Volume 3  Number 9  November 30, 2006
Second Opinions

Are Hospitals Bugging You?

On November 14, 2006 officials of The Pennsylvania Health Care Cost Containment Council (PHC4) released a "groundbreaking" report on life-threatening infections acquired after patients are admitted to Pennsylvania hospitals. The report, though 15 years behind several Western European countries, is the first in the United States to disclose actual number of infections reported by hospitals. Fifteen others states also require hospitals to report infection data, although, curiously, not all of them plan to make the data public.

The report includes information on approximately 1.6 million patients treated in the state's 168 general acute care hospitals during 2005. In addition to the number of cases and infection rate per 1,000 cases, information on mortality, and other data for cases with and without hospital-acquired infections are presented for each hospital. Since many differences exist between hospitals, such as volume, types of patients, procedures, etc., this initial report to does not attempt to compare individual hospital performance. Patients at greater risk for contacting Hospital-Acquired Infections (HAI), such as those hospitalized for an organ transplant, complications of an organ transplant and/or burn treatment were not included in the report. PHC4 grouped hospitals according to the complexity of services offered, the number of patients treated, and the percent of surgical procedures performed.

Statewide Highlights for 2005

  • Hospitals reported over 19,000 cases of hospital-acquired infection, 2.2% of all admissions, The combined mortality rate for patients with a hospital-acquired infection was 13%, more than five times the mortality rate for patients without a hospital-acquired infection
  • The average length of stay for patients with a hospital-acquired infection was 20.6 days; over four times longer than patients without a hospital-acquired infection.
  • Insurers paid over $53,000 for people who got infections, over six times as much compared with uninfected.

MRSA, Among First Offenders

Among the most common causes of hospital-acquired infections (HAI) is Staphylococcus aureus, usually called "staph," an organism commonly found on the skin and in the nose of unsuspecting healthy people. Staph does not cause infection until it enters the body, but any carrier once admitted to hospitals spreads staph around such that it is found almost everywhere including dishes, bedrails, toilets, towels, and virtually any surface. Doctors and hospital personnel maintain and enhance contamination by continuing to spread the bacteria in the hospital environment, multiplying the chances they will end up on charts, stethoscopes, pens, bandages, catheters, ventilators, and any open incision. In the past staph was highly susceptible to several antibiotics, especially methicillin. In 1974 only 2% of staph infections were resistant to methicillin; called "methicillin resistant Staph aureus" or MRSA. Today, over 60% of staph infections are MRSA's, i.e., resistant to the antibiotic because of widespread and largely inappropriate use of antibiotics.

Yet, as a recent article in the New York Times asked, why do the Centers for Disease Control, which only last month listed guidelines to prevent hospital infections, conspicuously omit universal testing of patients for MRSA, one of the most common causes of these hospital-acquired infections? As a typical example of Government groupthink, the CDC continues to call for voluntary AIDS blood testing while hospital-acquired infections cause five times as many deaths as AIDS in this country.

According to the Sentry Antimicrobial Surveillance Program, among developed countries, the United States has one of the worst records for curbing, not only MRSA, but other drug-resistant infections. The CDC itself noted a 32-fold increase in MRSA hospital infections between 1976 and 2003. 25 years ago, as McCaughey points out in her Times article, Denmark, Finland, and the Netherlands faced similarly soaring rates of MRSA, but have nearly eradicated it. How was this accomplished?

Hospital Infections in Europe and Canada

In an outstanding article in the online magazine, Slate, "Europe is killing off hospital infections. Why isn't the United States following suit?", Arthur Allen writes, "If you are an American admitted to a hospital in Amsterdam, Toronto, or Copenhagen these days, you'll be considered a biohazard. Doctors and nurses will likely put you into quarantine while they determine whether you're carrying methicillin-resistant staph…If you test positive for MRSA these European and Canadian hospital workers will don protective gloves, masks, and gowns each time they approach you, and then strip off the gear and scrub down vigorously when they leave your room. The process is known as "search and destroy" — a combat mission that hospitals abroad are undertaking to prevent the spread of germs that resist antibiotics."

After five years of deliberation, the CDC continues its refusal to endorse search and destroy. Allen adds, "...This is a bitter pill for many infectious-disease experts, who have been joined by the relatives of dead patients, Consumers Union, and even a few Congress members in pressing the CDC." "Why are we spending millions if not billions on bird flu, a ghost that might not happen, when you have thousands being colonized by MRSA and dying of it?" asks Dr. William Jarvis, a top CDC hospital-infection expert until he resigned in 2003.

Reducing HAI in the Future

Some hospital officials object that, since the average hospital infection adds $30,000 to a patient's bill, this is simply the "cost of doing business." But this attitude is more than dangerously disingenuous, since the biggest push for more effective methods to combat HAI may come, sadly, from the threat of huge lawsuits. Many of these cases have been settled with hospitals in which HAI have resulted in patient deaths. Moreover, as Allen also observes, while hospitals have traditionally passed on their costs to other payers, Medicare—which sets reimbursement standards—is starting to curtail payments to cover hospital errors, and may eventually stop paying to treat infections that could have been prevented. Some private insurers may ultimately follow suit.

Disclaimer: Don't let me Frighten You

Aside from the Pennsylvania report, all of the above facts about HAI have been in the news for some time. Some physician friends, including a medical director of a major health insurance company, have warned, "Whatever you do, stay out of the hospital," Such radical advice is obviously not to be taken literally, especially if one recalls that the hospital is the only place where major surgical procedures are performed, and where life-saving high level medical care is administered to seriously ill patients. My purpose here is to inform without alarming, and to make the reader a more skeptical patient, one who asks "Could I be treated as an outpatient rather than go to the hospital?" Other important questions include: "Why should I go into the hospital just for tests if I'm not sick?" "How soon can I get out of here?," and to the nurse, doctor, or person who brought in the lunch tray, "Have you washed your hands in the last fifteen minutes?"

Things are changing for the better. A growing number of physicians and health care experts say patients have the right to know a hospital's infection rate before being admitted-and before long this information will be available in 28 more states. Many hospitals have launched efforts to reduce infection rates which can immediately be lowered by such simple steps as hand-washing between patients by all personnel, sterilization and following rigorous practices during procedures with a high risk of infection. In 2002, Rhode Island Hospital in Providence began search and destroy, and the MRSA infection rate at the hospital has dropped 43 percent. The University of Virginia Hospital in Charlottesville imposed the same system in 1980, and has maintained lower rates of MRSA and other infections. Thanks to increasing public pressure, other institutions are following suit. Don't be afraid to add your voice to the crowd.

Martin F. Sturman, MD, FACP

Copyright 2006, Mathemedics, Inc.

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