These Things Happen

Excerpted from Paul Levy's BLOG "Running a Hospital"

I was reminded of this by our Chief of Medicine. In the movie, It's a Mad, Mad, Mad, Mad World, Ethel Merman, playing Mrs. Marcus, says:

Now what kind of an attitude is that, 'these things happen?' They only happen because this whole country is just full of people who, when these things happen, they just say 'these things happen,' and that's why they happen! We gotta have control of what happens to us."

I am struck by the relevance of this to running a hospital.

Several years ago, we had that attitude in our hospital with regard to certain types of medical outcomes. For example, we were content with our level of central line infections because we were below the national average. After all, these things happen. Then our chiefs of medicine and surgery said, "No, they don't have to happen. When they happen, people die. We are going to insist that we achieve zero central line infections." And then they got to work. As I have noted below, it is not an easy problem to solve, but it is worth the effort, and you can improve.

One way to encourage organizational improvement is to publicize the results of your program. I have done that below for our hospital, and I have made the suggestion that others in the city could do the same. As I noted, I did not make the suggestion for competitive purposes -- after all, I don't know if our numbers are better or worse than those of other hospitals -- but because public exposure of all our efforts will drive all of us to do better. Also, it will build, rather than erode, public confidence in the academic medical centers in our city.

The response, as you have seen from the press reports, ranges from simple recalcitrance to technically sophistic arguments about comparability of data. Please, does anyone argue that the goal should not be zero? If it is zero, it does not matter whether the data is measured in cases per thousand patient-days, cases per thousand catheter-days, or just the raw number of cases.

We all keep track of these numbers in some form or another. We could easily post them in real time voluntarily on a website maintained by the state or an insurance company, along with our own explanations of how and what we measure. (And perhaps, over time, we will agree on what single metric is most useful.)

People can and will understand this. They already spend hours on the Internet reading medical websites. Why do we give them so little credit? It will demonstrate to the public that we care about this problem, and will show our individual progress towards our ultimate goal.

Finally, it will enhance the reputation and credibility of all of the academic medical centers, two aspects of our character that will be more and more under siege because of the broader problems of the health care system.

POSTED BY PAUL LEVY AT 3/08/2007 09:22:00 PM

Your Purse is Contaminated

A purse. It’s something just about every woman, teenager or girl carries with them. We throw it over our shoulder or we carry it in our hand but we also put our purses in places with lots of germs.

WSB-TV, Channel 2 in Atlanta, GA. saw women setting their purses on a public sidewalk, on the floor at their office, on the floor in public bathrooms and on table tops and counters in restaurants and bars.

“I only have two hands and if it comes between putting the baby down on the floor or putting the purse down on the floor then I will put the purse down,” said Kerry Ludlum. “I usually sit it on the floor in my van, underneath my desk on the floor at work,” said Veronica Daniels. “You put your purse everywhere. At work I put it on the floor. Of course at home, I put it on the kitchen counter, that is not a good thing to do, but I don't think people give it any thought,” said Anna Hovind. “I go to the gym a lot and I am always putting it on the floor in the gym,” said Gloria Pritchett.

These ladies aren't the only ones who put their purses in germ-laden places. Channel 2’s Jovita Moore said she puts hers on the floor all the time and then sits it on her desk at work and even on her kitchen counter. So, she swabbed it to see what kind of germs were on it.

Channel 2 also took germ samples from 37 other purses. We swabbed the bottom and handles of purses and then put those samples in sterile vials and sent them to Nelson Laboratories in Salt Lake City for analysis. After incubation and intense testing what we found was pretty disgusting.

“We had several of them that came back with fecal contamination,” said Beau Rollins, a microbiologist with Nelson Labs. You read that correctly. Fecal matter was found on a lot of the purses we tested, including Jovita Moore’s. Needless to say, the women who let us test their purses were shocked to hear that.

“I am shocked. I am embarrassed. I am…my heart is palpitating. I'm thinking fecal matter? I have a 3-year-old. Where did that come from,” asked Daniels. “That’s disgusting. That is really, really gross,” said Kelly Gallagher.

