By Lambert Strether of Corrente
Spoiler alert: No. In this post, I want to continue my investigation of our enormous health system, adopting as ever the position of a citizen/patient — and not the “bending the cost curve wonk,” but no longer from the outside, as a single payer advocate, but from the inside, imagining what it would like inside the system, receiving treatment. Last time, I looked at overtreatment; this time, I’ll look at Hospital-Acquired Infections (HAIs), which also have the fancier moniker “nosocomial infections.” Readers will have noticed a tendency to focus on the worst that can happen, rather than the best; but that’s just who I am. And our system provides so many opportunities for the worst to happen!
So I will ask four questions:
1) Are Hospital-Acquired Infections (HAIs) significant?
2) Have measures been taken against HAIs?
3) Has HAI been eradicated?
4) Can you avoid HAI by being a “smart shopper”?
Let’s take these questions in order. (Note that I’m not taking about other bad things that can happen in hospitals, like mistakes by doctors, or overdoses, or Kafka-esque bureaucratic nightmares. I’m only talking about infection. Nor am I talking about other medical institutions, like nursing homes; only hospitals.)
Is Hospital-Acquired Infection (HAI) Significant?
In a word, yes. From the Center for Disease Control (CDC):
On any given day, about one in 25 hospital patients has at least one healthcare-associated infection.
Those odds seem uncomfortably high to me, all the more because they are unlikely to be evenly distributed. More:
In 2014, results of a project known as the HAI Prevalence Survey were published. The Survey described the burden of HAIs in U.S. hospitals, and reported that, in 2011, there were an estimated 722,000 HAIs in U.S. acute care hospitals…. Additionally, about 75,000 patients with HAIs died during their hospitalizations. More than half of all HAIs occurred outside of the intensive care unit.
That seems like a rather high number. To compare: 33,636 deaths due to “injury by firearms” (2013); 37,461 “motor vehicle deaths” (2016).
Have Measures Been Taken Against HAI?
They have. The CDC once more:
Among national acute care hospitals, the most recent report (2014 data, published 2016) found:
- 50 percent decrease in central line-associated bloodstream infections (CLABSI) between 2008 and 2014
- No change in overall catheter-associated urinary tract infections (CAUTI) between 2009 and 2014
- However, there was progress in non-ICU settings between 2009 and 2014, progress in all settings between 2013 and 2014, and even more progress in all settings towards the end of 2014
- 17 percent decrease in surgical site infections (SSI) related to the 10 select procedures tracked in previous reports
- 17 percent decrease in abdominal hysterectomy SSI between 2008 and 2014
- 2 percent decrease in colon surgery SSI between 2008 and 2014
- 8 percent decrease in hospital-onset Clostridium difficile (C. difficile) infections between 2011 and 2014
- 13 percent decrease in hospital-onset methicillin-resistant Staphylococcus aureus (MRSA) bacteremia (bloodstream infections) between 2011 and 2014
So it’s not like the powers-that-be aren’t working the problem; but you’ll note that all the dates listed have significant overlap with 2014’s 75K figure.
Institutional factors that encourage HAIs seem common-sense enough. Science Direct:
5. Determinants
Risk factors determining nosocomial infections depends upon the environment in which care is delivered, the susceptibility and condition of the patient, and the lack of awareness of such prevailing infections among staff and health care providers.
5.1. Environment
Poor hygienic conditions and inadequate waste disposal from health care settings.
5.2. Susceptibility
Immunosupression in the patients, prolonged stay in intensive care unit, and prolonged use of antibiotics.
5.3. Unawareness
Improper use of injection techniques, poor knowledge of basic infection control measures, inappropriate use of invasive devices (catheters) and lack of control policies. In low income countriesthese risk factors are associated with poverty, lack of financial support, understaffed health care settings and inadequate supply of equipment.
Low income “countries,” and not low income counties? From this list, it also looks to me like a lot of HAI prevention is tasked to what MBAs would call “cost centers,” as opposed to “profit centers.” You can bill for surgery, but not for handwashing, or training for handwashing. Hence the notion that HAI’s are profitable, hence incentivized:
While the exorbitant costs of health care associated infections (HAIs) have been repeatedly cited as a prime reason for prevention — second only to the higher calling of patient safety [thank you for that]— a somewhat shocking finding came out in a 2013 study by the respected Peter Pronovost, MD, and colleagues.
As previously reported in Hospital Infection Control & Prevention, they found that hospitals actually profit from infections in certain circumstances due to misaligned incentives in the payment system that reward higher payments for complications and outlier cases.
