals to even the most basic infection control.
CDC issues new guidelines on hospital infections
11-01-06 Parade magazine advises how to survive your local Emergency Room.
How To Survive Your Local ER
11-01-06 Nearly 40% of NIH scientists are reportedly searching for new jobs after new ethics rules were implemented.
Ethics Rules Send NIH Scientists Packing
11-01-06 Websites that compare hospital quality are often confusing for consumers.
Daunting data: Hospital flaws go public
11-01-06 A Virginia judge ruled that a physician cannot claim a defense of charitable immunity from malpractice just because that physician supplies indigent care.
Judge rejects doctors' claim of immunity
10-22-06
A small medical insurer in Illinois’s medical malpractice market is reducing its rates. Medical malpractice legislation that required insurers to share information on rate-setting allowed this small insurer to set their rates competitively.
Minor insurer is cutting malpractice rates for doctors
10-22-06 Newsweek profiles ten hospitals that are using innovative approaches to solve problems. Fixing America's Hospitals
10-11-06
A new study examining missed or delayed diognosises in office settings found that most mistakes were due to failure to order appropriate diagnostic tests, failure to create proper follow-up procedures, failure to obtain an adequate history or perform an adequate physical exam and incorrect interpretation of tests.
Study Links Doctor Errors, Bad Diagnoses
10-11-06
Wrong-site surgery is more common than previously believed and measures to combat it are inadequate.
Wrong-Site Surgery
10-11-06
A four-part series on PBS looks at hospital-acquired infections, medical errors and other problems facing the health care system.
Local health care efforts key part of PBS series exploring ...
10-11-06 The Charleston Area medical Center will be implementing the SHEA guidelines to prevent the spread of MRSA.
10-11-06 Newsweek magazine profiles ten hospitals that are implementing innovative programs to improve patient safety and health care.
Fixing America's Hospitals
9-29-06
A fatal drug mix-up at an Indianapolis hospital occurred when a pharmacy technician mistakenly stocked a cabinet with the wrong medicine and the nurses failed to notice the slight variation in name and color.
Fatal drug mix-up exposes hospital flaws
An Institute of Medicine report calls on the FDA to implement major changes to ensure the safety of new prescription drugs.
Prescription Drugs | IOM Report Calls on FDA To Improve Consumer Safety;
The body of broadcaster and TV personality Alistair Cooke falls victim to a fraud involving cadaver tissue.
More gruesome details about Alistair Cooke death
The skyrocketing growth of CA MRSA (USA 300 cited here) means that these strains are now becoming endemic to healthcare because there is no screening and isolation of high-risk admissions. According to this article, this is now happening in 44 States. The new HICPAC Guideline falls short of addressing this. The implications are enormous.
Quick rise of drug-resistant germ concerns doctors
Data on health benefits from automaker General Motors reveals that it loses about $4million a day due to medical errors and inefficiencies.
A sloppy, inefficient medical system costs lives and billions of dollars
9-27-06
Doing The Right Thing (and Figuring Out What That Is)
Barry M. Farr, MD, MSc
9-22-06
Top officials at the CDC received premium bonuses in recent years at the expense of scientists and others who perform much of the agency’s scientific work.
Inner Circle Taking More of CDC Bonuses
Three lawyers have sued the South Carolina state Board of Medical Examiners, saying a new law requiring out-of-state doctors to get a temporary medical license before testifying in court is unconstitutional.
Lawyers sue over doctors' licensing rule
A coroner’s jury in Illinois has declared the death of a heart attack victim who spent almost two hours in a hospital waiting room to be a homicide.
Death after two-hour ER wait ruled homicide
A medical malpractice cap in South Carolina that took effect in July 2005 has not lowered premiums in that state.
Malpractice cap hasn't lowered premiums
Concern over a 2004 outbreak of CA-MRSA in at least 2 health care workers at Johns Hopkins University has prompted doctors at Hopkins to call for tighter infection control guidelines and procedures. A 2004 study, prompted by this outbreak, found CA-MRSA – an even more aggressive form than HA(Hospital acquired)-MRSA – to be present throughout the clinic, including patient exam table surfaces, patient chairs and countertops. Tragically, awareness that not “just patients” can suffer and die from MRSA may prompt more hospitals to
implement and enforce long overdue, effective, infection control guidelines.
