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Thursday, July 25, 2002 - 12:00 a.m. Pacific, by By Michael J. Berens, Chicago Tribune
Hospitals' hidden killers: More germs are taking patients' lives
A hidden epidemic of life-threatening infections is contaminating America's hospitals, needlessly killing tens of thousands of patients each year.
These infections often are characterized by the health-care industry as random and inevitable byproducts of lifesaving care. But an investigation found that in 2000, nearly three-quarters of the deadly infections Ñ or about 75,000 Ñ were preventable, the result of unsanitary facilities, germ-laden instruments, unwashed hands and other lapses.
The industry's stance also obscures a disturbing trend buried within government and private health-care records: Infection rates are soaring nationally, exacerbated by hospital cutbacks and carelessness by doctors and nurses.
Hospital infections often are preventable by adopting simple, inexpensive measures. Strict adherence to clean-hand policies alone could prevent the deaths of up to 20,000 patients each year, according to the Centers for Disease Control and Prevention and the U.S. Department of Health and Human Services.
Hospitals provide ideal reservoirs for germs, with temperature-controlled environments and a steady stream of germ-carrying strangers pouring through the doors each day.
The most vulnerable
Germs that wouldn't be harmful to healthy people in their homes or at work can turn deadly for patients too young, too old or too weak to fight the infection.
In Chicago in 1998, as fever-ridden health-care workers tended to patients and as others worked without always washing their hands, eight children died of an infection that spread from a care home into a hospital. The flulike outbreak was halted weeks later after three dozen sick health-care workers were ordered to stay home.
In a Detroit hospital, as doctors and nurses moved about the pediatric-intensive-care unit without washing hands, infections killed four babies in the same row of bassinets, according to court records and interviews. But it took three months for administrators to close the nursery for cleaning.
Staphylococcus germs thriving inside a West Palm Beach, Fla., hospital invaded more than 100 cardiac patients, killing 13, according to court records. The survivors underwent painful and debilitating surgery, as rotting bone was cut from their bodies.
The health-care industry's penchant for secrecy and a lack of meaningful government oversight cloak the problem. Hospitals are not legally required to disclose infection rates, and most don't.
The Tribune analyzed records among 75 federal and state agencies, as well as internal hospital files, patient databases and court cases around the nation. The result is the first comprehensive analysis of preventable patient deaths linked to infections within 5,810 hospitals nationally.
The analysis found an estimated 103,000 deaths linked to hospital infections in 2000. The CDC, which bases its numbers on extrapolations from 315 hospitals, estimated there were 90,000 that year.
The CDC links infections to patient mortality both directly and indirectly. Direct cases typically involve patients who specifically died of complications caused by an infection. Indirect cases involve infections that played a role in a patient's death.
The Tribune examined federal health-inspection reports and other public documents from 2000 Ñ the latest year health-care records were available nationally Ñ to estimate that 75,000 of the deadly hospital infections took place in conditions that were preventable. Deaths were considered preventable if patients contracted infections that were spread as the result of deficiencies documented by state, federal or health-care investigators.
For every death linked to an infection, thousands of patients are successfully treated each year. And many hospitals battle infections with diligence and the latest technology.
But the investigation found that breakdowns occur more frequently than patients suspect and consequences often are deadly.
Government and hospital industry reports reveal that:
¥ Since 1995, more than 75 percent of all hospitals have been cited for significant cleanliness and sanitation violations.
In thousands of cases observed by federal or state inspectors, surgeons performed without washing hands or wearing masks. Investigators discovered fly-infested operating rooms where dust floated in the air during open-heart surgeries in Connecticut.
A surgical assistant used his teeth to tear adhesive surgical tape that was placed across an open chest wound during a non-emergency procedure in Florida.
¥ Hospital cleaning and janitorial staffs are overwhelmed and inadequately trained, resulting in unsanitary rooms or wards.
Because of cost-cutting measures, U.S. hospitals have collectively pared cleaning staffs by 25 percent since 1995. During the same period, half of the nation's hospitals have been cited for failing to properly sanitize portions of their facilities. ¥ Hospitals are required to have professional staffs devoted to tracking and reducing infections, but rampant payroll cutbacks have gutted those efforts. These staffs have been reduced an average of 20 percent nationally in just the last three years.