The lab technician that analyzed our samples said when he sees ladies putting their purses on restaurant tables, he cringes.

“I don't think they ever realize what they are transferring onto the plate. That is basically like wiping feces on your plate and eating it,” said Rollins.

Our testing also found the bacteria Staphylococcus Aureus. If you ingest it, it can cause serious food illness and sickness.

“My mom always said to never bring your purse home and put it on the kitchen counter or kitchen table. That was the rule always,” said Elaine Warren. Some other good rules to follow when it comes to your purse include hanging it on the hook in public bathrooms. Don’t set it on the floor. Also, clean your purse from time to time.

“I plan on cleaning that purse and all the other purses I have or getting rid of them,” said Daniels. If you have a cloth purse, throw it in your washing machine at least once a week. If you have a leather or vinyl bag, using disinfecting wipes at least once a week to keep it clean will help.

The Next BAD BUG

It's being called the next bad bug.

C-DIFF—an intestinal infection—is affecting thousands of people. In fact, it jumped 200 percent in the nation's hospitals between 2000 and 2005, according to a federal report.

If left untreated, C-DIFF can be deadly. Each year, C-DIFF is responsible for tens of thousands of cases of diarrhea and at least 5,000 deaths, according to the Center For Disease Control.

It's mostly prevalent in hospitals and is spread easily through direct contact. Antibiotics are to blame too, NBC 4's Amy Basista reported.

The bacteria don't create problems until they grown in large numbers in the intestinal tract of people taking antibiotics. "It's when there's an imbalance of bacteria either from antibiotics or sickness grows too much and makes a toxin," Dr. Mahr said.

The illness is more common in older patients. Symptoms range from diarrhea to life-threatening inflammations of the colon and include fever, abdominal pain, blood in the stool, nausea and dehydration.

Dr. Mahr advises people to wash their hands to keep it from spreading.

C-DIFF produces spores that cannot be killed by alcohol sanitizers—only with bleach.

Ironically, the thing that causes it — antibiotics — also cures it. If diagnosed, C-DIFF is treatable through antibiotics.

C diff Becoming More Prevalent

BY DAVID WENNER
The Patriot-News

The infection raged inside Kate Hannon for days before anyone could figure out what was wrong.It turned out to be C. diff, a bacteria that lives in the intestines of many people but is usually held in check by "good" bacteria.

Hannon had been taking antibiotics for acne. That likely killed too much of the good bacteria, allowing the C. diff to take over.

"Within three days I was just running to the bathroom constantly," said Hannon, who wound up spending 10 days in Holy Spirit Hospital. "Nobody had ever seen a case like mine. It was insane."

The number of hospital patients with C. diff increased by 200 percent from 2000 to 2005, according to the Agency for Healthcare Research and Quality, a government agency.

In the northeastern United States, where the infection rate was the highest, 144 in 100,000 people came down with C. diff in 2005. Of the ones who were hospitalized, the death rate was 9.5 percent compared to a 2.1 percent overall death rate for hospital patients.

C. diff often causes diarrhea and sometimes leads to more severe gastrointestinal problems and blood poisoning. Two-thirds of the people who get it are elderly.

"It's a problem. It's becoming a more prevalent problem," said Dr. Joseph Torchia, medical director at Holy Spirit. It's less common among younger people. When they get it, it often follows use of an antibiotic.

Torchia said people often have it when they arrive at the hospital. It's also prevalent in nursing homes where, according to Torchia, studies have found up to 20 percent of residents carry C. diff.

Torchia attributes much of the increase in C. diff to the "overzealous" use of antibiotics.

People who are older and weakened by other illnesses are especially vulnerable. That's why it strikes so many nursing home residents and can so easily spread.

There's also a new strain of C. diff that produces more of the toxin that causes the damage, resulting in a more severe illness, Torchia said.

Hannon, 29, is a human resources manager who lives in Susquehanna Twp. Her bout with C. diff happened four years ago. Her diarrhea became so severe that her parents took her to the emergency room. But a test for C. diff was negative, and she returned home. By the next day she was passing what appeared to be blood. Her parents took her back to the hospital, and she was admitted. Two more tests for C. diff came back negative; she didn't test positive for another week.