Source: Johns Hopkins Medical Institutions
The CDC is under investigation by the Government Accountability Office, an inspector general and two members of Congress.
GAO joins inquiry of CDC with 2 audits
9-12-06
In a rare joint letter to CDC Director Julie Gerberding, five of the six former directors expressed great concern over an exodus of key leaders and scientists from the CDC. all 4 news articles
9-12-06
Robert F. Kennedy Jr. investigates the link between thimerosal and speech delays, attention-deficit disorder, hyperactivity and autism, and efforts by top CDC and FDA officials and major vaccine manufacturers to cover up damaging data.
Deadly Immunity by Robert Kennedy Jr.
9-12-06
In this opinion piece, the author cautions that instead of limiting victims compensation in medical malpractice cases and denying them their to right to a jury trial, insurance companies must not be allowed to reap profits from good and caring doctors and hospitals in such huge sums that these health care providers will no longer be able to provide appropriate care.
www.stopmedicalerror.com
9-3-06
“Chief executives at charitable hospitals in Massachusetts received substantial pay and benefit increases in fiscal year 2005, for the first time boosting their overall compensation to more than $1 million at most of the largest institutions.” Hospitals say they need to keep talented people, but the Massachusetts Nurses Association is highly critical, noting that they have been asked to accept reductions in their compensation. Hospital CEOs join the $1m club
9-3-06
Physicians from abroad are increasingly filling the shortage of primary care doctors in the U.S. The new face of family practice
9-3-06
The California State Legislature is considering a bill that would allow California’s Department of Health Services to fine hospitals up to $100,000 for serious lapses in patient care.
Crackdown on Lapses in Patient Care Moves Through California Assembly
9-3-06
Robert M. Wachter, M.D., writes that the “quality and safety of health care is not just about the quality of individual practitioners, it is also about the systems of care in which we health care professionals work and in which you receive your care.” He discusses what the medical system can learn from the aviation industry, among others.
Curing medical mistakes
9-3-06
More bad news about MRSA and what you can do about it.
Drug-Resistant Staph May Get Nastier
9-3-06
In a disturbing trend, a defense of charitable immunity has increasingly been raised by Virginia doctors to insulate them from medical malpractice claims.
Physicians' defense stalls case
9-3-06
Some question whether doctor owned facilities, such as free-standing surgery centers and imaging centers, promote overuse by doctors.
Doctor-owned facilities offer convenience, controversy
8-28-06
Many public health advocates are upset that even though the EPA has banned the use of lindane as a pesticide, the FDA allows its continued use to treat lice and mites.
8-28-06
The VA Pittsburgh Healthcare System is spearheading an effort to help veterans hospitals around the nation eliminate MRSA.
VA starts war on bacterial infection
8-28-06
Commenting on the health care system’s lack of effective MRSA prevention, Dr. Barry Farr, professor emeritus at the University of Virginia notes that “[i]nfections spread by people in beautiful white coats have killed more that al-Quaida ever has.”
Caregiving: Choosing a hospital -- Part 5
8-28-06
MRSA has claimed the life of a baby in suburban Chicago.
8-28-06
Congress is cracking down on conflicts of interest within the Centers for Disease Control. A bill has been introduced that would give responsibility for vaccine safety to an independent agency within the Department of Health and Human Services, removing it from the CDC to avoid conflicts of interest with the large pharmaceutical companies.
Lawmakers Sever Ties Between CDC And Big Pharma
8/25/06
Surgical suffering made her an activist
Boonsboro resident's mother caught on fire in operating room
8-20-06
A new study published by the New England Journal of Medicine, which looked at patients treated in New York, Los Angeles and nine other cities, found MRSA to be present in 59% of skin and soft-tissue infections treated in emergency rooms. It also found that many of these patients had USA300, a virulent new form of MRSA transmitted in the community, outside hospitals. The study suggests doctors should presume MRSA is present and prescribe the appropriate antibiotic, such as trimethoprim-sulfa. The Wall Street Journal, 8-17-06.