So, much depends on reimbursement. Who eats the excess costs? From a study in the Journal of the American Medical Association:
If all 547 [Surgical Site Infections (SSIs)] were eliminated, the data suggest that The Johns Hopkins Health System would experience a cost increase of $9,124,029 ($2,606,865.43 annually) and a billable capacity increase of 362 admissions (103 annually), equating to a revenue increase of $11,392,618 ($3,255,034 annually). Additionally, if it is assumed that payers refuse to reimburse for 30-day readmissions related to SSIs, then the elimination of SSIs would provide The Johns Hopkins Health System an increase in revenue of approximately $21,288,486 ($6,082,425 annually) over the study period by increasing their available billable capacity by 922 admissions (264 annually). The data suggest that the total change in profit over the period for the health system, if they eliminated all SSIs, would be $2,268,589, $12,164,457 if it is assumed 30-day readmissions would not be reimbursed
Note that Medicare has been penalizing hospitals for re-admissions (a proxy for HAIs) and this has had some effect.)
Has HAI Been Eradicated?
Obviously not, according to CDC’s own figures. One particular area of concern is antibiotic resistant germs (or, if you’re gaslighting, “superbugs“). From Kaiser Health News:
Each year, at least 2 million people become infected with bacteria that are resistant to antibiotics, including nearly a quarter million cases in hospitals. The Centers for Disease Control and Prevention estimates 23,000 people die from them.
Infection experts fear that soon patients may face new strains of germs that are resistant to all existing antibiotics. Between 20 and 50 percent of all antibiotics prescribed in hospitals are either not needed or inappropriate, studies have found. Their proliferation — inside the hospital, in doctor’s prescriptions and in farm animals sold for food — have hastened new strains of bacteria that are resistant to many drugs.
It is true that Medicare is now measuring for and penalizing the presence of superbugs, it’s not clear that such regulation as we have can outrun the abiity of superbugs to adapt. From an excellent series in 2016 by Reuters:
Yet the United States lacks a unified nationwide system for reporting and tracking outbreaks. Instead, a patchwork of state laws and guidelines, inconsistently applied, tracks clusters of the deadly infections that the federal government 15 years ago labeled a grave threat to public health.
Imagine if our IT systems were coding for outbreaks instead of for billing…
Can You Avoid HAI by Being a “Smart Shopper”?
Of course, if you live in a rural area with zero or one hospitals, you’re going to take what you can get. For those with more than one hospital to choose from, it’s hard to see on what basis — besides local reputation — comparison shopping might be done, even if your insurance network (if any) permits it. Medicare publishes tables of hospitals that it penalizes, at least, but it gives no details on what the penalties were for! And the CMS has an online “hospital compare” service that gives star ratings. But there are problems with it. Health Affairs:
A single summary score that describes overall quality at one hospital is probably not very useful for consumers. Consumers [sic] want to know about the quality a hospital delivers for their condition or for a medical procedure. Given that the quality for different types of care can vary widely within a single institution, it is unlikely that a single summary score would accurately represent the quality of care for all conditions or procedures at one hospital.
The stars are also fitted to a bell curve, which is the wrong sort of curve:
To construct the summary star scores, some fairly complex statistical calculations are performed, which essentially use rank order performance on individual measures, weighted by importance to come up with a summary score. The end result is a distribution of summary scores that approximates a bell-shaped curve with 48 percent of hospitals assigned 3-stars; about 3 percent assigned each 1- and 5-stars, and the rest 2- or 4-stars. There are several problems with using a curve. First, it implies a meaningful difference in performance when there might not be one. For many of the individual measures from which the summary score is derived most hospitals are no different than the national average. Second, it implies that many stars equal high quality and few stars low. Regardless of whether quality across hospitals is uniformly high, low, or average, the curve will distribute hospitals across the 5-stars. Consider the measures reported in the “effectiveness of care” domain. The average national score is over 92 percent for most of the measures; for several it approaches 100 percent. There is little clinically meaningful difference in scores across hospitals and the performance is uniformly high. If our objective is to drive the delivery of high-quality care across our health system, it would be better to define clinically meaningful thresholds that define high quality and report performance against those standards. For some measures, most hospitals would achieve the threshold; for others few. Whether or not a hospital reaches a quality standard for an individual measure is more important to patients and policymakers than the relative performance on individual measures, especially when performance is uniformly high or low.
Conclusion
I hate to say that picking a hospital is a crapshoot. But absent personal contact with hospital personnel who have “clinically meaningful” knowledge of you, your condition, and the procedure you may need, I don’t see an alternative. Reader comments on this topic, as always, are welcome.
