Maryn McKenna

Journalist and Author

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.

It’s flu season: Watch for MRSA pneumonia.

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Via the (Tucson) Arizona Daily Star, I’ve just caught up with the very sad story of Robert Sweitzer, a Tucson resident who died on his 39th birthday, of MRSA pneumonia.

Sweitzer died last Feb.10, but his name is in the news now because a lawsuit filed by his wife Rachel against the hospital where he died has just been scheduled for a Sept. 2009 trial.

The apparently undisputed facts of the case (according to news reports that I cannot usefully link to because they require registration) are:

  • Sweitzer was a healthy man, married three years, who worked a full-time job and devoted all his spare hours to animal rescue.
  • On Saturday, Feb. 9, he woke up feeling as though he were coming down with a cold, with a cough and low back pain. He and his wife went to a regular volunteer shift at a local cat shelter, but by evening, he was having trouble breathing. They arrived at St. Mary’s Hospital ER at 6:30 p.m.
  • Sweitzer was triaged within a half-hour, judged to be a low-acuity case, and sent to wait.
  • It was February, the height of a bad flu season, and the ER was slammed with 170 patients.
  • Sweitzer’s breathing and back pain got worse and his wife twice asked unsuccessfully for him to be re-evaluated.
  • When he was finally seen at 2:30 am, an X-ray showed his lungs filled up with fluid. He was put on 100% oxygen.
  • He arrested twice and was pronounced dead near 7 a.m.

Following an autopsy, the Pima County Medical Examiner and the Arizona Department of Health Services asked the Centers for Disease Control and Prevention to evaluate Sweitzer’s case; based on the extensive lung destruction, they feared he died of hantavirus. Tissue samples were sent to the CDC, which reported in August that Sweitzer actually died of necrotizing pneumonia caused by MRSA.

We have talked before (here, here, here, here and here) about the particular danger of MRSA infection during flu season, when (it is theorized) micro-trauma to the lungs by flu infection allows MRSA to gain a foothold. Once it begins, MRSA pneumonia proceeds with incredible speed — I have spoken to parents whose children went literally from apparently healthy to dead or close to it, within 24 hours — and it is commonly mistaken either for flu or for community-acquired pneumonia, the usual drugs for which have no impact on MRSA.

So, constant readers: It is flu season. Please get a flu shot. The observations and research on this are still limited, but it does appear that if you prevent flu, MRSA will have a more difficult time gaining a foothold in the lungs. (And if you nevertheless find yourself in a situation similar to Robert Sweitzer’s, and you truly believe it is life-threatening for yourself or your loved one, do whatever is necessary to direct clinical attention to you in time.)

Because I cannot link through to the Arizona Star stories, here are the dates and headlines:

  • 20 February 2008, “His pet projects: rescuing dogs, cats,” byline Kimberly Matas
  • 16 March 2008, “39-year-old’s ER death leaves a lot of unanswered questions,” byline Carla McClain
  • 27 August 2008, “Feb. death of Tucson man, 39, tied to staph,” byline Stephanie Innes
  • 1 December 2008, “Suit over death at St. Mary’s ER set for trial in September” (no byline).

British infection control: Epic fail

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Via the Guardian comes news that British hospitals are failing miserably at hygiene and infection-control targets set by the Healthcare Commission, a government-funded but independent watchdog agency somewhat analogous to the United States’ Joint Commission (formerly called JCAHO).

While community-associated MRSA is still a somewhat new story in the the UK, hospital or nosocomial MRSA is a major epidemic, with resistant Clostridium difficile (“C.diff”) coming close behind. So there has been significant attention paid in the UK to improving infection control programs in hospitals, through the vehicle of benchmarks set for the National Health Service trusts (essentially, regional organizational groupings of hospitals).

And the results, according to unannounced spot-checks made by the UK commission, are appalling. Only 5 of 51 trusts ( 51 = 30% of all acute-care hospitals in the UK) that were checked hit the mark. For those slow at math, that means 3% of UK hospitals are doing what they should to protect patients from infections they cause. (UPDATE: To be fair, if we assume the “5 out of 51” holds true across the NHS, then 10% are doing what they should. That’s still appalling.)

“At nearly all trusts we have found gaps that need closing,” said Anna Walker, the commission’s chief executive. “It is important to be clear that at these trusts we are not talking about the most serious kind of breaches. But these are important warning signs to trust boards that there may be a weakness in their systems.” (Byline: Sarah Boseley)

How weak? This weak, according to the commission’s own report:

  • 27 of the 51 trusts inspected were failing to keep all areas of their premises clean and well maintained. These lapses covered issues ranging from basic cleanliness, to clutter which makes cleaning difficult, to poorly maintained hospital interiors.
  • One in five trusts in this sample did not comply with all requirements for the decontamination of instruments and other equipment used in the care of patients. Trusts that breached this duty tended to have no clear strategy for decontamination or to lack an effective process to assure compliance.
  • In one in eight trusts, the provision of isolation facilities was not adequate. The containment of infections is extremely important to managing outbreaks. Hospitals without adequate facilities must ensure they have contingency plans so that the risk of infections spreading between patients is minimised.
  • For over one in five trusts there were issues related to staff training, information and supervision. While training on preventing and controlling infection was often in place, boards could not always ensure that training days were well attended or that staff used their knowledge in practice.

UK hospitals have until next April to learn to hit these benchmarks or be held accountable under a new Care Quality Commission.

For infection-control geeks, the full text of the “hygiene code” which the hospitals must abide by is here. Details of inspections at individual trusts are here.