8-20-06
According to a study published in the Archives of Internal Medicine, doctors in the U.S. and Canada, while generally supporting the disclosure of medical errors to patients, vary on when and how they would tell patients. If a more apparent error has occurred, the doctor is more likely to disclose it even though “[b]asing disclosure decisions on whether the patient was aware of the error is not ethically defensible.” A second study found similar attitudes toward error disclosure in the U.S. and Canada despite the different malpractice environments. In fact, doctors’ fear of lawsuits did not affect their support of disclosing medical errors. “The medical profession should consider whether the culture of medicine itself represents a more important barrier than the malpractice environment to the disclosure of harmful medical errors to patients.”
Physicians More Likely to Disclose Medical Errors That Would Be Apparent to the Patient
8-20-06 A study at Seattle Children’s Hospital & Regional Medical Center found that children with leukemia who received treatment as outpatients had a 20% chance of being given the wrong medication or dosage. The study looked at each possible point for error, from the doctor’s prescription to the pharmacy to dosing by parents or caregivers. No mistakes were made by the pharmacy; many errors were committed by parents.
Study finds 1-in-5 chance of error in kids' cancer drugs
8-20-06
Many patients and doctors bemoan the increased presence of corporate medical practices, where nurses and assistants take on more of the tasks and patients receive less time with physicians and a poorer quality of care. The insurance industry often encourages the formation of corporate practices to enlarge their network and increase their profits.
Critical care can get lost in corporate medical practices
8-20-06 A study by Dartmouth Medical School has found that medicare patients in Elyria, Ohio receive angioplasties at a rate four times the national average. The question arises whether the financial incentive to perform the more lucrative angioplasty, as opposed to giving the patient heart drugs, influences medical decisions.
Heart Procedure Is Off the Charts in an Ohio City
8-14-06
Patients who are concerned about the cost of healthcare are often frustrated when hospitals either refuse, or are unable, to tell them the cost of routine medical procedures. With more consumers covered by high deductible health insurance, the ability to comparison shop for the best priced medical procedure remains difficult.
Some health care providers and insurance companies are attempting to change this.
8-14-06
A South Carolina jury awarded $30 million to the estate of Dr. Asif Sheikh. Lawyers in the state were astonished at the large award. Due to an agreement reached early in the trial limiting the hospital’s exposure, the family will likely receive only a small percentage of the award. Although South Carolina does have medical malpractice caps, Dr. Sheikh’s death occurred before the caps were in place.
$30 million awarded in death of physician
8-06-06
Millions of medical mistakes occur in pathology labs, where millions of blood samples, biopsies and tissue specimens are analyzed every year, and in radiology labs. These mistakes can have devastating consequences for patients. There are steps you can take to protect yourself.
Gambling With Your Life
8-06-06
In an unusual case in Atlanta, a remorseful doctor apologizes and tells his patient to sue him.
Doctor apologizes, tells patient to sue
8-06-06
In an important medical malpractice case, a family receives a substantial settlement from Ohio State University Medical Center for the care of their daughter, which means she will not have to go back to a Medicaid program. The family will now be able to provide for her at home, which is what they wanted to do, and the taxpayer will no longer have to provide for her care.
Injured patient's case settled
7-30-06
A survey by the Union of Concerned Scientists reveals concern among a number of scientists that the FDA too often places less emphasis on product safety than on speeding new drugs and medical devices to market. Senator Barbara Mikulski of Maryland notes that many FDA employees feel that public safety is being compromised.
Criticism of FDA resurfaces in survey of agency scientists
7-30-06
The following link provides the statement of Joanne Doroshow, Executive Director, Center for Justice and Democracy, before the House Committee on Energy and Commerce, Subcommittee of Health, on July 13,2006, regarding the issue of Health Courts.
http://www.centerjd.org/issues/ECtestimony060713.pdf
7-24-06
In an extremely important development, Johns Hopkins Hospital and Franklin Square Hospital will begin screening patients for MRSA (a virulent antibiotic resistant infection) improve hygiene practices and isolate those testing positive for MRSA. The Coalition for Patients' Rights was the force behind this year's state legislation that, had it passed, would have required all Maryland hospitals to implement these measures.
2 hospitals to test for bacteria
7-24-06
The Institute of Medicine estimates that medication errors injure more than 1.5 million Americans every year.
