Items in the News
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 Y