33 comments
Comments are closed.
I’m curious how the rates of infection and death in US hospitals compare to those in other developed countries.
My mother died of C-diff acquired at the “world-class” Cleveland Clinic. This excellent article explains that nurses and doctors in large teaching hospitals are “too busy” to wash their hands each time they enter a new patient’s room:
https://www.consumerreports.org/doctors-hospitals/consumer-reports-names-hospitals-with-high-c-diff-infection-rates/
I have read in the past that doctors and nurses in countries other than the U.S. seem to have “more time” to wash their hands — but I did a quick search just now and could not come up with any comparative data.
Avoidance is the key, Lambert. Just don’t go. I don’t even like to visit and feel dirty when I come out, splashing germ killing foam wherever I see it. It’s almost impossible, with germs resistant to antibs and some disinfectants, to keep theses places clean with the ‘000s of people that come and go each day. If the private hospitals are better, I don’t think it shows in the stats, there is no smart shopping for hospital care.
My smart shopping: whole foods, low processed anything, except beer, some fats are ok, bit of weed … oh and you gotta move the body, doesn’t work otherwise
Sorry to break the news, Chris, but overuse of ‘germ killing foam’ can also contribute to to the emergence of antibiotic resistant strains of bacteria (and removes the harmless, protective commensalism bacteria on your skin).
A thorough hand wash with just soap and water is all you need.
Bleach works ..
A great sanitizer .. 2 tablespoons per 5 gallons of water is what I use when sanitizing my brewing equipment, counters, buckets, etc.
thank you, Chris, yet the image of the killer virus or germ on the elevator buttons, for example, means I can’t help self.
Even though, I know my hands need their own micro environment, including bugs and natural oils, so try not to do it otherwise.
Understand, Chris, very scary.
When I’m in a potentially contaminated environment, I try to use the back of my hand instead of the front whenever I can.
For example, I push the elevator button with a knuckle rather than a fingertip, push doors open with a closed fist, and don’t use handrails.
If you can’t wash your hands and still need to decontaminate, try using denatured alcohol on its own instead of products containing Triclosan.
I walk 2.5 miles daily to stave off difficulties with aging – am nearing 60 – and when I encounter the “walk” push button to cross at a stop lighted intersection I always use my elbow, rather than my hand or fingers, to push button. Seems to work fine for germ avoidance. I’m a big hand washer at home, too.
Agreed. Just don’t go.
Be a medical dropout.
Having spent three weeks in a hospital this year, I don’t think there’s a lot you can do coming in. However, you can be aware of what’s going on around you–this puts undue and unfair pressure on you, the patient, but you can see when someone doesn’t clean their hands, present a sterilized needle properly, etc. In my case, the nurses (I had about 15 different ones over time) all were very careful–and I still nearly died due to other factors related to poor communication between various doctors.
The smart shopper would avoid teaching hospitals, using community hospitals instead.
Please elaborate.
The primary goal of a teaching hospital is the education of the medical residents. Cleanliness is expensive to the management. Community hospitals are smaller.
. . . Community hospitals are smaller.
I get it. Less surface area for the germs to latch onto.
I think that a lot depends on whether you are in a specialized care area. Last January, a friend had the head of neurosurgery perform microsurgery on his spine. His hospital floor was exclusively neurosurgery patients. Everywhere you looked there were signs reminding hospital personnel to wash their hands. Every single person who was going to be involved in the surgery stopped in for a 5-10 minute visit prior to surgery to explain what part he/she was going to be performing in the procedure, and each of them double checked my friend’s list of medications and allergies one more time–which was just as well, since they had been planning to use an anesthetic to which he likely would have had an allergic reaction. It was clear to both of us that it was an exceptionally well run department in the hospital, and that the professionalism and carefulness was due to insistence on specific protocols by the head of neurosurgery.
When my friend had his two-week follow-up appointment with the doctor, he pointed out to the doctor how impressed he was with the cleanliness and the professionalism of the entire neurosurgery staff. The doctor seemed genuinely pleased that at least one patient could truly notice the difference. So I do think that when the head of a department is truly committed, infections can be reduced and care improved.
This isn’t a solution to the problem of hospital acquired infections, but in the long run, it will reduce the prevalence of antibiotic resistant infections:
A corollary to this is that CAFOs (confined animal feeding operations), also known as factory farms, must be eliminated. When animals are crammed together in a CAFO, it’s almost impossible to avoid infections, so antibiotics become almost a requirement. And using antibiotics on such a vast scale inevitably breeds resistant strains of bacteria.
