GUESTWORDS: Hospital Homicides

By Richard Rosenthal

   The heralded Obama-Berwick plan to reduce health care infections and errors by 40 percent by 2014 is much too cautious. It falls short of goals already achieved by infection-control advocates in hundreds of hospitals throughout the country and would still leave us with an annual toll of more than 120,000 preventable health care deaths, more than a million preventable illnesses and injuries, and an annual taxpayer cost of $21 billion.
    The Centers for Disease Control and Prevention and the Institute of Medicine report that about 100,000 Americans die annually from health care errors, e.g., administering patients the wrong medication or a lack of backup oxygen during surgery, and another 100,000 die from health care-acquired infections such as methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile, unsterile catheter insertion, and ventilator-acquired pneumonia.
    All in all, 200,000 deaths a year — a figure that has not changed since the Institute of Medicine first announced it in 1999. Indeed, the real figure is probably higher. Adverse events in hospitals are often unreported. Our health care providers are killing us faster than the Axis did in World War II, when our military fatalities averaged 116,000 per year.
    The East End has not been spared. Betty Fox, a producer at LTV, and the artist Howard Kanovitz died in the past few years from infections acquired in the area’s hospitals. Others have been seriously sickened. I am among them, having nearly died of a staph infection followed by Clostridium difficile, which I acquired after surgery at the Stony Brook University Medical Center in 2009.
    The Obama administration’s low target of a 40-percent reduction reflects reluctance to properly address this carnage in the face of health care industry obstinacy. There is ample proof we can do better. The recently released Veterans Administration study of its 157 hospitals reported a 62-percent drop in cases of MRSA in its intensive-care units and 45 percent in other wards. A five-year study of 10 North Carolina hospitals, published in The New England Journal of Medicine in November 2010, reported that 63 percent of patient harms it identified were preventable. A remedial program in 2006, led by Dr. Peter Pronovost of Johns Hopkins in more than 100 Michigan intensive-care units, reported an 85-percent reduction of central line infections, which are estimated to kill 30,000 Americans a year.
    We are not dealing with complex science here. The solution is low cost, low tech, and has been known for nearly two centuries. Ignaz Semmelweis and Oliver Wendell Holmes preached it in the 1840s. You prevent infections by keeping your patient, yourself, your equipment, and your surroundings clean. You prevent errors by being careful. Some remedial steps are as simple as altering dress codes to prohibit male physicians from wearing neckties, which can transmit germs by draping on patients.
    Another step would be for hospitals to invest a little more money in the most effective infection-control products. Studies reported in The New York Times in January 2010 suggest that hospitals largely reject a superior preoperation swab, chlorhexidine-alcohol, because it costs $8.50 more per patient than povidone-iodine, which hospitals use 75 percent of the time, even though researchers have found that patients receiving it were significantly more likely to develop infections.
    Dr. Betsy McCaughey, a former lieutenant governor of New York and founder of the effective advocacy group Reduce Infection Deaths, reported that in an Ohio hospital, MRSA, C. difficile, and other lethal germs survived on 78 percent of near-bed surfaces and implements, such as call buttons and TV remotes, even after the areas were vacated and presumably sterilized for incoming patients. A more thorough cleaning with disinfectants reduced the rate to 1 percent.