Hannon was given antibiotics intravenously and recovered. She had lost 10 pounds. She said she feels the ordeal has made her more vulnerable to gastrointestinal ailments, such as bloating. Her doctor also has told her she's at higher risk of future C. diff infection, and she must be careful in her use of antibiotics. "You have to weigh the risk versus the benefit," she said.

Holy Spirit has devised policies aimed at controlling C. diff. Patients who arrive with diarrhea are tested for it. Those who have it are put in isolation rooms. Everyone who enters must wear gloves and gowns and then dispose of them. Caregivers wash carefully, and rooms are sanitized.

C. diff involves a spore that's hard to kill.

"They can live for weeks on surfaces," said Joann Gallagher, the infection-control manager at Holy Spirit.

Simple Reminders Reduce Deadly Infections

New York Times
by Anemona Hartocollis

Loose strands of sweaty dark hair fell across the woman’s face, but she was too sick to push them back. She was in respiratory failure, and nurses were rushing her to intensive care. They grabbed a sheet under her body and heaved her from the gurney onto a bed as if she were a fish in a net, then attached her to a beeping monitor, hand-pumped oxygen into her lungs and got ready to administer an intravenous sedative.

“Timeout!” a first-year resident called, as the medical team at Woodhull Medical and Mental Health Center in Brooklyn was about to insert a catheter into the woman’s jugular vein.

Then he reminded everyone to wash their hands.

Timeouts to wash hands and put on hairnets, a simple checklist to ensure that such seemingly obvious precautions are done, and advertising campaigns directed at everyone from the most senior doctors to the poorest of patients have been credited with drastically reducing the number of serious infections at New York City’s public hospitals.

Since 2005, central-line bloodstream infections, which stem from bacteria invading a catheter leading to the heart and can often be fatal, have fallen 55 percent in adult intensive care units at the city’s 11 public hospitals, according to statistics released last week. Ventilator-associated pneumonia, caused by bacteria in breathing tubes and which also can be fatal, declined by 78 percent.

Before the hospital system began cracking down on them in late 2005, preventable infections were considered part of the collateral damage of advanced lifesaving techniques, such a routine occurrence that few people questioned their prevalence, or the deaths that resulted from them. In fact, there had been a perverse financial upside to hospital-based infections, since they filled beds that might otherwise be empty. But changes in government reimbursements have driven New York’s public hospitals, which serve the city’s poorest patients, to tackle the problem.

As part of a pay-for-performance plan, the federal government and many private insurers are planning to stop reimbursing hospitals for harm caused to patients by certain preventable errors.

In October, Medicare, the federal insurance program for the elderly, will no longer cover the additional cost of eight preventable complications, including central-line bloodstream infections. Some hospital administrators expect Medicaid, which covers health care for the poor, to follow suit. The government may also stop covering ventilator-associated pneumonia in 2009.

The turning point in the campaign to stop hospital infections in New York had all the glamour of compiling a grocery list.

In late 2005, the city’s Health and Hospitals Corporation adopted a series of simple, standardized protocols based on those developed by Dr. Peter J. Pronovost, a crusader against preventable hospital deaths and a professor of anesthesiology and critical care medicine at Johns Hopkins University. Dr. Pronovost calls his protocols a checklist, and that is pretty much what they are.

A red binder at the nursing station at Woodhull contains dozens of forms, labeled “Central Venous Catheter Insertion Checklist,” which instruct doctors to, first of all, make sure that they have the right patient and are planning the right procedure. The 14-item list goes on to include washing hands; putting on caps, masks, sterile gowns and gloves; draping the patient from head to toe; preparing the patient’s skin with chlorhexidine antiseptic; maintaining a sterile field; and applying a sterile dressing.

One person, usually a nurse, acts as the referee by calling, “Timeout!” and checking off the “completed” or “not completed” columns on the list as each step is called out and performed.

Dr. Pronovost, who developed his checklist at Johns Hopkins in 2001 and tested it in more than 100 intensive care units in Michigan in 2003, found that the simple hygiene it takes to avoid many infections can seem like a low priority in the frenzied atmosphere of high-tech medical care.

