Maryn McKenna

Journalist and Author

One more set of recommendations

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… and then next week I’ll be back to analyzing the medical literature: A stack of interesting new journal articles is threatening to topple and bury my computer.

For the moment, though:

First, the Hearst newspapers chain has conducted a nationwide investigation into medical errors that should be required reading for anyone who wonders why hospitals can’t do a better job controlling hospital-acquired infections. It is a 7-part series focusing on the 5 states (New York, Texas, California, Connecticut, Washington) where there are Hearst papers, and hosted on the site of the San Francisco Chronicle. The introductory article says:

Ten years ago, a highly publicized federal report called the death toll shocking and challenged the medical community to cut it in half — within five years.
Instead, federal analysts believe the rate of medical error is actually increasing.
A national investigation by Hearst Newspapers found that the medical community, the federal government and most states have overwhelmingly failed to take the effective steps outlined in the report a decade ago.
… in five states served by Hearst newspapers — New York, California, Texas, Washington and Connecticut — only 20 percent of some 1,434 hospitals surveyed are participating in two national safety campaigns begun in recent years.
Also, a detailed safety analysis prepared for Hearst Newspapers examined discharge records from 1,832 medical facilities in four of those states. It found major deficiencies in patient data states collect from hospitals, yet still found that a minimum of 16 percent of hospitals had at least one death from common procedures gone awry — and some had more than a dozen. (Byline: Cathleen F. Crowley and Eric Nalder)

From that opening statement, the investigation goes on to explore many patient stories that individually are tragedies and collectively — as we here know all to well — are a scandal.

There is just one notable MRSA story in the mix, the death of a retired hospital president who contracted the bug in his own hospital. But they are all worth reading.

Second, an executive and apparently new writer named David Goldhill has written for The Atlantic a passionate and well-thought out piece on his father’s death from a hospital-acquired infection and on what needs to change for such deaths to never happen again. “My survivor’s grief has taken the form of an obsession with our health-care system,” he writes:

My dad became a statistic—merely one of the roughly 100,000 Americans whose deaths are caused or influenced by infections picked up in hospitals. One hundred thousand deaths: more than double the number of people killed in car crashes, five times the number killed in homicides, 20 times the total number of our armed forces killed in Iraq and Afghanistan. Another victim in a building American tragedy.

You may not agree with his conclusions, but it is worth reading through to the end to experience how one intelligent citizen from outside health care understands and attempts to re-think our broken system.

Infections rise, but hospital budgets – and infection control – shrink

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Bad news from the Association of Professionals in Infection Control and Epidemiology (APIC): In a survey of almost 2,000 of their 12,000 members, 41% say that their hospitals’ infection-prevention budgets have been cut due to the down economy.

According to the survey, conducted March 2009 and released Tuesday morning:

Three-quarters of those whose budgets were cut experienced decreases for the necessary education that trains healthcare personnel in preventing the transmission of healthcare-associated infections (HAIs) such as MRSA and C. difficile.
Half saw reductions in overall budgets for infection prevention, including money for technology, staff, education, products, equipment and updated resources.
Nearly 40 percent had layoffs or reduced hours, and a third experienced hiring freezes.

As we know here, there are (by CDC estimate) 1.7 million hospital-acquired infections and 99,000 deaths as a result of them, each year. These are numbers we are supposed to be trying to reduce. That is going to be less likely if less money flows toward what may already be an underfunded goal:

A third of survey respondents say that cuts in staffing and resources have reduced their capacity to focus on infection prevention activities.
A quarter of respondents have had to reduce surveillance activities to detect, track and monitor HAIs.

Disturbingly, at a time when electronic health records are such an important part of the health-reform debate, “Only one in five respondents have data-mining programs – electronic surveillance systems that allow infection preventionists to identify and investigate potential infections in real time.” (APIC press release)

The full report is here.

10 years but little progress on patient safety

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Constant readers, I’ve been away for a week — trying to get my breath back now that the chaos of the novel H1N1/swine flu is diminishing — and so I’ve missed a lot of news. Over this week, I’ll try to catch you up on it.

