Sunday, February 25, 2007

Hospital patients in the United States have to worry about something other than their illness or pending surgery — the very real threat of acquiring an infection while hospitalized, which may be far more serious than the original problem.

These infections, many of which are drug-resistant, affect one in 20 patients — or about 2 million people — each year, according to the Centers for Disease Control and Prevention (CDC). Hospital infections are the eighth-leading cause of death in the United States.

Johanna Daly, 63, of New York City, died of complications from a hospital infection in May 2004, four months after she went to the Hospital for Joint Diseases in Manhattan for treatment of a fractured shoulder.

“She walked into the hospital as a healthy, beautiful woman. But she wound up there as a quadriplegic on a ventilator. How could this happen?” asked her daughter, Maureen Daly.

Mrs. Daly was a victim of methicillin-resistant Staphylococcus aureus (MRSA), a particularly dangerous drug-resistant bacterium.

The CDC estimates there are more than 126,000 MRSA infections each year in U.S. hospitals, and more than 5,000 deaths, according to Fran Griffin, a director of the Boston-based Institute for Healthcare Improvement (IHI).

Mrs. Daly was released from the hospital five days after her Jan. 20, 2004, surgery. But she returned in mid-February “in great pain,” Maureen Daly said. “When the doctor opened the wound, he became alarmed, as all this horrible, rotten-smelling pus came pouring out.”

Maureen Daly worried that her mother might lose her arm. But the surgeons in the hospital’s emergency room were much more concerned: They told Maureen Daly her mother’s life was in danger.

“They cut open her arm without anesthesia, explaining they could not wait,” Maureen Daly said. “I held her down, and the two of us became covered in that horrible, foul-smelling liquid.”

Maureen Daly said she left the hospital after the second surgery, but returned after receiving a call that her mother had been put on a ventilator and had a temperature higher than 106 degrees Fahrenheit.

When her daughter next saw her, Mrs. Daly was unable to move any part of her body except her head. She remained in that condition — on a ventilator and a feeding tube — until her death on May 23, 2004.

“I never could have dreamt something like this would happen … it was so pitiful,” Maureen Daly said.

The family thought about suing the hospital, but Maureen Daly said it was not possible because infection was listed as a risk that the family accepted in authorizing Mrs. Daly’s surgery. It is a common predicament faced by those contemplating litigation.

The Hospital for Joint Diseases did not respond to requests for comment on the Daly case.

Promoting change

The AARP, the nation’s largest advocacy group for seniors, addressed the issue of hospital infections in its January newsletter. The group’s bulletin, titled “Dirty Hospitals,” examined why 90,000 Americans die each year from the infections and offered tips on how to avoid them.

The elderly are especially susceptible to hospital infections because “they go to the hospital more and stay there longer” and may have weaker immune systems, said Lisa McGiffert, head of the Stop Hospital Infections campaign at Consumers Union. But she stressed that patient fragility and vulnerability do not excuse exposure to hospital germs, which should not happen.

The 54,500-member American Hospital Association (AHA) also recognizes that infections pose a huge problem.

“It’s absolutely clear from all the information we have that we are struggling against the enemy of infections and that the bugs are getting stronger all the time,” said Nancy Foster, AHA’s vice president for quality and patient safety.

Betsy McCaughey, a health-policy analyst and former lieutenant governor of New York, works to reduce infection rates by promoting changes in hospital procedures.

“Almost all infections are preventable. We’ve worked with hospitals that have reduced infections by 90 percent,” said Mrs. McCaughey, founder and chairwoman of the nonprofit Committee to Reduce Infection Deaths (RID).

Changing attitudes

Patient advocates say that, for too long, hospitals were reluctant to disturb the status quo, insisting that the infections were inevitable.

“That was the prevailing attitude three years ago when our group started, but the culture is changing,” Ms. McGiffert said. “Our goal is to get infections down to zero, and some hospitals are saying that is also what they want.”

One reason for the change in attitude, she said, “is that there are public reporting laws in 45 states.” Previously, many hospitals kept such information private.

Ms. McGiffert said her organization has “heard from more than 1,700 people [across the country] who have shared their stories” about infections they contracted during hospital stays or about deaths of loved ones that followed hospital infections.

Similarly, Mrs. McCaughey said her group gets “hundreds of e-mails every day” about new infection cases.

“Every day, patients are rescued from the brink of death by medical miracles and marvels. But too many hospitals practice first-class medicine, but third-rate hygiene,” she said.

Mrs. McCaughey addressed this contradiction in an opinion piece published Feb. 3 in the Los Angeles Times.