At Woodhull last week, when the resident called timeout for hand-washing, he was interrupting a team focused on serious and complex issues like the woman’s respiratory rate and ratio of body weight to medication.

“What’s going on in the critical care units is so complicated that the simple things get overlooked,” said Alan Aviles, president of the city’s Health and Hospitals Corporation, which administers the 11 municipal hospitals.

Dr. Pronovost, testifying before Congress last month, estimated that infections acquired during treatment affect 1 in 10 patients nationally and kill about 90,000 people a year, costing the health care system $5 billion to $11 billion.

City officials said that because patient deaths are often attributed to the primary illness rather than complications like hospital-acquired infections that may have pushed the patient over the brink, they could not provide parallel local statistics.

As an answer to a seemingly intractable problem, Dr. Pronovost’s checklist epiphany recalls the classic medical school story of Ignaz Semmelweis, the 19th-century Hungarian physician who found that deaths from puerperal fever in obstetrical clinics could be sharply reduced when doctors washed their hands. He noticed that the death rate was much lower at a clinic staffed by midwives, and traced the difference to medical students who failed to wash their hands after autopsies.

Because the checklist is so simple, its potency is easy to underestimate, Dr. Pronovost said, joking that, “If the checklist were a drug, I’d be rich.”

The secret of the checklist, he said, is focus, and the theory behind it has broad applications. He likes to illustrate his point by telling how in the Netherlands, “they paint flies on the urinals because they found that men were four times more accurate if aiming at a fly than if they weren’t.”

“It’s a simple intervention to help you focus and execute,” he said.

In an article last week in the Journal of the American Medical Association, Dr. Pronovost wrote that the new federal policy of refusing payment for some mistakes in treatment could be flawed because some errors were more preventable than others.

In principle, he said in an interview, “I actually think that’s wise policy. People suffer preventable harm in this health care system, regulators and the public get outraged by it, but we haven’t been really disciplined in trying to improve it.”

At Woodhull, the focus begins in the lobby, which can be almost as crowded as a subway platform during the evening rush.

Other than a giant Keith Haring mural, the most prominent d├ęcor is a banner that proclaims: “Clean Hands Save Lives.”

Outside of every room in the intensive care unit, there is a squirt bottle of hand sanitizer attached to the wall. “What are the top 10 carriers of infectious agents?” asks the caption of a poster on the wall, a picture of 10 fingers.

Patients have been enlisted to spread the anti-infection gospel, urged to watch whether their doctors wash their hands and to remind them if they do not. Doctors have been told to receive such reminders with a polite thank you, said Iris Jimenez-Hernandez, Woodhull’s chief executive.

“It has been a culture change,” said Dr. Jose O. Mejia, chairman of Woodhull’s department of medicine and critical care division.

But the checklist can be cumbersome and time-consuming. The team treating the woman in respiratory failure last week fidgeted nervously as they waited for their referee to tick off the items.

The attending physician, Dr. Rose Marie Flores, said doctors in the emergency room do not always have time to follow the list to the letter. But once the patients are stabilized, she said, they go back and do it all over again.

The Paralyzed Man Who Moved Us All

The True Story of Josh Nahum: The Unwitting Face of Healthcare Infections by Victoria Nahum, Co-founder of SAFE CARE CAMPAIGN (Safecarecampaign.org)

Once there was a little boy who liked to jump up and down on his bed.

Whenever the mood would strike him he’d bounce relentlessly on the soft mattress until the covers were messy and the sheets became untucked. He would laugh and laugh until he ran out of breath, his face flushed and warm as he dared to jump off the bed as far and as high as he could, onto the smooth wooden floor with a bang and a jolt that shook everything hard and made a noise so loud it got everyone’s attention.

One gray cold winter’s day when he was 12, he climbed out of his bedroom window onto the roof so that he could throw himself off and fall into nearby high-piled snowdrifts, all tall and white like those soft-serve ice cream cones, cold, vanilla and creamy – just waiting for someone to eat them. Overlooking the snowdrifts before he jumped, he imagined himself sinking all the way to the bottom of them, leaving a funny boy-shaped hole all the way down, like in those cartoons where the roadrunner runs so fast he goes right through the tree trunk.