First up: Some of you know that, 10 years ago, the nonpartisan, Congressionally-chartered Institute of Medicine (IOM) published a groundbreaking report called To Err is Human (html here, pdf here) that jump-started examination of medical quality in the United States. That report said:

Health care in the United States is not as safe as it should be–and can be. At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented…
Preventable medical errors in hospitals exceed attributable deaths to such feared threats as motor-vehicle wrecks, breast cancer, and AIDS. …
Beyond their cost in human lives, preventable medical errors exact other significant tolls. They have been estimated to result in total costs (including the expense of additional care necessitated by the errors, lost income and household productivity, and disability) of between $17 billion and $29 billion per year in hospitals nationwide. (To Err is Human, executive summary)

The report prompted a huge groundswell of legislative interest and patient advocacy that led, years later, to the successful passage of state laws insisting on public reporting of hospital infections and more recently on disclosure of hospital-acquired MRSA.

And yet: Despite all that scrutiny and activism, we are nowhere near as far as we should be in reducing medical errors. Just in the area of hospital infections, which is our greatest interest here, there is not mandatory reporting in all states, and there is no nationwide reporting.

So says the Safe Patient Project of Consumers Union, which has produced an update to the IOM report called To Err is Human — To Delay is Deadly. They conclude:

Ten years later, we don’t know if we’ve made any real progress, and efforts to reduce the harm caused by our medical care system are few and fragmented. With little transparency and no public reporting (except where hard fought state laws now require public reporting of hospital infections), scarce data does not paint a picture of real progress.
Based on our review of the scant evidence, we believe that preventable medical harm still accounts for more than 100,000 deaths each year — a million lives over the past decade. This statistic by all logic is conservative. For example, the Centers for Disease Control and Prevention (CDC) estimates that hospital-acquired infections alone kill 99,000 people each year.

The project finds that many of the reforms recommended by the IOM in 1999 have not been created:

  • Few hospitals have adopted well-known systems to prevent medication errors and the FDA rarely intervenes.While the FDA reviews new drug names for potential confusion, it rarely requires name changes of existing drugs despite high levels of documented confusion among drugs, which can result in dangerous medication errors. Computerized prescribing and dispensing systems have not been widely adopted by hospitals or doctors, despite evidence that they make patients safer.
  • A national system of accountability through transparency as recommended by the IOM has not been created. While 26 states now require public reporting of some hospital-acquired infections, the medical error reporting currently in place fails to create external pressure for change. In most cases hospital-specific information is confidential and under-reporting of errors is not curbed by systematic validation of the reported data.
  • No national entity has been empowered to coordinate and track patient safety improvements.Ten years after To Err is Human, we have no national entity comprehensively tracking patient safety events or progress in reducing medical harm and we are unable to tell if we are any better off than we were a decade ago. While the federal Agency for Healthcare Research and Quality attempts to monitor progress on patient safety, its efforts fall short of what is needed.
  • Doctors and other health professionals are not expected to demonstrate competency.There has been some piecemeal action on patient safety by peers and purchasers, but there is no evidence that physicians, nurses, and other health care providers are any more competent in patient safety practices than they were ten years ago.

The entire report is well worth reading. Its lamentable but well-supported conclusion:

We give the country a failing grade on progress on select recommendations we believe necessary to create a health-care system free of preventable medical harm.


GlobalPost launches and SUPERBUG is there

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Constant readers, I am thrilled to let you know that SUPERBUG is among a select list of blogs invited to be featured on GlobalPost, a gutsy and innovative new online news site that launches today.

GlobalPost is the creation of Charles M. Sennott, formerly an award-winning foreign correspondent and bureau chief for the Boston Globe, and Philip Balboni, founder and former president of New England Cable News. The service links 65 foreign correspondents living in 46 countries. The founders say in their introductory note that they are:

…acutely aware of the fact that quality journalism in America is threatened more profoundly today than at any time in our history from an unprecedented combination of forces: the transformational power of technology and the internet, the dramatic erosion in the economic underpinnings of the traditional media, and a steady migration of the most devoted consumers of news as well as younger people to new content platforms, most importantly the web.
GlobalPost is a direct response to these forces. Our mission is to provide Americans, and all English-language readers around the world, with a depth, breadth and quality of original international reporting that has been steadily diminished in too many American newspapers and television networks. GlobalPost is at the leading edge of what we hope and believe will become a new flowering of journalism in the digital age, built around new models of financial support.

The site has a number of pages and options, and a notable commitment to transparency in its reporting. Sennott takes new visitors through the details in his editor’s blog. For an outside take on why GlobalPost is worth reading and supporting, read editor and digital consultant Ken Doctor’s thoughtful take.

I know that all of you who gather here regularly already understand the irrelevance of borders to infectious disease control. (For just a few recent examples, see the MRSA outbreak in a Prince Edward Island hospital, the astonishing lack of hand-washing in British health care, and the movement of the pig strain of MRSA from the Dominican Republic to New York City.)

