I began my quest: A MRSA infection

Kathy Day’s story:
My father had a minor fracture of his ankle, and was in the hospital for 12 days of rehab, and then was home for a day and a half. Then he collapsed, and was brought back to the hospital. On admission, they diagnosed him with pneumonia. After he was in the hospital for six days and after he developed a MRSA urinary tract infection after a catheter insertion, I asked for a sputum culture (I'm a retired E.R. nurse, so I know about these things). It took them a day and a half to get the results, which showed them it was a MRSA infection. We'd been visiting him with no precautions; now they told us to use full precautions – gowns, gloves, and masks.

Dad was in the hospital for a total of 20 more days. He suffered through sepsis, complete loss of energy, appetite, and independence. He got blood transfusions, and very strong IV antibiotics. His treatment caused him thrush, a body-wide allergic reaction and loss of hearing. He had been living independently with my mother at home before. Once his acute care (hospital) was "complete" he was sent to a nursing home. He had become a totally bed-bound nursing home patient because of this, and couldn’t sit up without passing out. After nine weeks in the nursing home, in an isolation room, he became very depressed. In total, he lost a third of his body weight. He never walked again. What happened to him wasn’t so rare, as a month before he’d been admitted, two joint replacement patients had had MRSA in the same small 25-bed hospital, and had died from it.

After this happened to my father, I began my quest for MRSA prevention. I wrote letters to the hospital, did research, and came upon Jeanine Thomas, who was the founder of MRSA Survivors Network in Chicago. She's a real powerhouse! She got a law passed in Illinois. Then I wrote a proposal for Maine, got the necessary support and a sponsor, Representative Adam Goode. We passed a law in June 2009 to screen all high risk patients for MRSA on hospital admissions.

Kathy Day's advice: If someone is at risk for MRSA, e.g., they're elderly, coming from a nursing home, with ongoing health problems, or are about to have implant surgery, request MRSA screening from the admitting physician for their own safety. For an elective admission, it's best to be screened a week or two ahead of time to allow decolonization (to clear the MRSA from the patient's body) through five days of preparation, including showering daily with Hibiclens, and the ointment Mupirocin for the nose, which is a prescription antibiotic. If you test positive for MRSA before entering the hospital, you should be either isolated or cohorted (roomed with someone with a like organism).

There's a higher risk of infection for surgery involving implants, e.g., knee or hip replacements, or cardiac valve replacements.

Read Jeanine Thomas' MRSA story.

Five minutes of education: Physician-patient communication upon hospital discharge

From Dr. Jeffrey Schnipper's research:

A patient was admitted for worsening shortness of breath and weakness. Evaluation showed ischemic heart disease [reduced blood supply to the heart], which was managed medically by changing her blood pressure regimen from metoprolol tartrate (50 milligrams, twice a day) to metoprolol succinate (extended release, 100 milligrams, once a day), lisinopril, and isosorbide mononitrate. She came to her nurse practitioner eight days after discharge for a blood pressure check, complaining that she’d been experiencing three days of scalp tingling [paresthesias] and headache; her blood pressure was markedly higher. On questioning, she reported not taking the long-acting metoprolol prescribed at discharge, because of a misunderstanding. She was brought to the Emergency Department, where she was treated, observed for several hours, and discharged home.

This was due to a discrepancy after discharge; she had stopped her short-acting drug and did not realize she needed to start the longer-acting one.

Such misunderstandings are common, partly because changes in medications are made so frequently. Upon an inpatient’s discharge from the hospital, doctors change 40% of the medications the patient has been taking, on average. “Five minutes of education of the patient and having them ‘teach-back’ what they have learned could eliminate the need for an E.R. visit later,” Dr. Schnipper says.

Advice to patients leaving the hospital:

Ask these three questions:

1.What changes should I make to the meds I’ve been taking?

2. Why are these changes needed?

3. What do I need to watch out for?

To ensure you’ve heard the answers correctly, repeat the answers back to the nurse or doctor.