New newspaper series on HA-MRSA

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The Seattle Times this morning launched an three-day investigative project on incidence of HA-MRSA in Washington State that is worth reading.

As readers here already know, MRSA is not a reportable disease, and there are no diagnosis codes that directly correspond to MSRA that make infection or death easily trackable through hospital records or death certificates. The Times’ team came up with some innovative data-drilling techniques and apparently did a massive amount of number-crunching to come up with the incidence estimates that underpin their reporting. They use those to challenge hospitals’ reluctance to undertake surveillance and treatment that would wipe out MRSA on colonized patients and thus reduce the likelihood of MRSA infecting those patients or spreading to others via healthcare workers who neglect infection control. (NB, Michael Berens, the series’ co-author, did a huge project on nosocomial infections when he was at the Chicago Tribune a number of years ago.)

I am puzzled by one thing I am seeing on the story’s web page — one of the items in the break-out box that sums the story up very quickly to attract eyeballs to it. It says: “About 85 percent of people infected with MRSA get the germ at a hospital or other health-care facility. ” That figure doesn’t make sense to me; it sounds as though it is a mis-translation of the CDC finding a year ago (in the Klevens JAMA paper) that approximately 85% of invasive cases of MRSA have hospital-associated risk factors. Constant readers will remember that estimate has been challenged by researchers on community MRSA, who believe that CA-MRSA accounts for a much larger proportion of the current epidemic than has been acknowledged, and think that the wide spread of the community strain is the actual driver of the overall epidemic. I can’t see where in the text the Times team has done the math to support that assertion, so if anyone else spots it, or knows the reference it comes from, please let me know.

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.

Emergency medicine in crisis (important for MRSA also)

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Constant readers may remember that, before I began this MRSA project, I spent a year as a media fellow with the Henry J. Kaiser Family Foundation, researching overcrowding and stress in emergency rooms. (Some stories from that project here, here and here.)

So I was particularly interested in and saddened by a post on the excellent blog Health Beat (now in the blogroll!) that explores in good detail why emergency rooms are so crowded and especially what the loss of experienced emergency nurses is doing to the quality of emergency care.

Why is this important for MRSA? Well, if you or a family member is struck with what looks like one of the dramatic presentations of MRSA — bone infection, rapidly progressing pneumonia, even a serious skin infection — where are you likely to take that problem? Yes, to the ER. Even if you have insurance; an increasing number of studies are pointing out that the vast majority of people waiting for care are not the uninsured or undocumented, but insured people who can’t get care from their regular doctors.

So be prepared.

Not-reimbursing hospitals for MRSA: The reaction

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You’ll remember that early in the summer we talked about the proposal by the Center for Medicare and Medicaid Services to cease reimbursing hospitals for the additional care of a patient that is required when a hospital gives a patient a nosocomial infection. CMS has been debating whether to include several types of hospital-acquired infection in the 2009 iteration of its “never event” no-reimbursement list. (CMS has not announced its final choices.)

Healthcare’s reaction has been, hmmm, not positive. At The New Health Dialogue, Joanne Kenen captures the reactions, many of which run along the lines of “infections are inevitable because patients are so sick.” But she’s also found a marvelous (and appalling?) argument that goes, more or less, “Preventing infections will be more costly, not less, because hospitals will introduce additional procedures to protect themselves.”

This recalls the intriguing and dismaying suggestion in JAMA a few weeks ago that “search and destroy” active surveillance is driven less by wanting to halt in-hospital transmission and more by hospitals wanting to build a case that patients brought the infection with them.

Surveillance to stop MRSA: Where, when, how costly, how much?

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My colleague Joanne Kenen — longtime health policy correspondent for Reuters, now a staff member at the New American Foundation, and a Henry J. Kaiser Family Foundation Media Fellow with me in 2006-07 — very kindly invited me to guest-blog at the New Health Dialogue. Most of the post is reproduced below, but please be kind and visit them so they can record the hits!

Stopping the spread of MRSA in hospitals is one of the most contentious topics in infectious disease policy right now. A small sample of the, umm, highly divergent views on the subject filled up the letters pages of the Journal of the American Medical Association last week. Community-associated MRSA has grabbed the public’s attention over the past year, but hospital-acquired MRSA remains a huge problem — so much so that the Center for Medicare and Medicaid Services has proposed treating it as a medical error and declining to reimburse hospitals for the extra care that must be given to a patient when it occurs.

Within health care, there is vociferous debate over how to control MRSA. Because MRSA can live on the skin, nostrils and other body sites for a long period of time before causing an infection — either in the person colonized by the bug or in someone else who acquired it from the colonized person — many hospitals espouse a program of checking new patients who are most likely to be carriers, including patients in high-risk units such as ICUs, new admits from long-term care facilities, and people who have had MRSA infections on the past. But a small set of institutions are pursuing a more aggressive program, variously called “active surveillance and testing,” “universal screening” or “search and destroy,” that checks every inpatient for MRSA colonization and confines them to isolation until the bug has cleared.

“Search and destroy” was the topic of an important JAMA paper and editorial last March that decided the effort wasn’t worthwhile. (A simultaneously published paper in the Annals of Internal Medicine completely disagreed.) The five letters in JAMA tear the topic apart, examining definitions, methodology, cost-effectiveness, adherence to infection control and more. The most intriguing suggests that “search and destroy” contains a hidden agenda: That if hospitals can demonstrate patients were carrying MRSA on admission, they may be able to make a case for any subsequent infections not being their fault — and so escape the lowered reimbursement rates that CMS proposes.