Maryn McKenna

Journalist and Author

Bad news from California: MRSA quadrupled

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Via the Fresno Business Journal and the Torrance Daily Breeze come reports of a new study by California’s Office of Statewide Health Planning and Development: Known MRSA cases in the state’s hospitals increased four-fold between 1999 and 2007, from 13,000 to 52,000 cases per year.

From the Torrance paper:

The good news is that the percentage of people who die of MRSA has decreased, from about 35 percent in 1999 to 24 percent in 2007. The raw number of deaths, however, more than doubled to about 12,500. (Byline: Melissa Evans)

From the Fresno paper (no byline):

Fresno, Kings, Madera and Tulare counties were among 38 counties in California that had 61 to 80% of patients with staph infections.
Only one county, Sierra, fared worse. Eight-one to 100% of patients ended up with staph infections in that county’s hospitals.
In 1999, Kings and Madera counties were in the 0 to 20% range and Fresno and Tulare counties were in the 21 to 40% range.

100%??



My guest-post elsewhere: Bad news on hospital error rates

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It’s been 10 years since the publication of the pathbreaking Institute of Medicine report, “To Err is Human,” which for the first time focused policy attention on medical errors. The Interdisciplinary Nursing Quality Research Initiative has been running a two-week special series of posts to mark the occasion, and they very kindly asked me to contribute.

Here’s a link to my guest-post, “Hospital Error Rates — Still a Long Way To Go,” looking at a recent paper and editorial in the Journal of the American Medical Association that reported very discouraging results in rates of infections in ICUs worldwide. (And, umm, yes, that is what I look like.)

While you’re there, please take a look also at another guest post by my good friend Nancy Shute, former staff writer and now blogger for US News & World Report, who discusses the difficulty of speaking up as a patient, based on her own experience in the hospital last summer. It’s very worth a read.

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.

An inside look at combating HAIs

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I’ve been moving my RSS feeds over to a new reader and so am behind in reading things. That’s my lame excuse for not noticing an excellent story in the Washington Post Tuesday, a first-person account tracing the “conversion” of one skeptical physician to the cause of reducing hospital infections.

The story was highlighted at the New Health Dialogue, a must-read health-reform blog, by my friend and former fellow Kaiser fellow, Joanne Kenen.

US Air 1549 and the relevance of checklists

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Constant readers, when we discussed the importance of surgical checklists last week, I mentioned parenthetically that I am a licensed pilot. (For av geeks: single engine, taildragger, VFR. And, just to complete the geekery, married to an avionics engineer.) So I’ve been particularly fascinated by the story and back-story of US Air flight 1549, which — as I am sure most of you know — bellied into the Hudson last week after losing both its engines to bird ingestion and landed beautifully, with no injuries to its passengers or crew.

The landing is being called a miracle, but to a pilot, it’s no miracle: It’s a testament to excellent performance under pressure by pilot-in-command Chesley “Sully” Sullenberger III and his first officer and crew. How did they perform so well? They ran down a checklist. Why did they reach for the checklist immediately, almost instinctively, and perform so well as a group? Because they trained many, many, many times to do exactly that.

Last week’s New England Journal of Medicine article made clear the value of checklists to medicine. But patient-safety analyst Bob Wachter asks an additional vital question: Even when medicine has such measures, how often do we train to implement them? The answer, he finds, is not often:

We need to continue to work, as aviation has for the past generation, to train our “pilots” to become Sullys. Because we in healthcare are flying over some pretty cold rivers, each and every day.

(Hat tip to KevinMD.com for calling attention to Wachter’s post.)

Reducing errors: Worldwide proof that it’s not so hard

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There’s an encouraging joint announcement coming this afternoon from the World Health Organization and the New England Journal of Medicine. (I’ve set the timer on this post to publish when the embargo lifts.)

Using a simple but detailed checklist, eight hospitals in a mix of high-income and resource-poor areas were able to reduce their rates of surgical complications by one-third and their rate of death due to surgical complications by almost one-half.

The checklist study was sponsored by the WHO’s Safe Surgery Saves Lives campaign. It was headed by surgeon and author Atul Gawande, MD, who is lead author of the NEJM paper and has spoken passionately about checklists as a simple, reliable, reproducible, low-cost intervention that can return extraordinary improvements.

The checklist idea originates in medicine with Dr. Peter Provonost, Johns Hopkins University critical-care researcher and MacArthur “genius” fellow. Gawande wrote a profile of Provonost, and plea for checklist implementation, in the New Yorker in Dec. 2007, and followed that article two weeks later with a New York Times op-ed piece.

The checklist idea has been borrowed from other tech-intensive fields, notably aviation. As a licensed pilot, I can testify that no pilot or crew, no matter how experienced, would ever dare take off without running through a checklist. To believe that you can keep everything you need to do in your head without reference to an external reminder is, in aviation, simply not a credible position. It is considered an absurd display of ego that puts others at unnecessary risk. (For a taste of how aviation looks at medicine’s resistance to improvement, see Sir Richard Branson’s comments last month.)

In the current study, one hospital in each of eight cities — Toronto, New Delhi, Amman, Auckland, Manila, London, Seattle and Ifakara, Tanzania — agreed to follow a pre-, during- and post-surgery checklist for every noncardiac surgery on patients older than 16. The study group collected data before implementation of the checklist on 3,733 consecutively enrolled patients, and during the checklist implementation, on 3,955 patients.