Drug errors costing billions
7-20-06
Having an advocate with you when you undergo medical treatment is extremely important. In Seattle, an entire softball team "went to bat" for an injured team member. In Redmond, Jan Harris founded Angel Care which provides volunteers who advocate for breast cancer patients. As nurses become more overworked, patient advocates become even more crucial.
Medi-pals there to help during a critical time
7-18-06
The Washington Post reports on Catherine Lake, a CPR board member, who campaigns tirelessly to educate the public about surgical fires. Her mother died 18 months ago after being set on fire in the operating room, and a subsequent series of medical errors. Although mandatory reporting is not required by any health organization, health industry experts hear of one to three fires a week. Lake is pushing for better training within hospitals and “mandatory reporting of surgical fires and full disclosure to families of hospitals investigations and subsequent actions.”
Frederick Mother's Burning Inspires Daughter's Activism
7-18-06
The Los Angeles Times reports on the pros and cons of electronic medical records and what government, medical and consumer groups are or are not doing to protect patients’ privacy.
At risk of exposure
7-18-06
A couple’s decision to question their doctor’s determination that a C-section was necessary led to consultation with a patient advocate and, ultimately, transfer to a high-risk hospital where a successful vaginal delivery was performed. Patients who question their hospital care generally can request a patient advocate or ethics consultation.
When doctors, patients clash: a solution
07/14/06
Peter Curson, director of the health studies program at Macquarie University in Australia, writes in the Sydney Morning Herald that instead of spending billions of dollars on planning for the potential harm that a bird flu pandemic might cause, we should focus on current problems such as health care and hospital-acquired infections.
Beware the pandemic of hysteria
A nationally known drug treatment doctor is on trial in Portland, facing a total of 68 criminal charges.
Trial Begins For Doctor Accused Of Writing Illegal Prescriptions.
A Florida doctor is sentenced to life in prison for causing the deaths of five of his patients through overdoses of potent painkillers.
A Panhandle Doctor Sentenced to Life.
Becton Dickinson of Franklin Lakes, New Jersey has recently acquired GeneOhm Sciences, which makes a 2-hour diagnostic test for MRSA (a deadly infection). These rapid tests will be crucial weapons in the fight against hospital-acquired infections. Not only will screening patients for MRSA save thousands of lives and untold suffering, but they will also greatly reduce health care costs. If hospitals won’t, literally, clean up their act to prevent pain and death, they may finally be pushed to do so because “federal centers for Medicaid and medicare services plan to end reimbursements for expenses arising from hospital-acquired infections by mid-2008.”
http://www.newhousenews.com/archive/may071106.html
The New York State Health Department is investigating the deaths of 2 children at Stony Brook University Hospital. One child’s heart stopped after routine adenoid surgery. The other was given a drug at full strength, which should have been diluted. As recently as February of this year, the hospital had been cited for violations “related to their quality assurance program.”
Dr. Irvin Krukenkamp, former chief of cardiothoracic surgery at Stony Brook, has gone public with his concerns for patient safety at the hospital. His current statements come after receiving a $3.3 million settlement from the hospital in September after the hospital retaliated for his previous outspokenness about patient safety.
Doctor shares concerns over safety
The Journal of the American Medical Association (JAMA) says it was misled by researchers who failed to disclose financial ties to drug companies when submitting their recent article for publication. JAMA’s editor-in-chief acknowledges that readers need to know about researcher’s financial ties to properly evaluate their studies.
JAMA Says Docs Misled Over Industry Ties
7-10-06
In a New York Times editorial, Dr. David Goodman comments on the recent call by the Association of American Medical Colleges to increase the number of doctors by 30%. Dr. Goodman notes that more doctors, who would most likely settle in areas like New York and Florida where there are already plenty of doctors, do not lead to better health care or more patient satisfaction. The Dartmouth Atlas of Health Care, in a study that included comparing the Miami and Minneapolis health care markets, found that the increased number of doctors per elderly patient in Miami led to more hospitalizations and more diagnostic tests but not to better health. Dr. Goodman speculates that one reason for this may be that with more doctors and more hospitalizations, patients’ risk of medical errors increase.
Michael Preston, outgoing executive director of MedChi, the state medical society, answers a Baltimore Sun reporter’s questions about physician quality and accountability.