So when he became a man, no one who knew him was surprised that the boy still jumped, only now he jumped out of airplanes with his friends from great, exciting heights into thin, crisp air through puffy white clouds that hung there in the nothingness, patiently anticipating his arrival. Yes, the man who had been a boy had to jump into the beautiful blue sky; it was like he couldn’t help it.

And to make matters worse, jumping once wasn’t good enough. No, that would never do.

Now the man jumped and jumped and jumped until he had jumped one thousand times. And still, for him, he was not satisfied. He knew he had to jump from as high as he could as OFTEN as he could for in doing so it caused his very heart to beat faster underneath his ribs, making the small, coarse hairs on the back of his neck stand straight up on end – the outward physical evidence of an inner thrill he could hardly contain.

To the man who had been a boy, jumping made him feel like he could FLY; like he was new and light and wild and free. But really, the true reason the man who had been a boy could not stop jumping was because - simply - it just made him smile.

Oh, yes – jumping was for him, for every time he plunged downward through the billowy clouds, the wind would gently call to him in this amazing musical way, speaking wonderful words only he could hear as it whipped playfully in and out of his ears as he fell, fell, fell fast toward the dull, brown ground.

One day the man who had been a boy jumped out of the airplane just like always … except this time it was different. This time he did not enjoy his usual graceful descent landing easily with both feet steady upon the solid earth. This time he crashed hard, very hard - much, much too hard to walk away from the unforgiving spot where he landed. The man who had been a boy who liked to jump became paralyzed. And then he died.

But this is not the end of his story.

The man who had been a boy who liked to jump had died doing what he loved to do. And isn’t that what we ALL want - to have lived and died, doing and being what we wanted to do and be all along?

Indeed. It is the legacy and swan song of patriots and pirates and prophets.

But this is not the end of his story either. It is only the beginning.

The man who had been a boy had NOT died because he jumped too often or because he fell too hard from his most treasured place in his most precious sky among the birds whose wings he had envied and near the stars that shined so bright.

Instead, he died because, as he was being cared for by the many who truly cared FOR him, he caught a single germ that caused an infection in the fluid around his brain. The germ created so much pressure that it pushed part of his brain into his spinal column and damaged him so badly that it took away his ability to breathe on his own ever again. Or walk. Or jump. Or fly.

Now the man who had been a boy could not even feel the cool wind that flirtingly blew at him, still beckoning him affectionately from the window of his hospital bed. Nor could he feel his fathers’ last loving embrace or the drop of his mothers’ bitter tear when it fell wet and warm upon his arm as she bent over to kiss his forehead one last time.

In the end, the man who had been a boy who liked to jump
died
so that he might BECOME
the bang and the jolt that shook everything hard and made a noise so loud it got everyone’s attention because dying from a “healthcare-acquired infection is not an acceptable way to die”,
… said the wind.

And when the people found out what happened to the man who had been a boy and when they heard what the wind had said, they all agreed that the wind was right. And so it was.

After that, hardly anyone ever died in that same way. Eventually, healthcare acquired infections became a thing of the past. And that was a good thing indeed.

The real wonder of this story is that it came to us not with bang and a jolt that shook everything hard and made a noise so loud it got everyone’s attention, but instead it came to us as a gentle whisper in the ears of caregivers that made its way to their hearts, uttered by and carried on the very wind the boy himself had loved so much.

And that is the true story of a paralyzed man who, while he could not move a single finger for himself, ended up moving us all.

The Empowered Patient

A regular feature from CNN Medical News correspondent Elizabeth Cohen, helps put you in the driver's seat when it comes to health care.

ATLANTA, Georgia (CNN) -- Like many young men, Josh Nahum loved a thrill. That's why he took up skydiving. But on Labor Day weekend in 2006, he had an accident while skydiving in Colorado, fracturing his femur and skull. Josh spent six weeks in the intensive care unit. Slowly, his condition improved, and his doctors predicted that with rehabilitation, he could fully recover in a year or two.