As the election primary season in the U.S. approaches, we should remember to ask all candidates for the Senate and the House of Representatives to state their position on this issue.
Thank you so much for pointing this out. Antibiotics in animal feed is obviously the elephant in the room when it comes to antibiotic-resistant organisms.
In fact, if you wanted to design a system for growing and spreading antibiotic-resistant organisms, it would look exactly like the meat industry. First, confine vast numbers of borderline sick animals together in a small space. Second, give them low doses of antibiotics throughout their lives, so that antibiotic-resistant organisms would tend to evolve and survive. Third, cut these animal carcasses into small pieces and distribute them throughout the country for people to keep around their house, handle, and ultimately eat. For extra bonus points, discharge of vast quantities of untreated sewage from these facilities into the environment.
Yep, sounds just about perfect!
Some detail is available from the Medicare report on hospital infections.
Reference: http://www.healthcareitnews.com/news/hospital-acquired-infections-state.
Medicare’s “Hospital Compare” also has ranking information.
https://www.medicare.gov/hospitalcompare/search.html
It has an HAI section that will show whether the hospital was better or worse than the national average.
The article I linked above provides the type of infections for each hospital on the right side of the table.
My mother, who died in 2014, had a hospital acquired infection from a two month stay at a small town Tenet owned hospital during one of her common respiratory ailments. She had what was obviously, to me, a MERSA infection which appeared on her lower legs and persisted until her death a few years later. I flew across country to tend to her for a few months and spent her last year at home with her and I was meticulous about tending to her legs on a daily basis.
The physical characteristics of this MERSA infection were pretty darned straight forward – easily identifiable to anyone who cares to look at many, many pictures of different rash-type maladies manifesting on the lower extremities – and I am as sure as I can be that this is what she had and where she got it. A nurse at the facility, off the record, of course, did confirm during a subsequent stay that a MERSA infection was what she had.
It is becoming quite a common thing to come home with a hospital acquired infection these days.
Some hospitals are definitely dirtier than others, but all have problems. All hospital personnel travel in a cloud of germs, on their clothes, hair, hands, even in their noses. Doctors are notorious for wearing the same white coats for days at a time. The nursing aids, especially, have little training and seem to be unable to understand basic cleanliness. My advice–don’t drink hospital water unless it comes in a bottle! Many times I’ve seen aides scooping ice from the camping coolers they roll around the halls without washing their hands after patient care. Likewise, avoid using your bathroom sink. Often, they dump the bedpans in it. (Take bleach along and disinfect your bathroom.) If you need dressings, ask the RNs to show you how to do it yourself. At least you will only have your own germs. Sheets and bedding are not generally an issue. Likewise, needles, tubes, etc. are single-use only and not a problem.
Well, I got one. Our daughter was hospitalized and I got a horrible MRSA infection. Take my word for it, you don’t want one. Also, I have multiple friends who got MRSA infections from surgery at HSS in NYC. A friend who is an MD there said it’s a known problem. Their solution reduce housekeeping staff to increase profits.
Just one wee problem appears to be that some/most?/all? Hospitals are trusted to report adverse events on their own (emphasis mine):
Further, in California (and, most likely, some/many other states):
(Given the post surgery brain infection referred to in the above linked article, I’m presuming that adverse events include Hospital acquired infections.)
Worked in a top rated E.R. as unit secretary for years, here in San Diego, and I can tell you that our administration would visibly squirm every time JCAHO came around doing accreditation inspections. Did not inspire confidence for me as I had to use their services as a patient, too.
Also, beware of the hospital “patient advocate.” They are most certainly not there to advocate for you, the patient, believe me. They are there to talk you out of reporting to relevant authorities any adverse experiences you may have had while a patient in their institution.
After the skin, what protects against infection are your own bacteria. By competing with pathogenic bacteria. In an illness situation, antibiotics devastate your natural flora, and select the antibiotic resistant ones. If you visit a doctor, having fever, chances are high you will get an antibiotic. Live with colds. Visit a doctor only when you feel ill. This maxim is not useful for the under 1, more than 65, and the immunecompromised.
And try maintain a diverse body flora. Probiotics may help. Literature on their use is evolving.
2/3 of Antibiotic use is in farm animals. Daily use. This ensures an increasing resistance to antibiotics and difficult to treat infections. Human use excretes them in urine and stools, thus also helping resitant organisms develop in the environment.