Thanks to Dr. Schnipper, whose article appeared in the March 13, 2006 issue of the Archives of Internal Medicine.

Still waiting: Apology for a medical error

Jeni Dingman's plaint:

Today it will be 16 years ago that I lost my dear and wonderful mother due to multiple medical errors, miscommunications, and a flawed healthcare system that did not pay attention to the needs of patients and families. As there have been some changes in those years, years that I have freely given to a cause that I hope someday will save lives, 250,000 Americans still die every year due to medical error. The most important change has yet to come. It must concern communications, patient engagement, patient empowerment and partnering. This can ONLY occur if we are welcome and invited to participate by our providers. Most of all, patients and families must be listened to. I do not know what outcome might have occurred had clinicians listened to my mother and I so long ago, but do I know that my pain would not be as intense as it is every single day had we not been discounted, written off and ignored by those entrusted by our family to do the right thing. My mother was NOT anxious as the clinicians indicated, she was in trouble, and no one rescued her, no matter how hard I tried to get them to listen, they didn't, and they never ever apologized either, I am still waiting for that apology.

Thanks to Jeni for her source posting to Facebook.

Here in Massachusetts, many members of the Consumer Health Quality Council of Health Care for All have experienced errors in their families, but have not received apologies. We have filed a bill to encourage doctors and nurses to apologize for medical errors. We hope that any upcoming federal legislation about medical malpractice claims would strongly encourage, if not require, apologies.

Read a story about a hospital's apology.

In a new way: The American Society of Professionals in Patient Safety

Diane Pinakiewicz and her team at the National Patient Safety Foundation recently announced the launch of the American Society of Professionals in Patient Safety.

In an interview, Diane told the story and described the vision behind it. This is excerpted from our interview:

In 2007, we took stock, and said, We've been working in this area for ten years, and now, patient safety is a legitimate discipline. So how do we legitimize and organize it and help move it forward? We developed the Leape Institute, as a think tank for the field.

There were many passionate people, but no membership organization for them to connect to. NPSF had a membership programs for hospitals, but not one for individuals with patient safety as its uniting principle.

And the field lacked a certification program like the ones there are for Risk Management, Quality Improvement, and so forth.

We want people to understand that this is everyone's responsibility.

Our vision of success for the ASPPS ten years from now would have two parts. First, everyone in the healthcare system who delivers services to patients would have learned, and could exhibit, competencies for safe care. Second, that patients and their families would be educated and involved in a new way in the tenets of patient safety, and they'd know why their involvement is so important.

Read another story about http://www.patientsafetyblog.com/2011/01/recent-progress-by-patient-activists.html">visionary patient safety experts. Thanks to Diane Pinakiewicz for the interview.

Human judgment is better: Patient advocates and fatigue alarm

Liz Kowalczyk's recent articles in the Boston Globe highlighted the problem of alarm fatigue in Massachusetts hospitals. The noisy alarms are so often false alarms that staff learn to ignore them. Since most of the alarms are false alarms, ignoring them is usually harmless. But sometimes, of course, the alarms are genuine. One set of disregarded alarms led to the death of Madeline Warner in a Massachusetts hospital. Alarms had sounded for 75 minutes, warning that her heart monitor's battery needed to be replaced. Kowalczyk found that hundreds of deaths had been causes by such alarm fatigue in the last five years; indeed, this probably represents only the tip of an iceberg.

"If there were an obvious solution to this problem, we would have done’" it, said Dr. James Bagian, the former chief patient safety officer for the Veterans Administration hospitals, where he said there have been multiple patient deaths and close calls because alarms were turned off or the volume was turned down. "No one has one."

I disagree. There may well not be a technical solution now, given the current state of technology. Human judgment is better. But most humans in hospitals are busy taking care of numerous patients. A dedicated patient advocate, on the other hand, is focused on a single patient. When family members acting as advocates, or professional patient advocates, insist on a Rapid Response by hospital staff, for example, in a de facto humanly-triggered alarm, about half the Rapid Responses are later ascertained as valid, with the benefit of hindsight. That true positive rate of 50% is far higher than the true positive rate of machine alarms. That is one of the most powerful reasons why people should bring a patient advocate, preferably a professional, into the hospital with them.

