Friday, March 20, 2009

Healthcare in the United States

A friend of mine works in medicine, and I told her that if she were to write up commentary on the state of healthcare in the United States I would print it for her. I expected an essay, but instead she forwarded to me two emails she had sent to another organization, the second as an addendum to the first.

To: Department of Health and Human Services

Re: Action plan to to prevent healthcare-associated infections

I am responding as an individual, not representing any organization.

Myself, BS, BSN, MPH, formerly CIC

I currently work as an Infection Preventionist (name recently changed from Infection Control Nurse) in a 500+ bed community hospital. I cover all the intensive care units in the facility, so I am aware of the problems faced on the front line of infection prevention.

1. Basics: Make sure government agencies at all levels do not impede best practice.

Research has shown that alcohol-based hand hygiene products can improve compliance in intensive care units. (Maury et. al, Am J Respir Crit Care Med Vol 162, pp 324-327). The hospital I work in has had alcohol based hand sanitizer available for over 8 years. We spent time and effort in selecting a product that was acceptable to all involved. The Georgia State Insurance Commissioner is currently investigating removal of foam sanitizers under pressure for a theoretical fire risk. The last time we were forced to remove our current product from the hallways, our cross transmission of MRSA skyrocketed. Replacing the hallway dispensers stopped the outbreak.

2. Partnership of all involved groups: The patient also needs to be seen as a partner in reducing healthcare associated infections.

Transmission of flora within the hospital does cause healthcare-associated infections, but for SSI (surgical site infection), the patient's own flora can be the source. Aside from complying with preoperative showers for elective surgery, patients need to prepare themselves for the surgery by stopping smoking and controlling blood glucose levels. Smoking has been shown to increase SSI. Post-operative glucose control is important in prevention of SSI, but patients who know they are going to have surgery should prepare themselves.

Patients also need to understand that requiring their physicians to prescribe unnecessary antibiotics also contributes to infection with CD (C diff).

Physicians also need to be involved in getting patients ready for elective surgery. The following is a true story. My mother and the brother of a friend of mine both had knee replacements on the same day. It took a long time to get my mother ready for surgery because her surgeon insisted that she see her primary care physician and her dentist for clearance.. She had to be screened for infection--UTI. Our hospital does nasal screening for MRSA and MSSA on all orthopedic implant surgeries. The brother did not have to do any of this. Within three weeks of surgery, my friend told me that her brother had an infection. My mother is now over one year out from her surgery and doing fine. We switched surgeons early in the course of getting her knee replaced because the first surgeon we went to wanted to basically go from his office to the OR without the preparation the second one required.

3. Focus on MRSA: I find this short sighted.

The worst infections in our facility are caused by Gram negative rods (GNR) for which there are no antibiotic treatments. It is much easier to track MRSA and may be easier to put in interventions. However, GNR are a much worse and growing problem.

4. Futility of Care and End of Life issues: something nobody want to discuss as part of the solution. Strong guidelines on futility of care, and decreased payments for care after such a determination is made need to be in place now.

The last three infections I identified (2 BSI and 1 VAP) were all in patients in whom it had been acknowledged that there was no hope of recovery and all medical interventions were futile. DNR discussions had been ongoing with the families for as long as three weeks prior to the infections. All three patients died of their underlying conditions within three weeks of the onset date of the infection. The infection was not the immediate cause of death, even if it might have hastened the inevitable. Physicians discuss the problem openly during our intensive care rounds. The family will be around after the patient's death and might bring a law suit if their wishes (the family's) are not carried out. The wishes are usually expressed as "Do everything for Mama" even if they have been told that everything will not work and that Mama is going to die anyway. We have discussed the reason for families not to withdraw care. Sometimes it is just too soon. It because apparent today that the patient was beyond hope. Sometimes it is the level of education and sophistication of the family. When you talk to them, they are very nice but they just don't seem to understand the issues. Guilt can play a part also. Having neglected Mama for the past year (nursing home patient, living with a friend, not family), the family wants to make amends. We see cultural differences. African American families seem less able to withdraw care. Sometimes we find out that there is a financial reason.. Mama's Social Security check is going into a family member's bank account.

What ever the reasons are, physicians are not comfortable withdrawing care and instituting palliative care measures if the family still states they want everything done, even if it prolongs death and does not lead to life.

5. Payment issues: The assumption appears to be that hospitals control doctors. I wont' even go there.

We ask, we coax, we nag. We already use a Foley catheter reminder sticker for physicians. It is usually ignored, even though it is part of the chart. Some physicians sign the reminder without indicating why the Foley is to continue and without giving an order for its removal. Physicians have not reason to listen. I recommend that payment for physicians whose patients develop a healthcare-associated infection (HAI) also be reduced, just as payments for hospitals are. The payments are reduced to the extent that hospitals used to get reimbursed for care of infections. Yes, hospitals need good systems to ensure timely care, but physicians have to do their part by responding in a timely fashion.

In my introduction, I noted that I was formerly CIC. One of the most important things that you can do is make sure that all front line workers are adequately prepared. I dropped CIC for three major reasons: my current employer does not pay for the test and it is expensive, I do not get any pay differential for it, and CIC ensure entry level competence. I have been in infection control for over 20 years now. I will have to pass the new requirements for getting my NHSN certificate so I can continue to use the CDC computer-based reporting system. Hospitals should be supported in efforts to make sure that employees are qualified.


1. Best practice. The Office of Insurance and Safety Fire Commissioner has denied the request of the hospital that I work in to keep the foam hand santizing product. The reason that is stated is that the "State is bound by contract to meet the requirements of CMS 211, which supersede those of the State of Georgia..." This ruling was given by the Regional Director for CMS.

If CMS will not pay for HAI then CMS must allow the use of the best products to prevent infection. Changing hand hygiene products is not as simple as it sounds. Not only do the products have to work, but the employees must use them. The products must not cause redness, skin breakdown, stickiness or other problems. The hospital did evaluate gels the last time it looked at hand hygiene products. The end users preferred the foam.

2. Please add to your reserach list: the best way to wean a patient from the ventilator. We have six Intensivists. Each has a way to do this. Each tells us the other ways won't work. ATC trials should not be done more than once a day. ATC does not work at all. Do ATC trials three to four times a day before considering extubation. PLEASE HELP. Meanwhile, we are having a difficult time decreasing our ventilator days and getting patients off the ventilator is the best way to prevent VAP.

3. Patient as partner: All patients should know that it is not a good idea to keep drinking patterns a secret. It can be a major problem when a patient comes in for elective surgery and goes into DTs three days post-op. The patient may wind up on the ventilator with central lines and then is at risk for hospital associated infections. DTs prolong stay no matter what.

1 comment:

Paul Weber said...

Can't find a thing to disagree with in this. All I can add is that I've known many people whose lives were deeply damaged by government intrusions in the health care system.