And therefore I know you understand the crucial importance of reliable journalism from abroad. So please welcome this intriguing effort and visit the new site. I’ve placed a GlobalPost button in the right-hand column.

(And just to add, because it’s important to say such things: No money is changing hands here. I don’t get paid for being featured there, and there are no revenues accruing anywhere else. Also, nothing about being featured on GlobalPost changes anything we do or say here: The site remains on Blogger, and your comments stay within this community and continue to be moderated by me.)

Reducing healthcare infections – what it really takes

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Happy holidays, constant readers. Whatever you celebrate, I hope your days are full of security, calm and joy.

For those of you reading over the break, here’s a pointer to a post that takes us on the other side of the curtain, into the world of hospital administrators. Those of us who are concerned about nosocomial infections are often confused about why HAIs are so intractable. I mean really, how hard could it be?

This post and especially its associated comments suggests why it’s so hard. It comes from the marvelous blog Running a Hospital, which is written by Paul Levy, president and CEO of the Beth Israel-Deaconess Medical Center in Boston. As a thought experiment, he proposes getting all the hospitals in Boston (which is a LOT of hospitals: Harvard-associated, Tufts-associated, Partners, community hospitals — a huge, dense concentration) to commit to eliminating three categories of infections: central-line infections, ventilator-associated pneumonias and surgical infections, three categories for which there are well-recognized, well-tested interventions. He says:

The medical community in Boston likes to boast about the medical care here, but we don’t do a very good job holding ourselves accountable. This would be a terrific way to prove that we are serious about reducing harm to patients and that we can cooperate across hospital lines for the greater good.

It’s a stirring and elegantly simple proposal — but as we all know, simple is seldom easy, and the commenters — whom I take to be health care workers and executives as well — light up how not-easy this might be. They say:

  • It isn’t simple enough for busy employees to put into real-world practice
  • It’s unreasonable to expect hospitals in competition to collaborate
  • It’s unthinkable that insurance companies would allow this much transparency

… and on.

The entire exchange, and Levy’s blog, is worth reading. It’s a consistently succinct, thoughtful, revealing look at the complexities of modern American health care, and at the unintended consequences — such as intractable infections — those complexities can provoke.

More on MRSA pneumonia, flu and ER delays

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Folks, yesterday I posted the very sad story of 39-year-old Robert Sweitzer of Tucson, who died of MRSA pneumonia after being triaged to an 8-hour wait, in an overcrowded emergency room, during the height of flu season.

As a follow-up, I want to emphasize that while necrotizing pneumonia may seem an unusual circumstance, there is one thing in his story that is very, very common: The ER wait.

Emergency departments all over the country are suffering extraordinary stresses thanks to a confluence of factors: The unfunded mandate of mandatory ER care or at least treatment and stabilization, through the federal legislation known as EMTALA. The closure of large numbers of in-hospital beds, which make it more difficult to get patients admitted. The lack of adequate primary care, which drives people to seek ER care because they cannot get into a regular doctor’s office. The extraordinary percentage of Americans who have no health insurance — a percentage that is likely to increase as the economic meltdown continues.

How crowded are emergency departments? On average in the United States, an ambulance is diverted — denied admittance because an ER is too full to take new patients — once every minute.

To quote a bumper sticker that got a lot of use over the past few years: If you aren’t outraged, you’re not paying attention.

(Disclosure: I was a Henry J. Kaiser Family Foundation fellow in 2006-07, and spent an average of eight nights a month, for a year, as an ER observer. So ER overcrowding is something I both have witnessed up close, and feel passionately about.)

I mention all this in order to let you know that the American College of Emergency Physicians released today a state-by-state “report card” on the condition of ER care in the United States. Our average national grade? C-. (If you don’t have time for the full report, the New York Times sums it up here. If you want to do more research, three Institute of Medicine reports on the issues, from 2006, are here.)

So, again: While Robert Sweitzer’s death may seem end-of-the-curve extraordinary, the conditions that contributed to his death — a crushing overload in a community-hospital ER — are very, very common. And that should frighten all of us.

New report and recommendations, “Why Infectious Diseases Are a Threat to America”

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I’m still catching up post-ICAAC – and in addition am on the road reporting, again. But I’m trying to keep all y’all informed. (That’s a clue to my destination. Where in the US is “y’all” a single noun and “all y’all” the plural? Hint: It’s the same place where “barbecue” is only made of beef… Oh, OK, I’m in Texas, enough with the quiz already.)