Advice to hospitalized patients: Bring a patient advocate with you.

Read another story on hospital Rapid Response methods.

In the check-out line: Safe counts for surgical sponges

Brian Stewart's background is in the investment industry, including investments in medical device companies. To help in his due diligence, he would often reach out to friends, family and outside consultants with clinical backgrounds. Much of that dialogue would result in clinicians sharing their thoughts on issues they often faced in their daily practice. This is where he first became aware of the issue of retained surgical sponges, their frequency and the real economic and human costs. Brian's father, a surgeon, added additional perspective by sharing the realities of the operating room and the typical usage of sponges in surgery. From a number of previous investments Brian had made, he was relatively familiar with various forms of automatic identification, including simple barcodes, two-dimensional codes and RFID technologies. Thinking out loud to his father as they stood together in a line at a grocery store, watching a woman quickly scan each item in their cart and hand them a detailed receipt of each item, he pondered "Why not use a technology of some sort to help nurses count more accurately?" That was the beginning of the company they co-founded, SurgiCount Medical.

Brian and his father worked for years to develop a cost effective, safe solution. Finally they found something that worked well, from the garment industry – it uses iron-on thermal transfer labels. So a bar code on a piece of plastic is basically melted onto the sponge, placing a unique identifier on each sponge. When used with a small handheld scanner, the solution helps increase the accuracy of sponge counts, in that each sponge can only be counting IN once and OUT once. This addresses the underlying issue in the vast majority of retained sponge cases, false "correct" counts. That is still the core of the product that the company Brian is CEO of today (Patient Safety Technologies, which acquired SurgiCount back in 2005) offers, called the SurgiCount Safety-Sponge. That has proven to help eliminate retained sponges and the costs associated with them for those using it, which includes over 65 hospitals, including five of US News and World Report’s 2010-11 Honor Roll Hospitals.

Now, in the February 2011 issue of the Joint Commission Journal on Quality and Patient Safety, there's an article about a multi-year study, the largest ever done on retained foreign objects, in which the Mayo Clinic examines the occurrence rates of retained sponges and profiles the success that Mayo had by implementing the Safety-Sponge System there. Before implementation, Mayo was averaging a retained sponge every 64 days (about one in 8,000 operations). Eighteen months after implementing the Safety-Sponge System and using over 1.8 million Safety-Sponges in more than 87,000 cases, they have not had a single retained sponge. In addition to the usage at Mayo, over 32 million Safety-Sponges have been successfully used in more than 1.6 million operations.

Read a story on a http://www.PatientSafetyBlog.com/2007/01/they-dont-count-non-surgical-towels.html">retained object.

Thanks to Brian Stewart for our phone interview for this blog post and to Stephanie Pavol.

Keeping the love growing: James's Project

Mary Ellen Mannix's Valentine's Day card:

I hope you enjoy a wonderful day with your special valentine!

James's Project is working to keeping the love growing and we are wearing our hearts on our sleeves today.

This past month James's Project helped a pregnant mom get care she was being refused, a 2-year-old who had a tonsillectomy to find medical coverage for expenses and help in the infection treatment post-op, educate a heart baby's mom about what questions to ask and how to search for a doctor's license, and advocated at the national level for standardizing Congenital Heart Defect screening in newborns via the pulse oximetry.

He wasn't open to the woo-woos: The Urban Zen Foundation

As a designer for Anne Klein, Donna Karan gave birth to her daughter Gabby the same week a collection of resort clothes was due, even as her boss Anne was succumbing to cancer. Donna's mother died on the day of a fashion show, and her husband died the same week as a show. Through it all, Donna kept working, later leaving Anne Klein to form Donna Karan New York. She got involved in philanthropic work when the AIDS epidemic broke out. It’s now the 25^th anniversary of the start of her fashion label, and two years since she founded the Urban Zen Foundation, located in a large art studio in Greenwich Village in New York City.