Various body defenses are bypassed or broken down, such as by catheters ( in blood stream infections),
urinary catheters (for urinary infections), tracheal tubes (in ventilate patients).These devices are intrinsic to modern medical care. Without their use, a lot of interventions and therapies would not exist. For these infections, a denominator is essential. (no of infections/ no of times procedure done) Comparison to accidents are meaningless. Remember, these patients are sick, and their natural defenses bypassed.
Cutting rates of these infections are imp goals in most hospitals, requiring significant effort for small gains.
Hand washing is relevant to 3 main infections: viral, c difficile intestinal infections and skin infections if the skin is breached..
Their are no certain criteria to differentiate viral form bacterial infections, ie Antibiotics will not work in the former. But getting sick is expensive.(clinic/ ER/ hospital/ labs) Missing work is difficult.(leave and pay policies) Not surprisingly, patients want ABX if there is any possibility of a bacterial infection.Participating in this indeterminable risk is something the public also has to learn to do.
Whether or not a hospital reaches a quality standard for an individual measure is more important to patients and policymakers than the relative performance on individual measures, especially when performance is uniformly high or low.
What do you mean, Dean?
Why? It is. There is no way we can be “smart consumers” of health care. It’s nearly impossible to be a “smart consumer” of health insurance, mostly because there’s no way to know what your medical needs are going to be, so you can’t meaningfully balance premiums against deductibles and co-pays. Lots of people have no choice in what hospital they will use. Even if they are lucky enough to live in a county that has more that one hospital there is no way to compare them. The whole idea that “health care” is a market is a lie, promoted by people with no souls.
X 100,000
You’re right. The health insurance company picks the hospital and there are no choices.
Anecdote based on local general practice. We are encouraged to check in using a big touch screen. No little alcohol based hand cleaner dispenser nearby. How many germs are on that screen and passed to patients there to see a medical professional? The mind boggles.
I’m a full time hospital physician for the last 20 years and have never gotten a ‘hospital acquired infection’. I avoid taking antibiotics like the plague, and I use the hand washing soap a million times a day.
Please take HAI and surgical infections as seriously as you do other areas of your health (diet, exercise etc). They are now a leading cause of death in the US and need to be weighed whenever you are considering any kind of surgery or hospital stay (or even a visit). Surgical infection and HAI are always mentioned in the drive-by risks at the end of the page when providing your consent and we have been conditioned to ignore them. Don’t!
I have always been blessed with remarkably good health and I take care of myself. I needed to have some minor surgery (overnight stay) this year and acquired a septic surgical infection that came moderately close to killing me. I spent ten days in the hospital including many hours in the ER and ICU. I will spare you the details but try to share what I learned. All this happened at a teaching hospital in Boston that is characterized as one of the five best hospitals in the world.
1. HAI and SSI are material risks. Think of it like there is a 10% risk that you will be hit by a truck when you leave the hospital when you consider any kind if elective surgery or where it will be performed. Tens of thousands of people die this way each from these infections and many of those are quite healthy before they go into the hospital. We’ve been conditioned to minimize the risk of infection because doctors discuss it in sort of a “shit happens” way – don’t ignore the risk!
2. Evaluate the quality and capability of the hospital and surgeon separately from the risk of infection. Great technical surgeons are generally narcissistic and may not have the ability or desire to manage all the mundane details necessary to minimize the risk of infection ( I learned this the hard way) and many hospitals have very poor records at managing infections even though they are highly rated.
3. The last resort antibiotics often used to treat these infections may save your life but they cause significant harm to your body. For example, I thought one of my IVs was defective after its blue plastic tip literally crumbled into pieces in less than 36 hours until the phlebotomist came in and nonchalantly told me that Vancomycin always rots and destroys plastic (and veins) in less than two days – It’s pretty much like “pumping Drano into your arm” he said. It took me months of probiotics, yogurt, kimchee etc. to begin to feel healthy again.
4. If you get a surgical infection DO NOT go back to the original surgeon. The worst part of my story is that I declined for four days (we were at the point of having our children fly home to see me while I still had awareness at times). My wonderful wife got fed up and demanded (loudly and in no uncertain terms) that other doctors from the Infectious Diseases unit be brought in addition to the original surgeon who had been treating the infection. Within two hours the ID docs ordered that fluid at the original surgical site be withdrawn and located the source of the infection. Not coincidentally, my official diagnosis immediately changed from “infection from undetermined source” to “surgically acquired infection” and I was able to go home in a few days. Surgeons are generally narcissistic and are often not capable of dealing with their own mistakes and failures consciously or unconsciously and they are not infection specialists.