While the ICAAC-IDSA meeting was happening, the very good nonprofit organization Trust for America’s Health released a report that, just in time for the election, proposed a policy framework for emerging infections and infectious diseases generally. “Germs Go Global: Why Emerging Infectious Diseases Are a Threat to America” lists five major, ongoing, under-appreciated threats:

  • Emerging infectious diseases that appear without warning (SARS, H5N1)
  • Re-emerging infectious diseases (measles, pertussis/whooping cough)
  • “Neglected” infectious diseases (dengue)
  • Diseases used as agents of bioterrorism (smallpox, anthrax)
  • Rising/spreading antibiotic resistance.

The report makes a number of important, well-argued recommendations for the next administration to consider. Several concern us particularly:

The U.S. government, professional health organizations, academia, health care delivery systems, and industry should expand efforts to decrease the inappropriate use of antimicrobials in human medicine, agriculture and aquaculture.
The U.S. Congress should amend the Orphan Drug Act to explicitly address infectious diseases like MRSA, or create a parallel incentive system to address the unique concerns in this area.

The entire report is worth reading. (If you’re short on time, there is an executive summary that covers the main points.) I recommend it.

Much new news on hospital-acquired infections

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There’s a ton of new, and conflicting, findings on prevention and detection of hospital-acquired MRSA and other infections.

First: Today, in the journal Infection Control and Hospital Epidemiology, three researchers from Virginia Commonwealth University add to the ferocious debate on “search and destroy,” the colloquial name for active surveillance and testing: that is, checking admitted patients for MRSA, isolating them until you have a result, and and if they are positive, treating them while continuing to isolate them until they are clear. “Search and destroy” has kept in-hospital MRSA rates very low in Europe, and has proven successful in some hospitals in the United States; in addition, four states (Pennsylvania, Illinois, California and New Jersey) have mandated it for some admitted patients at least. Nevertheless, it remains a controversial tactic, with a variety of arguments levelled against it, many of them based on cost-benefit.

Comes now Richard P. Wenzel, M.D., Gonzalo Bearman, M.D., and Michael B. Edmond, M.D., of the VCU School of Medicine, to say that the moment for MRSA search and destroy has already passed, because hospitals are now dealing with so many highly resistant bugs (Acinetobacter, vancomycin-resistant enterococci (VRE), and so on). They contend that hospitals would do better to pour resources into aggressive infection-control programs that broadly target a spectrum of HAIs.

The abstract is here and the cite is: Richard P. Wenzel, MD, MSc; Gonzalo Bearman, MD, MPH; Michael B. Edmond, MD, MPH, MPA. Screening for MRSA: A Flawed Hospital Infection Control Intervention. Infection Control and Hospital Epidemiology 2008 29:11, 1012-1018.

Meanwhile, the US Government Accountability Office recently released a substantive examination of HAI surveillance and response programs, in states and in hospitals, that looks at:

  • the design and implementation of state HAI public reporting systems,
  • the initiatives hospitals have undertaken to reduce MRSA infections, and
  • the experience of certain early-adopting hospitals in overcoming challenges to implement such initiatives. (from the cover letter)

The report is too thick to summarize here, but here are some key points:

  • No two places are doing this the same way — which means that data still does not match state to state
  • Experts are still divided about how much MRSA control is necessary
  • Hospitals that have undertaken MRSA-reduction programs have taken different paths
  • But MRSA control does work: It does reduce in-hospital infections, but at a cost.

This report is an important bookend to an earlier GAO report from last April that explored the poor state of MRSA surveillance nationwide. Read it if you wonder why we don’t really know how much MRSA – in hospitals or in the community – we have.

I am stillworking my way through the new Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals, released a week ago by a slew of health agencies (Joint Commission, CDC, et al.) and health organizations (American Hospital Association, ACIP, SHEA, IDSA et al.), to see how much the MRSA strategies have actually changed. If anyone has any comments, please weigh in!

UK: Hospitals’ MRSA deaths could bring manslaughter charges

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Last Wednesday was the first day of the new federal fiscal year, and therefore the day on which HHS’s new “non-reimbursement for medical errors” rule went into effect. Under this new rule (blogged here and here and covered in this New York Times story), the Center for Medicare and Medicaid Services will no longer reimburse hospitals for the increased care that a patient needs after an extreme medical error has happened. While infecting a patient with MRSA is not specifically disavowed in the rule, it outlaws reimbursement as of this year for infections associated with vascular catheters and coronary artery bypass graft surgery, and next year (Oct. 1, 2009) for surgical site infections following orthopedic procedures. (Disappointingly, CMS rejected requests to define staph septicemia and nosocomial MRSA infection as “never events.”)