    A faster, more effective way to reduce this carnage is to disaccredit the most dangerous hospitals so they cannot receive Medicare or Medicaid payments or bill patients for co-pays. They and other hospitals would get the message and snap to. Medicare and Medicaid payments provide health care facilities with 67 percent of their income. The mere threat of disaccreditation by Lyndon Johnson in 1967 integrated Southern hospitals that had declared they would not accept African-American Medicare patients. The hospitals changed their ways, as they would now. Physicians and hospitals know what needs doing. Threaten their wallets and they’ll do it.
    Standing squarely in the way of disaccreditation, however, is a conflict of interest akin to the bond rater to bond broker relationship that gave us the economic calamity of 2008.
    Here’s how it plays out. The Department of Health and Human Services deems that the Joint Commission, a $150 million per annum private nonprofit, can judge the safety, integrity, and efficiency of a hospital or ambulatory surgical center at least as well as H.H.S. can. So if the Joint Commission says that Fixup General Hospital doesn’t cheat the government too much or conspicuously botch too many operations, H.H.S., via the Centers for Medicare and Medicaid Services, okays the Medicare and Medicaid payments that keep Fixup afloat.
    The Joint Commission accredits 80 percent of the country’s hospitals and ambulatory surgical centers for these government payments.
    But guess who pays the commission for the inspections required for the accreditations and triennial reaccreditations. Yes, the very hospitals they are accrediting. And guess who pays a subsidiary of the commission for advance instruction on how to pass inspections. Yes, it’s the about-to-be-inspected hospitals. And who do you think sells the hospitals “We Are Accredited” coffee mugs and other PR doodads following their certification of worthiness in the face of such disinterested scrutiny? Right again. The proceeds go to the Joint Commission.
    It is Moody’s AAAing Lehman Brothers all over again, or, if you prefer, Arthur Andersen extolling Enron’s financial purity. Only in this case it kills people rather than their home ownership and life savings.
    In 2008, following the scandal of vermin infestation at Walter Reed Army Medical Center, which the Joint Commission had recently blessed with a 97-percent approval rating, Health and Human Services pressed the commission to strengthen its accreditation procedures. The commission responded with exhortations and education programs to get hospitals to right themselves but apparently did not exercise its authority to disaccredit dangerous medical facilities.
    In 2010, David Eddinger, who handles accreditation matters at the Centers for Medicare and Medicaid Services, affirmed to me that there had been no safety-related disaccreditations for the previous two years. A board member of the Joint Commission later informed me that the commission had not disaccredited a hospital for safety reasons during the previous 10 years. Nevertheless, the government renewed the commission’s deeming authority through 2014.
    The solutions we are proffered for this ghastly human and economic toll reflect Republican free-market theology and Democratic trepidation. Republicans tout removing government from the infection-error scene on the mystical premise that a market free of regulation will enable patients to identify and employ conscientious medical care. Democratic measures, embedded in Title III of the Affordable Care Act and recent proposals, remain tepid and subject to vaporization by industry lobbyists in the rule-making phase.
    The disaccreditation weapon, which H.H.S. can invoke without Congressional approval, is not on the table, and the carnage continues.