In the commentary, she noted that CDC data show “astoundingly, over half the time, physicians and other caregivers break the most fundamental rule of hygiene by failing to clean their hands before treating patients.”

The rise of antibiotics

Mrs. McCaughey said the sharp rise in drug-resistant bacteria correlates with a liberal use of antibiotics that began in the early 1970s.

Pointing out that bacteria “are largely spread through touch,” she noted that doctors and nurses were once trained not to touch doorknobs, cabinets, curtains and blood-pressure cuffs once they scrubbed their hands or put medical gloves on. But Mrs. McCaughey said medical personnel seemed to forget the need for strict hygiene as the use of antibiotics increased.

“We rely on technology to save lives, but sometimes this causes the system to forget the basics,” Ms. McGiffert said.

Ms. Foster said the AHA offers a program “to help clinicians know when to use antibiotics” in order to help prevent overuse. They need to know there is a “narrow window,” she said.

The Department of Health and Human Services agrees.

“Taking antibiotics for more than 24 hours after routine surgery is usually not necessary and can increase the risk of side effects, such as stomach aches, serious diarrhea and antibiotic resistance,” it says on its Web site.

Hospital-acquired infections invariably delay a patient’s recovery, often requiring many weeks of intravenous antibiotics or repeated surgeries to remove infected tissues.

‘Wrong one’

Marcia Litov, 68, of Pikesville, Md., needed both.

Mrs. Litov underwent a back-fusion surgery at Union Memorial Hospital in Baltimore on Jan. 6, 2004. The surgery was needed to ease pain caused by a degenerative spinal disc that pressed on the sciatic nerve.

On the fourth day of her hospital stay, Mrs. Litov said, she “experienced pain starting from my abdomen and going around to my back.” She was slated to be released the next day, but asked that she remain in the hospital until the source of the pain was determined.

Instead, Mrs. Litov was sent home the following day. Within 24 hours, the pain became worse and she had a fever of 103 degrees Fahrenheit.

She called her doctor, who told her to return to the hospital immediately. Mrs. Litov met with an infectious-disease specialist, who opened her surgical wound, washed the area and took cultures. Mrs. Litov says she was given an antibiotic before the strain of bacteria was identified, which she says was the “wrong one.”

Doctors discovered that Mrs. Litov had a staph infection, and it was “moving too close to the hardware from the back fusion,” so the hardware was removed, she said.

Mrs. Litov faced weeks of daily intravenous therapy at the hospital, in a nursing facility and at home. After six weeks at home, she “was very ill” and returned to the hospital.

“They found … that I still had infection encapsulated in front of my spine,” she said.

After another surgery, Mrs. Litov stayed at a nursing facility until the end of May, where she took a daily regimen of antibiotics. By then, she said, the infection was “cleared up, and they operated on me once more to replace the hardware.”

But more infections followed, Mrs. Litov said. She said she underwent “a total of nine operations,” continuing until August 2004. She also said she “suffered a lot of muscle deterioration,” which left her using a cane or a walker.

Of the Litov case, Debra Schindler, a spokeswoman for Union Memorial, said: “In complex surgical cases, particularly of the spine, patients are made aware that there remains a remote risk of infection. Union Memorial has an excellent track record in managing that risk with data below the national benchmark for hospital-acquired infections.

“But even when the most intense efforts to eliminate the risk of infection are employed, there are incidents, where various factors, when brought together, make it possible for infection to occur. We regret the suffering Mrs. Litov endured as a result.”

Increasing awareness

CDC data on the prevalence of hospital infections — both for the nation and for individual states — were last published nearly a decade ago. The non-random sample of 270 hospitals showed that the infection rate climbed 36 percent between 1975 and 1996.

But it said tracking infection sites was difficult because postoperative stays were often shorter than the incubation period for Staphylococcus aureus infections.

Late last year, Pennsylvania became the first state to disclose the number of hospital-acquired infections reported by the 168 hospitals in that state. The hospitals reported 19,154 cases in which patients acquired such infections in 2005, a rate of 12.2 per 1,000 cases.

The mortality rate for patients with hospital infections was nearly 13 percent. That compared with a rate of 2.3 percent for patients without a hospital-acquired infection.

Ms. Griffin of IHI said most of the nation’s hospitals are participating in initiatives the group has sponsored that are designed to prevent “unnecessary deaths and harm in hospitals.”

“Awareness is increasing, but reporting is just beginning,” Mrs. McCaughey said. “Meanwhile, these infections are adding $30.5 billion to the nation’s health tab.”

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