But instead of recovering, Josh developed a bacterial infection. He died two weeks later at the age of 27. "One nurse, who was trying to be comforting, said, 'These things happen,' " says Victoria Nahum, Josh's stepmother. "That's true, but they happen way more often than they need to happen."

According to the Centers for Disease Control and Prevention, Josh is one of 99,000 people who die each year because of infections acquired in the hospital. As Betsy McCaughey, the former lieutenant governor of New York, put it, "You don't often come across such a big problem that you can prevent."

After being contacted by families like the Nahums, McCaughey started the Committee to Reduce Infection Deaths. After Josh died, the Nahums started the Safe Care Campaign.

These groups, and others, have advice about what you can do to keep yourself safe in the doctor's office and hospital, from the waiting room to the operating room.

1. Bring your own toys:

At the pediatrician's office, don't let your child play with the toys or books in the waiting room. "They're covered with bacteria," McCaughey says. Also, don't let your child crawl on the floor; bacteria there could get into cuts on their knees or hands. "This is one place you ought to keep your child sitting still or on your lap," she says.

2. Heat up your car:

Yes, we know that sounds strange. But studies show staying warm before and during surgery can help you fight infection. So the Institute for Healthcare Improvement suggests that in cold weather, you heat up the car, wear warm clothes on the way to the hospital, ask the hospital staff to give you plenty of blankets while you wait for surgery, and ask how they plan to keep you warm during surgery.

3. Want to touch me? Wash your hands first.

Many people feel uncomfortable asking this. Nahum suggests putting it like this: "I didn't see you wash your hands. Do you mind doing it in front of me?"

Dr. Vicki Rackner, a patient advocate, also has a few ideas for lightening things up. "In the hospital, you can have the grandkids make a sign that says, 'Please wash your hands and keep Grandma healthy.' " Watch more on preventing hospital infections »

Another suggestion: Put a dish of wrapped candy near the sink and say 'Could you please wash your hands, and oh, please take some candy with you when we're done.' " If the doctor or nurse has gloves on, are you safe? "Don't be falsely assured by gloves," McCaughey says. "If they put on gloves without washing their hands first, those gloves are immediately contaminated."

4. Ask where that syringe has been:

Doctors offices sometimes reuse syringes - it's unusual, but it happens. In fact, there have been 14 documented outbreaks of hepatitis since 1999 because of reused syringes. The recent outbreak in Nevada, where 50,000 people will be notified that they might have been infected at a colonoscopy clinic, is one example.

It's not an easy question to ask, but when someone's heading at you with a syringe, ask if this is the first time it's been used.
Dr. Thomas Frieden, commissioner of the New York City Department of Health, suggests phrasing it like this: "I read in the paper that some doctors are reusing syringes. I can't imagine anyone would do that. Do you?"

5. Having surgery? Speak up!

A week or so before surgery, ask your doctor whether you should wash your skin daily with a disinfectant such as chlorhexidine to prepare.

Also, ask whether you should have a nasal or skin swab for MRSA, the superbug that causes many hospital infections. If you've got it, you can be treated with antibiotics. The day of surgery, if the surgical site needs to be shaved, ask to be clippered, not shaved with a razor, which can create nicks where bacteria thrive. Also on the day of surgery, if your doctor has ordered IV antibiotics just before surgery, make sure you get them, as they're sometimes forgotten.

One last note: If you or a loved one has a urinary catheter in the hospital, be extra vigilant - they can become breeding grounds for bacteria. First, ask if one is truly necessary. "If the patient is awake and oriented and alert and can use a bedpan, it may not be needed," says Dr. John Jernigan, a medical epidemiologist at the CDC. If you get one, make sure it comes out ASAP, since the longer it's in, the riskier it becomes.

Ask the same questions about central venous catheters, (also called central lines), another potential host for bacteria. "My brother was in the hospital and needed a central venous catheter for his procedure," Jernigan says. "The day after surgery, I asked the nurse, 'Are you all still using this? Do you still need it?' And she checked and came back and said, 'We don't need it anymore, we'll take it out.' "

Nahum says it all boils down to this: Passivity kills. "People need to start participating instead of just being spectators when it comes to their medical care," she says. "You need to do your due diligence."