******************
In 1983 the CDC recommended that all healthcare institutions identify and isolate those colonized or infected with antibiotic-resistant bacteria. These recommendations have been ignored by most institutions, including the CDC itself.
In May, 2006, the CDC gave $10 million to five academic centers for research to “find better ways to identify and prevent healthcare associated infections”. (May 6, 2006 Press Release)
This a terrible waste of money. An effective infection control protocol already exists. In 2003, the Society of Healthcare Epidemiology (SHEA) published guidelines for the control of MRSA and VRE (two of the most pervasive antibiotic resistant bacteria). Over 110 studies to date confirm the efficacy of these guidelines. Countries in Europe, as well as Western Australia, that have implemented the SHEA guidelines have virtually eradicated these bacteria from their hospitals.
The Atlanta Journal-Constitution, in a June 14th article, cites the questionable practice of the use of the CDC's private jet by Secretary of Health and Human Services Mike Leavitt, at a cost to taxpayers of $2.1 million. http://www.ajc.com/metro/content/metro/stories/0614meshjet.html
In Michigan, in 2005, Senator Bruce Patterson introduced the Safe Patient Care Legislation. The Michigan Nurses Association was the force behind this legislation which would ban hospitals from imposing mandatory overtime on nurses, require hospitals to implement minimum nurse to patient ratios and require hospitals to include nurses when deciding appropriate nurse staffing levels. California passed a bill mandating nurse to patient ratios in 2004.
In California, during the 2005-2006 session, Senator Elaine Alquist introduced the Hospital Error Reporting and Safety Act. It requires that hospitals report medical errors within 48 hours and requires the Department of Health Services to investigate, report and post their findings within 45 days.
In Massachusetts, An Act Ensuring Patient Safety has been filed by Representative Christine Canavan, RN, with the support of the Massachusetts Nurses Association and Coalition to Protect Massachusetts Patients. This Act mandates nurse staffing "which is sufficient to care for the planned and unplanned needs of patients."
http:/www.massnurses.org/safe_care/Safe_Staffing/what.htm
Robert B. Schultz, M.D., is a retired pediatrician with 40 years of clinical and academic experience. Writing for HealthLeaderNews, he notes that he observed many JCAHO site visits to hospitals and found them to be carefully choreographed presentations and ultimately ineffectual in monitoring or improving patient safety. Nurse to patient ratios suddenly increased on the day of the site visit and cleanliness became a top priority. Unfortunately, these disappeared when the visit was over. In addition, Dr. Schultz faults JCAHO for increasing an already overburdened nursing staff with paperwork.
Dr. Dennis O'Leary, head of the JCAHO, is retiring next year. He recently spoke out against the slow process of reforming the health care system. http://www.dailyherald.com/search/printstory.asp?id=205612
A 2004 challenge, titled "100,000 Lives Campaign", by Dr. Donald Berwick – a Harvard professor and president of the Institute for Healthcare Improvement – to hospitals to reduce medical errors by implementing 6 specific changes in patient care has saved an estimated 122,300 lives to date.
The Wall Street Journal reported on May 8, 2006 about hospitals that design their new facilities with patient safety as a top priority. Taking a cue from the automobile and aviation industry, where standardization has improved safety, St. Joseph’s hospital in Wisconsin has standardized hospital rooms. The rooms are identical, with medical equipment and instruments in the same place so that doctors and nurses can easily find them. Filters and ultraviolet light trap and kill germs. Tiles absorb sound. Lighting simulates natural light for better diagnosis. The bathroom is located near the bed to prevent falls and flooring is non-slip. At the University of Michigan Health System's new children and women's hospital in Ann Arbor, the air is not recycled, thus decreasing the risk of the spread of germs.
******************
While praising Dr. Berwick's efforts to improve the health-care system, some question the number of lives saved – 122,300 – as reported by the Institute for Healthcare Improvement ( IHI ). These critics point out that this number reflects self-reporting from hospitals (maybe only those hospitals with good results reported). In addition, there are no means to tell exactly what was responsible for the saved lives. Dr. Berwick agrees, telling Wall Street Journal reporter Carl Bialik that "it would be stupid" to assume these improvements came solely from IHI’s efforts. Nevertheless, all can applaud any effort to improve the health-care system and save lives.