Now, however, it seems that the UK government is willing to go much further than our own. According to a story in The Independent (first flagged here by ace flu blogger Crawford Killian), “tough new manslaughter laws” will allow corporations — including healthcare institutions — to be held accountable for deaths in which corporate behavior plays a role:

Maria Eagle, the Justice minister, told a meeting of more than 100 chairs and non-executive directors of NHS trusts that where managers ignore warnings of health risks, prosecutions may follow. She said: “Putting the offence into context, imagine that a patient has died in a hospital infected by MRSA and the issue of corporate manslaughter has been raised. Could the organisation be prosecuted and convicted? The answer is ‘possibly’. (Byline: Robert Verkaik, law editor)

Public attitudes in the UK are ripe for this change. In July, there was significant protest after it emerged — via a government report — that 345 patients died of Clostridium difficile infection at three hospitals, after government warnings, with no punishment to the hospitals. In fact, according to The Independent, the chief executive of the trust that operated all three was allowed to resign with $150,000 in foregone pay, and is now suing for additional compensation.

So far, US protests and citizen action over nosocomial MRSA infections have been within individual states (see this recent post on the new Nile’s Law in California). But isn’t it interesting to see what coordinated national action — granted, in a smaller country — can do.

Disease-related Do Not Fly list?

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This is not strictly MRSA-related, but it is so striking it’s worth posting on. This morning, the Centers for Disease Control and Prevention, the US public health agency, revealed in its weekly bulletin that it has begun maintaining a “Do Not Board” list for people who are thought to be a communicable-disease risk to others.

In slightly more than a year, 33 people have been refused transportation because of the list, which is operated in conjunction with the Department of Homeland Security.

The CDC began operating the list in June 2007, shortly after tuberculosis patient Andrew Speaker flew to Europe and back despite requests by public-health authorities that he not fly; he returned via Canada, driving into the United States to evade an alert given to airlines to locate him. At the time, Speaker was thought to have extensively drug-resistant (XDR) TB, an extremely dangerous form of the disease. Later, his doctors asserted and the CDC agreed that his TB was multi-drug resistant (MDR) — still dangerous, but nowhere near as dangerous as the almost-untreatable XDR form.

Patients’ names can be placed on the list by several entities though all requests are reviewed, the CDC says:

…state or local public health officials contact the CDC Quarantine Station for their region†; health-care providers make requests by contacting their state or local public health departments, and foreign and U.S. government agencies contact the Director’s Emergency Operations Center (DEOC) at CDC in Atlanta.
To include someone on the list, CDC must determine that the person 1) likely is contagious with a communicable disease that would constitute a serious public health threat should the person be permitted to board a flight; 2) is unaware of or likely to be nonadherent with public health recommendations, including treatment; and 3) likely will attempt to board a commercial aircraft.
Once a person is placed on the list, airlines are instructed not to issue a boarding pass to the person for any commercial domestic flight or for any commercial international flight arriving in or departing from the United States. (MMWR 57(37);1009-1012)

An important point here is the phrase “would constitute a serious public health threat.” Under US law (42 USC 264), most public health functions belong to the states, but the federal government is empowered to detain and isolate or quarantine people known or suspected to have a small list of communicable diseases: cholera, diphtheria, infectious tuberculosis, plague, smallpox, yellow fever, viral hemorrhagic fevers (such as Ebola), SARS, and novel strains of flu. The Do Not Board list, however, reaches beyond that list, according to the CDC bulletin:

The public health DNB list is not limited to those communicable diseases for which the federal government can legally impose isolation and quarantine; the list can be used for other communicable diseases that would pose a serious health threat to air travelers. However, to date, the list has only been used for persons with suspected or confirmed pulmonary TB, which is transmitted via the respiratory route and which has had transmission documented during commercial air travel.

Detecting and protecting against disease threats to the US is well within the CDC’s mandate. Still, this raises a huge list of questions, from how medical privacy is maintained when a patient’s name is so widely circulated, to whether healthy people with similar names will be mistaken for sick ones, to how easily people get off the list once they are deemed well.

The CDC says that, of the 33 people placed on the list in the past 15 months, 18 already have been removed. But the persistent problems with the original No-Fly list — snagging air marshals and toddlers and causing passengers to change their names — suggests that this may not be as easy to manage as the CDC thinks. It would be good to hear more about what safeguards they propose — or whether they have left that part of the issue to be handled by DHS.