    Richard Rosenthal’s local television show, “Access,” won the 2010 Alliance for Community Media’s Jewell Ryan-White Award for the quality of non-mainstream programming. He is the author of “The Dandelion War,” a novel about class warfare in the Hamptons, and lives in East Hampton.

Comments

Thank you for your commentary. I suspect the government's numerical target is tempered with a greater measure of pragmatism than of right-wing, cloak-and-dagger ideological conspiracy. Hospitals are where sick people go, so hospitals have germs. Hospitals are also businesses, and they have to stay fiscally afloat (something most on Long Island are not doing very well) while budgeting for resources and techniques to kill as many germs as possible. A balance must be struck, and in many cases the current balance is far from perfect. It's possible, however, that the government is only trying to be reasonable in its demands. Hospital rooms are never "sterilized" after a patient leaves. They are "disinfected." This distinction is of purely scientific and very practical significance. Unless a room is sterilized, it will always retain pathogens (germs) from prior use. It would be great if a hospital room were sterilized before every new patient enters. The problem is that, to sterilize a room, you would literally have to gas the air, every surface, every mattress and pillow fiber, and every mechanical instrument (including the all-important call button and TV remote!) with a deadly chemical. Remember, both good and bad organisms are alive, and if you want to kill the bad ones, you have to kill them all. There is no way to discern between the two on a scale as grand as that which a hospital room would demand. The gas used for sterilization of medical equipment and surfaces is so poisonous that, if it contacts any moisture on the equipment, it leaves a residue of poisonous liquid behind which must be carefully eliminated. The only nontoxic alternative would be to boil the whole room. So a hospital room is wiped down, instead, with somewhat less poisonous chemicals in-between patients. The chemicals evaporate relatively safely, and the room is ready for use without having killed any hospital workers in the process (at least not instantaneously.) That is called disinfection. It is the best that can be done in a hospital room, and it's done, by the way, by blue-collar workers, not doctors and scientists. I would say the folks who disinfect hospital rooms (and sterilize the equipment) are just ordinary cleaners, but, in fact, they are not. They are extraordinary cleaners, with a dangerous and dirty job. Ideally, they recognize that the stakes of their work are often higher than those in the field of domestic housekeeping, and they approach their profession with great care. Nevertheless, germs remain. A lot of them. Studies show that hospital infection rates can be dramatically reduced within whatever limited arenas those studies happen to study. The numbers are impressive, but, in legislation, care has to be taken not to expect identically stellar results from every hospital in every unique local, financial, demographic, and pathological situation nationwide. Little hospitals like Southampton have some advantages over big places like larger Stony Brook in thorough implementation of safety protocols (Southampton is known to be a very clean hospital.) Conversely, big institutions like Stony Brook have advantages over little hospitals like Southampton in terms of subsidy, resources, staffing, and readily available technology. The broad brush of legislation island-wide risks punishing small institutions such as Peconic, Southside, Brookhaven, Mather, St. Charles, and Eastern Long Island Hospital for being small, while at the same time punishing Stony Brook University Medical Center and Nassau University Medical Center for being large. Remember, by disaccrediting a hospital for its failure in one aspect of patient care, you will lose the entire hospital altogether, along with all of its successes in every other realm of care. If we lose any of our East-End facilities, the ambulance has that much longer a drive to get us to the nearest hospital when we need to be there ASAP. Moreover, if this kind of damage could be experienced island-wide, how much more might be on the line nation-wide? I appreciate your advocacy for high patient safety standards accompanied by honest and effective enforcement. I don't think it's simple enough to distill the complicated problem and its potential solutions to a single number, though, and especially not to upper-class-lower-class warfare theories or Right-Left party politics.
March 26, 2012 To The Star Dear Editor, An anonymous response to my March 15th Guestwords article, “Hospital Homicides”, appeared in the Star website but not in the letters section, I assume because the writer preferred to conceal his or her identity. The response, as I read it, seems to be from a physician, medical academic or hospital executive and to urge the public to be “reasonable”, exercise “pragmatism” and accept stunted safety objectives because hospitals are, among other things, businesses that must stay fiscally afloat. It also, somewhat desperately I feel, closes with a smack of Mc McCarthyism light, an insinuation that I am motivated by "upper-class-lower-class warfare theories or right-left party politics", when in the article I praise former Lieutenant Governor Betsy Mc Caughey, a conservative, and in other writings, Senator Charles Grassley of Iowa, a conservative Republican as leaders in efforts to control healthcare errors and infections. As if 200,000 preventable deaths a year plus my own near death experiences were not enough motivation. Republicans are dying too. I submit this letter to the Star in hope that Anonymous will come out of the closet and discuss this situation, which is clearly horrifying and urgent, and the Joint Commission’s conflict of interest in accrediting healthcare providers for Medicare and Medicaid payments. Hospital errors and infections have become the third largest cause of death in the country, after coronaries and cancer, and a wrecker of Medicare’s financial stability. Prestigious research and expert opinion suggests that an overwhelming number of these casualties are easily and inexpensively preventable. We have rightly sprung into action to reduce the death toll from drunk driving, which accounts for less than one-fifteenth of the fatalities as healthcare infections and errors. It is past time that the government and public adopt the same sense of urgency with healthcare deaths. Sincerely, Richard Rosenthal