Long a New Age devotee, she was transformed by her husband Stephan Weiss' seven-year battle with lung cancer. She says, "Stephen wasn't open to what he would call my woo-woos – all the alternative methodology journeys I would take. But all of a sudden, when he got sick, he realized the importance of them. He did yoga four times a week; he had an Iyengar teacher who would come because he needed postural positions to help him breathe. We did acupuncture, Chinese medicine, massage and raindrop therapy with essential oils. It became obvious to me that this was what was missing in the hospital system."

She was also deeply affected by the struggle of her best friend, Lynn Kohlmann, who died from breast and brain cancer in 2008. "When you get the call, panic sets in: What do we do? As loved ones, we're not trained in health care. But when you're a patient or a loved one, you need a guide….So I asked, 'Who is putting together a movement that is changing the hospital system?' There was a void. No one was integrating" the health care.

Now her Urban Zen Foundation offers a 500-hour Urban Zen Integrative Therapy program that brings together health professionals and yoga teachers who are taught in-bed yoga, meditation, Reiki, aromatherapy, palliative care and nutrition. The participants in the first year, who include doctors, nurses, yoga instructors, yoga practitioners, physical therapists and other healthcare providers, complete 100 hours of clinical rotation at a hospital.

"Our healthcare system today needs help. This is a huge project, and there's a lot of work to do. I have to take it one day at a time. This is in its infancy stage. This is a movement that's being created. I want to join with all these brilliant people: Deepak Chopra, Mehmet Oz, Mark Hyman, Woodson Merrell. If we all join forces, we have a lot of people on this path. It's definitely a mission, and it's the most challenging thing I've ever done."

Thanks to Leslie Bennetts for her source article in the July 2010 issue of Town & Country.

For many years: Crying by doctors

Dr. Amina Hassan Abdeldaim's letter to the Editor:

"A Mantra: No Crying in the CAT Scanner" on Feb. 1, Dr. Ellen Feld's exquisite telling of her experiences during her own treatment for breast cancer, finally allowed me to let go of the tears I have been blinking back for many years.

As a physician at a cancer hospital, I am in awe of the patients' stoicism and strength. If my patient cries, may I cry too? Will it help or hurt the patient to know I may have a dose of "unprofessional sympathy"?

Advice to doctors: Your compassion and empathy are much appreciated. I hope you can find some way to show that, maybe by letting yourself cry.

Read another story about compassionate physicians. Thanks to Dr. Abdeldaim and the editor of the New York Times, where her letter was published today.

In front of the entire class: Surgical success rates

Dr. Harvey Cushing became the father of brain surgery, following his surgical residency at Yale in the late 1890s. He attributed his success to meticulous care, rather than innovations per se. One key to his success was meticulous record-keeping. It started when he was assisting with surgery as a student, using a sponge to administer ether, and the patient died in front of the entire class. Appalled and mortified, Dr. Cushing and a classmate soon developed "ether charts," to keep track of a patient’s heart and respiration rates, perhaps his first major contribution to medicine. Such charting revolutionized surgery by greatly curbing complications and deaths from anesthesia, according to the Journal of Neurosurgery.

Since Dr. Cushing's era, anesthesia is the field of medicine where doctors have most greatly reduced their error rates. The systematic collection of their data and the scrutiny of it by those empowered to change medical practice saved many lives. Doctors in other fields also now record information on their success rates. It's time for this information to become routinely available to consumers. In Massachusetts, a legislative bill to require surgeons to provide some basic information to consumers is under consideration.

Advice: Find out the success rates for your surgery and your surgeon before you go under the knife.

Read another story about such transparency of surgical data. Thanks to Richard Conniff for the source story in the January/February 2011 issue of the Yale Alumni Magazine.

Our border collie is our personal trainer: Dogs' contribution to health

Groundhog Day came and went, but now we're back in the dog days of winter. Two dog lovers' stories:

Barbara Abrams' story:

We are in our 70s and have no doubt that our dog significantly contributes to our health. Gracie, a three-year old border collie, gets two long walks (two miles on average) every day, no matter what the weather. And the weather here in Rochester, New York can be brutal, with black ice on the sidewalks. But no matter how strong the temptation to stay in, Gracie demands her walks, appealing to us with her soulful, puzzled eyes when we are behind schedule. She is our personal trainer.

Will Mesa's story:

Not long ago my dog brought me my bottle of aspirin in her mouth while I was having a terrible headache, proving that pets indeed help alleviate pain in owners.

Advice: Keep using your personal trainer, of course, while leashed and curbed properly at all times.

Read another story about what dogs teach us about healthcare.

Thanks to the editor of the New York Times Letters to the Editor, for these stories published on January 10.

Vanderbilt University Hospital Advisory Council's Accomplishments of 2009

This is a small subset of the accomplishments in 2009 by the hospital's Patient and Family Advisory Council, led by Mary Ann Peugeot:

Inpatient Admission Guide;

Surgical Consent template revised to 5^th grade reading level;

How to Have a Safe Clinic Visit: core elements were defined for signage;

Discharge Video;

Clinic Kiosks: Discussed the effectiveness of check-in kiosks and made recommendations.

The full set of accomplishments in 2009-10 can be read here.

These changes make Vanderbilt’s council a model of how patients and families can guide hospitals in becoming more patient-centered. Kudos to Mary Ann Peugeot and her Council!

Advice: Ask to participate in your hospital’s council.

Read another story about innovative patient and family advisory councils. Thanks to Mary Ann Peugeot for the source.

Airline pilots and NASCAR teams have them: Hospital checklists

Dr. Peter Pronovost's story:

I was a young doctor doing specialty training in critical care, and I was exhausted. Partway through a 36-hour shift at my academic medical center, I was hungry and hadn’t slept for 24 hours, but I was facing an overflowing intensive care unit and somehow needed to discharge five patients to make room for more. Mr. Smith (not his real name), who'd had esophageal surgery [in the gullet], was a borderline call. But because of the pressure I was under, I decided to remove his breathing tube and transfer him to another unit.

That turned out to be a very bad decision. Before long, his breathing sped up as his oxygen levels dropped dangerously. I needed to reinsert his breathing tube. But what I didn't know was that he had severe swelling in his throat. When I looked into his mouth and tried to identify his vocal cords in order to insert the tube, all I saw was a swollen mass of dark pink tissue, like raw hamburger.

I took the instruments out and started to bag him, breathing for him, but he vomited, making that almost impossible. I finally go the tube in – but quickly realized it was in his esophagus, not his airway where it belonged. When you insert a breathing tube, you give the patient medication to stop his breathing. You have about four minutes before he suffers brain damage. It took me between three and five minutes to get the tube properly placed.

I waited anxiously for the medication to wear off, which usually takes about 15 minutes. But after an hour, he was still asleep. After six hours, I was panicked. Luckily, he regained consciousness shortly thereafter and recovered with no ill effects.

Before I pulled that tube, I should have had to complete a checklist that included input from the patient's senior physician and nurse. If anyone had disagreed, I wouldn't have been able to act. Many medical errors occur because hospitals lack standardized checklists for common procedures designed to minimize the chance of bad judgment. Airline pilots and NASCAR teams have them – why don't doctors?

A few years ago, I helped develop just such a list for doctors and nurses in more than 100 ICUs in Michigan. It focused on a common intensive care procedure: inserting a catheter into a vein just outside the heart for delivery of intravenous liquids. It ticked off five steps everyone had to follow, and in 18 months, it lowered the rate of catheter infection by 66% and saved 1,500 lives.

Such checklists are the subject of a bill just introduced to the Massachusetts legislature as Senate Docket #1766/House Docket #879.

Advice: Let your state legislator know you’d like such a law.

Read Paul Levy’s blog post about reducing central line infections through checklists, or read another story about checklists.

Thanks to Joe Kita and Dr. Pronovost for the source story in the October 2010 issue of Readers Digest.