A 75-year-old male with chronic obstructive pulmonary disease: Nursing ratio

A 75-year-old male has a chronic obstructive pulmonary disease (COPD) exacerbation. He is treated with steroids, gatifloxacin and help in breathing (mechanical ventilation). An initial X-ray showed his chest was clear, but on the fifth day of ventilation he got a fever and a raised white blood cell count, indicating an infection. The diagnosis was late-onset ventilator-associated pneumonia (VAP).

This man, the subject of a case study in a medical journal, survived. But many patients who get pneumonias that are associated with long times on a ventilator, i.e., late onset ventilator associated pneumonia, do not survive.

In the Intensive Care Unit (ICU), when managers allot fewer nurses to cover patients, late-onset VAP occurs more often, according to a study by Dr. Stephane Hugonnet and others that was published in Critical Care on July 19. Dr. Hugonnet calls VAP the most frequent preventable adverse event affecting critically ill patients, and says it prolongs the length of stay by up to 50 days, lengthens the duration of mechanical ventilation by 5 to 7 days, and generates substantial extra costs, of $10,000 to $40,000 per episode.

He thinks the reason is that rushed nurses take less time to wash their hands and skip other infection control recommendations. Time constraints can increase the probability of error by creating a busy, stressful environment with distractions and interruptions, leading to low compliance with hand hygiene recommendations and isolation procedures, or inadequate care for the ventilated patient. Cross-transmission of micro-organisms from one patient or the environment to another patient, or from one body site to another in the same patient, leads to colonization and infection, he reports.

Almost a quarter of patients on ventilators in the Intensive Care Unit (ICU) got pneumonia, and most of these were late-onset.

Advice to those with a family member in the ICU: Ask the ICU Nurse Manager the nurse staffing ratio.

Read one of our tired nurse stories, or read Dr. Hugonnet’s source article.

I’m sure they have some record: A laboratory medical error

The last time she saw her father - a soft-spoken man who "always had a joke for everyone" - was when she visited her parents' home in Florida for Christmas. "He was great," Jeanne Zeller said. "He even carried my luggage for me."

Around a week later, though, Thomas Zeller started to have shoulder pain. After enduring it for a week, the 69-year old man checked into the hospital, on Jan. 8, 2006. His initial vital signs were normal and his chief complaints were left shoulder pain and right hand swelling. X-rays of Zeller's left shoulder showed a slight dislocation of bone. On his first day in the hospital, he was given a Foley catheter to help with urine retention.

Thomas' temperature spiked to 102 degrees during the late evening of Jan. 11, and a blood culture was taken the next day. Meanwhile a cardiac catheterization on Jan. 11 had suggested dysfunction of the heart muscle (cardiomyopathy). Though the condition was serious, it didn't warrant his staying in the hospital any longer, and he was discharged to a nursing home on Jan. 14.

Thomas’ fever continued to spike during the next week, while he was having rehabilitative physical therapy in the nursing home. At the end of that week, he was transferred back to the hospital, on Jan. 20. There, the blood and urine cultures revealed Pseudomonas aeruginosa, a "superbug" resistant to most antibiotics. From there, his condition deteriorated, as the infection spread to his heart valves. On Feb. 15, Zeller's wife signed the "do not resuscitate" order, and he died soon afterward.

The superbug had spread, unknown and untreated, for a week, because the Jan. 12 blood culture result was delayed or missing until after he left the hospital. "By not having important lab results in the chart in a timely manner," Jeanne Zeller wrote to the Florida Agency for Health Care Administration, the hospital "sentenced my father to death."

The most likely explanation: "Persistent Pseudomonas aeruginosa bacteremia blood poisoning probably started off as a urinary tract infection," Dr. Murali Puthisigamani wrote after examining Thomas on Jan. 30.

The hospital had made at least three errors. First, unsanitary conditions were surprisingly prevalent. Three of nine patients sampled by AHCA "were not provided catheter care and/or personal hygiene care," according to AHCA’s report. Second, the initial lab result was delayed. Third, when the critical result was determined, staff told no one. Apparently the hospital had no effective system in place to immediately sound an alarm to doctors when laboratory staff learn of such critical lab results (also called "panic values").

The AHCA inspector had asked the infection control nurse why Thomas Zeller's Jan. 12 blood culture never made it to his chart. Her response: "If a patient left before the final results were in, they may be - I don't know how medical records does their filing. I'm sure they have some record."

Advice: Before you let your father into a hospital, ensure that the hospital participates in the Five Million Lives campaign of the Institute for Healthcare Improvement.

Read a story on misplaced lab results, or read Elena Lesley’s source story, dated April 1, 2007.

Cheatum was cheated: A nursing home lawsuit

This week the family of a Tennessee man won $4 million in a lawsuit against the nursing home chain that had cared for him. Cheatum Myers suffered numerous falls during his nursing home stay, one of which broke his hip. He didn’t get treatment for the injury for a week.

 And an infection around where Myers’ catheter was located led to a high fever complicated by pneumonia. He had one bedsore all the way to the bone on his heel.

 Mr. Myers died in 2005, and the lawsuit claimed it was because of the lack of care.

Advice to the adult children of frail elders: Check the quality ratings of nursing homes with your state’s department of public health.

Read another lawsuit story, or read the source story in the Daily News Journal.

Ed Bradley's Fatal Infection

The CBS reporter Ed Bradley died last month at age 65 from complications of chronic lymphocytic leukemia. Bradley, who underwent a quintuple bypass operation on his heart in 2003, had been diagnosed with leukemia "many years ago,” said Bradley's cardiologist, Dr. Valentin Fuster, but it had not posed a threat to his life until he got an infection. It is not publicly known whether the fatal infection came from home, a hospital, or somewhere else.

Hospital-acquired infections can come from germs on the hands of doctors or nurses, or unclean medical or surgical devices or instruments. Urinary tract infections are the most common infections for hospitalized medical (i.e., non-surgical) patients like Bradley, according to an article offering an overview of the topic in a microbiology journal, based on 26,000 infections in the National Nosocomial Infections Surveillance system. Though some safety experts recommend that a patient routinely ask each doctor, nurse and phlebotomist (person who draws blood) whether they have washed their hands, this may be embarrassing or impractical for the patient.

Lesson for caregivers: It may be easier for the patient or advocate to post a sign on the door or hospital bed saying, “Please wash your hands, and tell me you’ve done so. Thanks.”

Readers: Do you know of errors like these?

Bradley news source: “Admirers to Pay Final Respects to Bradley,” from BET.com News Staff & Wire Services, Updated Nov. 21, 2006.