Accounting for safety
Studies on Medical Errors
Warrant a Second Opinion
******************
The Wall Street Journal reported on June 28, 2006 that the Joint Commission on Accreditation of Health Care Organizations is requiring hospitals to develop standards for "hand-off" or transfer-of-care communication. Effective "hand-off" communication is crucial to prevent errors when patients are moved from one unit to another or a new doctor or nurse takes over during a shift change. Standardized hand-off communication already exists in the air-traffic control industry and the military, where errors can also have devastating consequences. The Institute for Healthcare Improvement (mentioned above) is working with some hospitals on a communication model with the acronym of SBAR – Situation (describe the situation), Background, Assessment and Recommendation. Other hospitals are developing similar hand-off procedures, standardizing and structuring communication to decrease the chance of tragic errors.
******************
A new idea in tort reform involves the establishment of special health courts. These health courts would handle medical malpractice cases which would be outside the regular civil court system, and not subject to appeal to the civil court system. Recently, the U.S. Senate Committee on Health, Education, Labor and Pensions looked into the possibility of establishing experimental health courts. Those in favor of special health courts claim that such courts would provide malpractice victims with more consistent compensation and eliminate the doctor's fears of huge verdicts being unjustly returned against them, and protect them from "frivolous litigation." In fact, the Harvard School of Public Health, in an independent review, has concluded that there are extremely few frivolous lawsuits. There are many more egregious cases of clear medical error for which no compensation is ever received. In addition, there are numerous problems with special health courts. Many fear that a fixed award schedule, which would be applied by these courts, is equivalent to establishing ceilings on awards. Also, judges would have backgrounds similar to that of the defendants. Furthermore, without the threat of litigation, doctors will be reluctant to settle.
Health Courts' Proposed to Fix Civil Malpractice System
******************
7-6-06
The Wall Street Journal, in an article by David Wessel titled "Grading Surgeons May Be Healthy Practice", looks at the practice of some states of issuing report cards on doctors and/or hospitals. The Harvard School of Public Health found that cardiac-bypass surgeons that got bad marks were more likely to give up surgery than those who scored higher marks. In Madison, Wisconsin, where hospitals were given report cards, patient care improved. Hospital concern for their reputation and fundraising ability were cited as motivating factors.
******************
7/10/06
In a New York Times editorial, Dr. David Goodman comments on the recent call by the Association of American Medical Colleges to increase the number of doctors by 30%. Dr. Goodman notes that more doctors, who would most likely settle in areas like New York and Florida where there are already plenty of doctors, do not lead to better health care or more patient satisfaction. The Dartmouth Atlas of Health Care, in a study that included comparing the Miami and Minneapolis health care markets, found that the increased number of doctors per elderly patient in Miami led to more hospitalizations and more diagnostic tests but not to better health. Dr. Goodman speculates that one reason for this may be that with more doctors and more hospitalizations, patients’ risk of medical errors increase.
******************
Michael Preston, outgoing executive director of MedChi, the state medical society, answers a Baltimore Sun reporter's questions about physician quality and accountability.
A robust voice for state's doctors
******************
The Florida Supreme Court is being called upon to untangle Constitutional
Ammendment 7, which gives patients the right to medical error records from
hospitals, from a statute interpreting that Ammendment.
Resolving 'right to know' will take time
******************
A Federal judge in Utah allowed a case to go forward against government
officials who sought to remove a child from his parents custody because his
parents believed he did not need to have chemotherapy.
http://www.sltrib.com/justice/ci_3948653
The Canadian Medical Association Journal reports on the spread of CA-MRSA (community acquired methicillin-resisistant Staphylococcus Aureus). Typically acquired in hospitals as HA-MRSA (hospital acquired), the infection of healthy adults and children outside the hospital has been increasing. Historically, CA-MRSA appeared among those groups in the community who were known to be at high risk – the homeless, crack cocaine smokers, prison inmates and gay men. Now, however, CA-MRSA has been found in day-care centers and on sports teams, both in Canada and in the U.S.
In Trinidad and Tabogo, three nurses have contracted MRSA from their
patients. The full report can be found at: