When Hospitals Accept High Infection Rates: A “Cultural Problem”

Find Hospitals in Your State on the Map from Consumer Reports Below

Summary:  Consumer Reports Health (CRH) has just released a report showing wide variation in how likely it is that a hospital patient will pick up a deadly bloodstream infection. Much depends on the culture of the hospital the patient chooses. Does the head of the intensive care unit insist that doctors and nurses all follow a protocol to prevent these infections? Does the hospital administration back him up? The CRH review of more than 1,000 hospitals show that 142 have reduced infections associated with central line catheters to zero. Only two of the 142 are academic medical centers. Why?

In a telephone interview John Santa, M.D., M.P.H., director of the Consumer Reports Health Ratings Center, explains the shocking fact that these infections are, accepted within the “standard of practice.” What would it take to change the standard of practice? “Doctors testifying in a malpractice suit.” I would like to think there an easier solution.

Imagine that you live in Westchester County, not far from the Bronx, and you’re girding yourself for elective surgery. It should be a routine procedure, but you can’t help but worry about the infections that patients pick up in hospitals. You know that they kill 90,000 Americans each year. You also know that when hospitals commit to patient safety, infection rates plummet. In fact, some medical centers have been able to virtually eliminate one of the deadliest—the bloodstream infections associated with central line catheters that are inserted directly into the jugular.

As you consider nearby choices, you ask yourself, where would I be safer, at New York Westchester Square (a 205-bed hospital that serves the Bronx and lower Westchester County), or at Montefiore Medical Center, (the university hospital for the Albert Einstein College of Medicine), also located in the Bronx?  Or perhaps I would be better off at one of Manhattan’s illustrious hospitals: Mt. Sinai, Lenox Hill, New York Presbyterian, Beth Israel Medical Center, or NYU Medical Center?

Of course in reality, few patients pick a hospital based on blood stream infection rates. But perhaps they should. They account for 30 percent of hospital-acquired infections, and one in four patients who contract them die. Moreover, as Dr. Atul Gawande has pointed out in The Checklist Manifesto, if hospitals simply use a humble five-point checklist, the incidence of central line infections can be cut to zero. These are two solid reasons to view bloodstream infection rates as a marker, signaling a hospital’s commitment to patient safety. And Consumer Reports can tell you which hospitals tolerate high infection rates—and which ones don’t.

In New York State, Where are Infection Rates Lowest?

This week, Consumer Reports Health (CRH) released an eye-opening update to its “Hospital Ratings,” comparing bloodstream infection rates at 1,119 U.S. hospitals to national averages published by the Center for Disease control. The analysis suggests that the Westchester patient would stand the best chance of dodging the bullet if  he chooses New York Westchester Square.

Click here to view CRH’s review of 178 New York State Hospitals as a PDF. In the second column, headed “Bloodstream Infections” symbols indicate where a hospital stands on a 5-point scale ranked from “better to worse.”  Those with the lowest infection rates are marked with a solid red circle, hospitals with the highest infections rates receive a solid black circle. In between, a half red circle signals “better than the national average,” a clear circle means  “average” and a half black circle warns that infection rates are “worse than the national average.” (In the third column, CRH uses the same symbols to indicate how well a hospital is succeeding in fighting surgical site infections. As Gawande explains in The Checklist Mainfesto, they, too, can be reduced simply by using a checklist.)

Under the heading “bloodstream infections,” New York Westchester Square in the Bronx earns a half-red circle signaling that it’s beating the national average. Meanwhile, New York Presbyterian, Montefiore, Beth Israel, and Memorial Sloan Kettering Cancer Center are marked with clear white circles, indicating “average” infections rates. By contrast, Mt. Sinai, Lenox Hill and NYU Medical Center (a.k.a. NYU Langone Medical Center) all report infection rates that are “worse than average.” (All ratings have been statistically adjusted to minimize differences among hospitals due to the types of patients they serve).

These statistics on infection rates are self-reported. New York State is one of a few states that sends inspectors to the hospital to audit the reports, and this is why I am focusing on New York. The numbers on the New York list may be more reliable than in many other states. Though when a hospital reports a high rate of infections—which many do—I would assume that it is telling the truth. (Readers who would like to see infection rates at hospitals in other states should go to the map at the end of this post.)

Surprisingly, none of Manhattan’s highly-respected medical centers garnered a solid red circle. Peninsula Hospital Center in Far Rockaway is the only city hospital with this distinction. But if you scroll down the New York State list, you will discover a number of upstate institutions did receive the highest rating including hospitals in Saratoga Springs, Rome, Poughkeepsie, Glen Cove, Ithaca and Kingston.

Perhaps it’s just too hard for busy urban hospitals that treat a wide cross-section of patients to crack down on errors? Not necessarily. “Detroit hospitals are doing very well,” points out CRH’s Santa. “Michigan paid attention to the idea of checklists.”   Indeed, the CRH report shows that both Harper University Hospital/Hutzel Women’s Hospital and Detroit’s Henry Ford Hospital rank “better than average” for central line infections.

       Wide Variation among Academic Medical Centers

What is striking is that medical centers with marquee names don’t consistently outrank less prestigious hospitals: “While some well-established teaching hospitals do perform well, others perform poorly, and some choose to keep their data under lock and key,” a CRH press release explains. “Most of us think of teaching hospitals as setting the standard for the right way to do things, so it’s surprising to see so many teaching hospitals near the bottom of the list,” adds Santa.

Three teaching hospitals got CHR’s lowest rating in preventing bloodstream infections: Saint Louis University Hospital, Saint Louis, Mo.; Roswell Park Cancer Institute, Buffalo, N.Y.; and Regional Medical Center at Memphis, Memphis, Tenn. In addition, CRH lists 64 teaching hospitals that ranked worse than the national average. The group includes familiar names such as USC University Hospital, Los Angeles, Calif., Hackensack University Medical Center, Hackensack, N.J., Tufts Medical Center, Boston, Mass, and University of Maryland Medical Center, Baltimore, Md.

By contrast, of the 1,119 hospitals of all types that CRH reviewed nationwide, 142  hospitals (almost  13%) reported zero central line infections. But only two of the 142 were teaching hospitals.

Why Do Some Hospitals Accept High Infection Rates?   

In the past, I have been told that some brand-name hospitals don’t use checklists because they are afraid of offending powerful physicians who bring well-heeled patients to their hospitals. In a phone interview, I asked CRH’s Santa if this is true.

“The nice way to put this is to say that it’s ‘a culture problem,’” he replied. “There is no $2 million dollar machine that you can buy to solve this.” Well-endowed academic medical centers know how to spend millions on cutting edge equipment.  But they’re not sure how to persuade physicians to collaborate to solve problems. After all, many of the doctors who bring their patients to the hospital are in private practice. They have “privileges” to practice at the hospital, but they are not employees.

The solutions are cheap: hand-washing, checklists. Granted, some physicians are insulted by the idea that they should use a checklist. But hospitals can insist. “I’ve been on a panel with folks in the Beth Israel System,” Santa reports. “In their ICUs it’s clear, when lines are inserted, what the protocol is. If you see someone making a mistake, you should report it, and you will be supported by the administration.”

But “hospitals that are reluctant to confront powerful doctors or nurses aren’t as good at this,” he concedes. “And it’s harder to organize doctors who are not employees to do anything . . .  though I think that it’s disappointing when you hear that doctors who are not employed by the hospital are objecting to clear-cut evidence-based well-established protocols that would increase safety.”

Central Line Infections and the “Standard of Practice”

What Santa says next is so shocking that I almost drop the phone: “One unfortunate aspect of central line infections is that, ironically, the standard of practice includes accepting that they occur, and that they kill people. Not preventing them is within the standard of practice.” In some hospitals, a certain number of deaths are accepted as “inevitable.”

“Lawyers have told me that they see patients or relatives of patients who died of a bloodstream infection all of the time,” Santa adds. “The lawyers tell them, ‘You don’t have a case’.”

If they try to go to court, the hospital will say, “We don’t know who fouled your central line.” It could have been any one of a number of people. And all the doctors will testify that failing to prevent the infection falls “within the standard of practice.”

Perhaps the standard of practice should change? “You know what it would take to make that happen, don’t you?” Santa asks. “One or more of these doctors would need to testify in a malpractice case involving a central line infection.”

It would be difficult to sue an individual doctor, but it might be possible to sue the head of an intensive care unit that reports a high number of infections, holding him or her responsible for not establishing protocols that would slash the number, if not eliminate the infections altogether.

“We think that having a goal of zero is reasonable,” says Santa

I agree. But doctors shouldn’t have to sue hospitals (or other physicians) in order to make it happen. There must be an easier way.

Check Out the Hospitals in Your Area

InteractiveHospitalsMap

To view infection rates in your state, click on the map above, and you will find yourself on the Consumer Reports site where the map is interactive.  If you are not a Consumer Reports subscriber and want to use the map you will need to sign up for a month, at a cost of $4.95. See the red button “Subscribe Now” to the right of the map.  Once you have signed up, you can click on any state, and a chart will pop up, just like the list of New York State hospitals in the PDF.

 

9 thoughts on “When Hospitals Accept High Infection Rates: A “Cultural Problem”

  1. It is astounding that anyone would think that a certain number of deaths from infection is inevitable. I think that many deaths are indirectly caused by infections as well. A friend of mine with cancer had so much trouble with infections that she was not able to get the life-saving surgery she needed and died. Would this be considered an infection death? Probably not but in a very real way it actually was. Thank you for alerting the public to this important issue – Frederick Sallaz

  2. Frederick–
    Thank you.
    My guess is that in your friend’s case, the cause of death would have been labeled as “cancer.”
    We have no way of knowing if the surgery would have saved her.
    But if infections weakened her so that she wasn’t eligible for the surgery, they certainly contributed to her death.
    I think that serious infections have become so commonplace in our hospitals that administrators and many others have become inured to them– especially in the case of weak or older patients.
    In hospitals, people die all of the time. And those who work in hospitals understand that death is inevitable.
    But death caused by hospital acquired infections is not inevitable.
    So much research–and so much empirical evidence at individual hospitals– shows that we don’t have to tolerate these high rates of deadly infections.
    I agree with Santa: Zero infection is a reasonable goal. (I realize that we cannot achieve this all of the time in all places. But if it’s the goal, infections rates could be slashed– not just reduced, but slashed.
    If hospital administrators won’t respond, then physicians and nurses should lead the battle.

  3. They should take a couple of pages from the aviation handbook.
    First, there is no acceptable level of failure. Professional pilots expect to go entire careers without crashing. A 100% success rate is the only acceptable goal. Mistakes to happen and people do die, but it is unbelievably rare and every instance is investigated and problems are addressed.
    Second, the anonymous reporting pilots do about mistakes, errors in judgement and other take-aways they have are published and shared. They share learned experiences from each other without fear of repercussions by the FAA or their employers.
    Third, they LOVE checklists. This is because they don’t want to die and they have to get it all right every time.
    Lastly, after Pan-Am 747 ran over another 747 in Guam(?), the culture of the cockpit changed from captain/co-pilot, leader/follower, to really more of a co-responsibility. In that flight the captain rolled for take-off and the co-pilot tried to stop him, but was overruled. These days, the captain doesn’t have that type of authority. Furthermore, if he rolled for takeoff over the co-pilots objections he’d lose his job and possibly his license.
    I think surgeons these days have that captain sense of entitlement and it is not deserved, at least not in the O.R.
    Many of these types of cultural changes would make a big difference in the operating room.

  4. Good subject.
    It is absolutely correct that infection rates can be slashed. There is actually no excuse for not implementing strict protocols which can easily be national in scope. It would include sophisticated measures, such as removal of carpets (of which I have seen plenty).
    Hospital-related deaths are similar in number to casualties on roads.
    So the big question is:”Why is this big issue not being tackled in a major way?”.
    Do we follow the money…..again?
    Did it really take repression/deconstruction of the health care system down to 37th in the world (for overall quality of care; NEJM, Jan 2010) in order to elevate the health industry, as a financial concern, to number 1?

  5. Noah,Ruth
    Noah Yes, for pilots there is NO acceptable level of failure.
    As you say, they don’t want to die,(or be responsible for killing a few dozen people, even if some survive.) And, most importantly, people are not supposed to die when they fly on a commercial plane.
    One reason hospitals are more likely to accept a certain number of deaths as a result of hospital-acquired infections is that many people are expected to die in a hospital. So hospital workers become somewhat inured to death.
    Of course people are not supposed to die Becuase they are in a hospital (of a hospital acquired disease). But when someone dies, hospital workers are not as upset as a pilot and stewardess would be if someone had a heart attack and died on their plane. In a hospital, death is an everyday event.
    This may help explain why
    hospitals tolerate infectiosn.
    But the “I’m the captain” mentality also explains a lot. In many cases nurses and assisting physicians don’t dare speak up when they see something amiss– presumably, they often are not quite sure, and they’re intimated.
    I’m glad to hear that a pilot who ignored his co-pilot would be fired.
    As you know, the whole idea of a checklist is borrowed from the aviation industry.
    Ruth–
    Good question.
    Part of the problem, I think, is that hospital CEOs tend to look at a hospital as a business, and they focus on one question: what will bring in revenues?
    Patients tend to be impressed by posh private rooms, views, etc. Even if you tell them “the infection rate is pretty high in this hospital”, it doesn’t quite register.
    They think: “How could the infection rate be high– the hospital is so modern-looking, and looks so clean.Even the carpeting is so nice!
    They also probably don’t realize that these infections Kill. Or, that it could happen to them.
    People just don’t want to realize how dangerous their hospitals are.
    Meanwhile, from the hospital’s point of view launching a big campaign to reduce errors and infections means first, admitting that they are hurting and even killing people unnecessarily.
    Many of today’s businessman/CEO’s don’t want to make that admission.. Bad PR. Some ae in denial themselves.
    If a nurse or physician tries to warn them, they
    write the nurse or doctor off as a trouble-maker, someone with a “bad attitude,” etc.
    Finallly, and most importantly, too many hospital CEOS dont’ quite get it that the raison d’etre of a hospital is keeping the patients well.
    They realy think their main job is to raise revenues and protect the reputation of the hospital.
    We need fewer hospital CEOs with MBA, more hospital CEOs who have an MPH, an MD or an RN—peope who are patient-centered, and who realize that a hospital is not like any other business.
    The responsibility to the “customer” is much, much greater because the customer is someone who is sick, and who you have taken an oath to protect.

  6. To imply the solution of infection control is litigation, even in jest, is a harbinger of the disease in health care. The checklist lowered infection rates by standardizing a protocol for inserting life saving central lines. No checklist can prevent all complications. I would foresee litigation for a doc’s failure to use the newest unproven fourth generation antibiotic.
    As a surgeon I would question why any intelligent practitioner would attempt a difficult surgery, like a joint replacement or bariatric surgery or a Halstedian organ resection, in an obsese, diabetic, neuropathic or immunologically incompetent patient. With increased risk factors the infection rates increase.
    It would be nice to see more MPH’s than MBA’s; On the other hand Peter Pronovost notes that many of these same MBA’s were influential in instituting technical reform in ICU’s.

  7. Richard Scott-
    The checklist didn’t just lower the rate of mainline infections. In some hospitals it eliminated them.
    There is no question: the medical evidence is clear. Patients die when health care workers don’t use chekclist when inserting mainlines. And patients die when surgical teams don’t use checklists.
    Pilots are required to use checklists. But not surgeons. Why?
    On litigation, you write: I would foresee litigation for a doc’s failure to use the newest unproven fourth generation antibiotic.
    This is an apples to oranges comparison: you are talking about UNPROVEN antibiotics. Gawande is talking about a PROVEN procedure.
    Regarding operating on an obese diabetic: if the doctor used a checklist and the patient developed an infection, he would not be held responsible.
    Checklists prevent doctors from being sued over something that could not have been readily prevented.
    The notion of having to sue hospitals to get doctors to do “the right thing” seems absurd. But I supppose that if some doctors continue to say: “I don’t need to do that,” then eventually, someone will sue a hospital or ICU director.
    Or Medicare (or some other part of the govt) will require that hospitals that wish to receive Medicare reimbursements must require that doctors and nurses use checklists–or lose their privileges.
    Would this be a gov’t takeover? Not really. The checklists we are talking about were invented by a doctor (Peter Provonost) and publicized by another doctor (Atul Gawande). Neither was working for the govt.

  8. Barry–
    You seem to be saying that the for-profit insurance business is a tough business. It’s hard to turn a profit, especially when bond returns are anemic, at best.
    I agree. Some would argue that this is why there are few for-profit insurers in Europe. Most are non-profit.
    As we regulate insurers in the U.S., I suspect that many for-profits will get out of the business.
    I have repeatedly said that insurance profit margins are Not a major driver of health care inflation. Though most have added little value to health care.
    I would add that it is also very difficult to make money in the for-profit hospital business– unless you cheat Medicare, cheat private insurers, lie to patients or lie to shareholders. The large for-profit chains have done all of the above. This is one reason why New YOrk State bars for-profit hospitals.
    For profit companies just don’t work well in certain sectors: prisons, schools, etc. See Baumol’s law: Baumol is an economist who pointed ou that these are labor-intensive businesses that are typically run by government, and for good reason. Govt doesn’t need to make a profit for shareholders.)
    As to whether the Affordable Care Acts reforms are “small ball.”
    When it comes to saving money, CBO says that the ACA will save or raise close to $1 trillion — and that doesn’t include the deep structural reforms which the most recent Medicare Trustee’s report notes could “transform” U.S. health care “in both the way it is delivered and in the manner in which it is financed.” The legislation “takes important steps in this direction” the trustees observe, “by initiating programs of research into innovative payment and service delivery models as ‘accountable care organizations,’ ‘patient-centered medical homes,’ “payment bundling’ and ‘pay-for-performance.’”
    These reforms could save billions–above and beyond the $1 trilion that the ACA raises or saves in ways that CBO could “score”
    Of the $1 trillion, $750 billion represents provisions that CBO could score with confidence. These do not depend on providers or others responding to financial incentives in a particular way. These are firm numbers. (See the itemized list at the end of my recent “Shaggy Wolf” post.)
    The structural reforms that the Medicare TRustees speak of above do all of the things that advocate –though you never mention that these reforms are in the ACA..
    (As you know, under reform, pilot projects in “tort reform” are starting, My guess is that we’ll wind up with health courts, at least in some states.)
    $1 trilion PLUS may seem “small ball” to you. it does not seem small ball to me.
    The President would veto any attempt to eliminate IPAB. The chances that he will be replaced by a Republican shrinks every time one of the Republican candidate’s open their mouths. (I don’t mean to insult REpublicans, but I think many Republicans agree that this is a sorry crew of candidates.) When this party opened its doors to the lunatic fringe, it self-destructed. I’m sorry about that. I think we need a two-party or three-party system. )
    Democrats will ride into Congress on Obama’s coat-tails and may take control of both Houses.
    Finally, on the NY Mag story on hospitals:
    Consider for a moment how much advertising revenue New York magazine’s annual issue on “New York’s Best Hospitals” brings in.
    And that’s not the only issue of NY Mag that draws extremely lucrative hospital advertising.
    The story is filled with misinformation. I could have been written by a PR person at one of our more expensive hospitals.
    It leads with the demise of ST., Vincent’s. In fact, this hospital needed to be closed.
    As the Boston Globe reported: “The now-defunct St. Vincent’s Hospital was destroyed by mismanagement as it teetered at the edge of bankruptcy– including a $278,000 golf outing and more than $100 million in unspecified spending for just one year, according to a lawsuit filed Monday.
    “Top executives at the debt-ridden, 160-year-old Greenwich Village institution earned $1 million each, while spending $17 million for management consultants, former hospital staffers and community members said in the suit filed in Manhattan state Supreme Court.”
    New York Magazine claims that New YOrk hospitals have more debt because of the “demands of an urban setting.”
    This is not true. First of all, Detroit makes as many demands on hospitals as NYC. But, as noted in the post, their hospitals do a better job of controlling hospital errors. Yale-New Haven does a better job of focusing on patient-safety–and they care for many poor patients. They have their priorities straight.
    New York hospitals have more debt, in many cases, because they over-spend on lavish, unnecessary amentities.
    (Even St. Vincent’s was spending on golf outings.)
    The article mentions Lenox Hill as among the struggling hospitals.
    About two years ago, I toured Lenox Hill’s ER where they had installed all-new flat-sceen TVS, one of each patient in a curtained cubicle. (If you’re in an ER chances are high that you arew in no condition to watch TV)
    They also had installed IT in the ER– except, it couldn’t talk to IT in any other part of the hospital.
    What a waste of money.
    Until recently, they didn’t have palliative care because, I was told “the CFO would rather spend the money on expanding the cath lab ( a money-maker.)”
    Lenox Hill won’t let nurse mid-wives deliver babies. As a result, they have a very high level of C-sections and inductions– very expensive for the rest of us, and unnecessarily risky for mothers and babies.
    I could go on.
    In the NY MAG story a hospital official whines about Medicare reimbursements.
    The fact is that Medicare pays the average NY hospital significantly more than similar hospitals are paid in other parts of the country. (This was arranged years ago by a New York Senator)
    Moreover, 1/3 of all hospitals turn a profit on Medicare reimbursements.
    If NY hospitals lose money on Medicare it is because they are terribly inefficient, care is poorly co-ordinated, and their priorities are upside down.
    Consumer Reports 2010 report cals attention to low patient satisfaction in New York City hospitals when compared to the rest of the nation.
    My daughter is having a baby in a few months. Based on the reserach I have done on Manhattan hospitals, she is having it at Maimonides, an outstanding hospital in Brooklyn. The lowest C-section rates in New York State. Outstanding CEO.
    Cosmetically it is not as attractive as some Manhattan hospitals, but patient satisfaction is high. Excellent nurse-midwife program.
    Yet most of the local media protects Manhattan hospitals because they are major advertisers

  9. @ Maggie – Of course you are right, there is no way of knowing if my friend’s surgery would have saved her life, but it would have at least given her a shot. The doctors were going to remove a fistula which prevented her from eating. If she could have taken in food she perhaps could have regained her strength. I appreciate your personal reply. Thank you.

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