The checklist is on the WHO website (.pdf in English) along with toolkits for implementation. If you look, you’ll see it is very simple. For instance, before anesthesia:

  • Patient has confirmed: identity, site, procedure, consent
  • Site marked (or marking confirmed not applicable)
  • Anaesthesia safety check completed
  • Pulse oximeter on patient and functioning
  • Does patient have a known allergy? (No/Yes)
  • Does patient have a difficult airway/aspiration risk? (No/Yes, and equipment/assistance available)
  • Is there a risk of >500ml blood loss (7ml/kg in children)? (No/Yes, and adequate intravenous access and fluids planned)

There are similar short, thorough and noncomplex checklists for before skin incision and before patient leaves the operating room. Amazingly — or not, for those of you who follow the struggle against medical errors — these interventions, simple as they are, were new to most of the study hospitals.

Now, the research team is careful to point out the possible confounders to this study: It introduced changes in systems at the hospitals that may have created independent effects. It may suffer from the Hawthorne effect (“Observation changes the behavior of the observed.”) Given that it used consecutively enrolled patients, it may be affected by secular trends at the individual institutions. And it does not track complications post-discharge.

All that being said, I think we can take this as a very potent argument for the adoption of surgical checklists as a component of campaigns to reduce medical errors. And, as Gawande says in the press release that WHO put out this afternoon, a pointer to possible improvements in other specialties as well:

These findings have implications beyond surgery, suggesting that checklists could increase the safety and reliability of care in numerous medical fields… [I]n specialties ranging from cardiac care to pediatric care, they could become as essential in daily medicine as the stethoscope.

The cite on the study is: Haynes, AB, Weiser, TG, Berry, WR et al. Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. N Eng J Med 2009: 260: 491-9. Published ahead of print Jan. 14, 2009.

UPDATE: The full text has been placed online for free.

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.

Sign of the times: Taking your own cleaning materials to the hospital

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There are several new and important reports out on hospital-acquired infections (HAIs) that I hope to get to this week, but I spotted something today that I just had to highlight first:

Constant readers may know that I’ve done a lot of reporting in the developing world. In parts of Asia and Africa, it is assumed that patients or their families bring food to the hospital. People do not trust the hospitals to feed them, with good reason: Hospitals can’t afford it. Provision of food in the hospital, which we take for granted, is not part of the health-care culture. (In particularly poor countries, the family may feed not only the patient, but the health care workers taking care of the patient as well.)

Here now is an industrialized-world version of that developing-world practice. A company in England (which, as we’ve discussed, has ferocious rates of hospital MRSA and C. difficile) has begun marketing the PatientPak, the “world’s first personal anti-superbug kit.” It’s a $28 sample-sized collection of antimicrobial hair and body wash, hand wipes, hand sanitizer and a germ-killing spray for sheets and cubicle curtains, along with lip balm, bar soap, and a disposable nail brush and pen.

It’s entirely possible that using products like this might protect a patient from some hospital-acquired infections; the company suggests that a patient use the wipes and the hand spray when going to and from the bathroom or after touching any surfaces. But the difficult reality, of course, is that most hospital-acquired infections are not the patient’s fault: They are due to infection-control breaches by hospital staff, something over which a patient — with antimicrobial wipes or without — has little control.

This company will probably sell quite a few of these kits — and I don’t know that I can criticize them for doing so. If one of my family members was being admitted to hospital, I might well send something like this with them. But what a sad commentary on our own health-care culture that any of us would consider this necessary.

Maybe we just build them better? (But who pays?)

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OK, campers, I know I’m tossing crumbs here, but I drove 6 hours today and am now, umm, well, not in any major metropolitan area, that’s for sure. But I’m visiting a very interesting hospital program tomorrow. And my chain motel is smack-dab between a Denny’s and a Waffle House. Just think of the breakfast options. (And imagine my arteries clogging. OK, don’t.)

Skittering back to the reason why we’re here: Via the LA Times, an intriguing article about the possibilities of reducing hospital-acquired infections by designing hospitals better: single rooms, improved airflow, more sinks, etc.

“Private rooms are the most important design element that reduces the spread of infection between patients,” says Richard Van Enk, director of infection control and epidemiology for Bronson Methodist Hospital in Kalamazoo, Mich. Bronson is a pioneer of evidence-based design and was among the first hospitals in the United States to build a facility with all private patient rooms.
The hospital’s new design also incorporates two sinks in each patient room, one of which is dedicated for the exclusive use of the healthcare worker. Many easily cleaned surface materials such as water-based low VOC (volatile organic chemical) paint, plastic counter coverings and linoleum floorings with antimicrobial properties were also used throughout the hospital. (Byline: Lisa Zamosky)

It sounds plausible to me. Superbug Spouse is an expert in human-factors design, and we both do photography and web design (he’s better), so issues like this – which way do your eyes go? what button do you naturally want to push? – get tossed about a lot in our house. And just yesterday I listened to an infection-control nurse describe the difficulty of getting healthcare workers to use sinks in older rooms in which the sinks are within the bathrooms; the HCWs perceived the bathrooms as the patients’ private space, not as accessible to all. So there may be something to this.

But retrofitting is expensive. And the bill will be paid by… ??