Since 1969, when U.S. Surgeon General William Stewart confidently told Congress that the nation could "close the book on infectious diseases," hospital infection rates have quietly pushed higher each year, registering a 36 percent rise in the past 20 years, CDC records show.
Today, about 2.1 million patients each year, or 6 percent, will contract a hospital-acquired infection among 35 million admissions annually, CDC records show.
The American Hospital Association said the last decade of unprecedented cost-cutting and financial instability has impacted all areas of hospital care, including infection control.
Nurses, in particular, say staffing cutbacks have made the most basic requirements of their jobs difficult to fulfill, and a survey by the Harvard School of Public Health recently linked nurse staffing levels to hospital-acquired infections.
The national study of 799 hospitals found that patients were more likely to contract urinary tract infections and hospital-acquired pneumonia if nurse staffing was inadequate.
A deadly outbreak that swept through a Connecticut medical center in late 1996 reveals how washing hands or wearing clean clothes can be as critical to a patient's life as a surgeon's skill.
Bridgeport Hospital's Operating Room 2, where up to one in five patients in 1997 contracted infections, epitomized the facility's problems.
The air often was contaminated by dust because of faulty ventilation, hospital records show. Flies buzzed overhead during open-heart surgery. Doctors wore germ-laden clothes from home into the operating room. Many never washed their hands.
Gloria Bonaffini, 71, was wheeled into Operating Room 2 in December 1996 for what doctors considered routine coronary artery bypass graft surgery. Instead, an infection burrowed into her sternum, and she remained hospitalized for more than a year.
"I asked a nurse what was wrong with Gloria," said her husband, Phil Bonaffini, 73, who later sued the hospital. "The nurse looked at me and very quietly said, 'She has the infection.'
"I asked, 'What infection?' but the nurse ran away."
On her 448th day in the hospital, Gloria Bonaffini died.
Her death certificate indicated that heart problems had killed her, but medical records showed the presence of a staphylococcus germ.
She contracted staphylococcus sometime during surgery. The germ and resulting infections attacked most organs in her body and ultimately caused her heart to fail, records show.
Staphylococcus is typically spread by touch and is commonly found on the skin and nasal passages of healthy people. Most staph infections are minor, but for a heart patient, the bacteria infect a person who already is weakened and often invade deep inside the chest during surgery.
To gain access to the heart, doctors slice the sternum bone. Germs carried by contaminated hands or instruments can become embedded in the bone before the sternum is fused back together. Removing contaminated bone often stunts the spread of infectious germs. But in many cases, the germ can never be fully eradicated.
In 1995, Bridgeport Hospital officials hired a respected nursing organization to survey the facility after a dozen patient infections were linked to unsanitary conditions. As a result, the Association of Perioperative Registered Nurses drafted a comprehensive report detailing a dozen deficiencies and specific improvements.
However, many recommendations were ignored, court and hospital records show.
The report's primary recommendation Ñ and the most expensive to implement Ñ called for replacing the air-filtration system in Operating Room 2. Yet, the $20,000 repair price was deemed too costly, hospital records show.
Between October 1996 and January 1997, four other patients died "with probable hospital-acquired" staph germs, according to a hospital memo.
The infections at Bridgeport didn't always kill. Dozens of patients survived but with a lifetime of pain, hospital and court records show.
In January 1997, during cardiac bypass surgery in Operating Room 14, Eunice Babcock, 59, became infected with staphylococcus. Doctors later removed much of Babcock's sternum, and the operation left deep, disfiguring scars on her chest. Doctors had to take her abdominal muscles and fold them over her chest cavity for protection.
That procedure has impaired her ability to walk more than 20 yards without collapsing.
Even as Gloria Bonaffini hovered between life and death in a coma, doctors at Bridgeport Hospital voted on April 21, 1997, against testing all patients for infection because it was not "cost effective," according to minutes of a meeting by the hospital's infection-control committee.
Instead, the hospital decided to wait until patients showed symptoms before initiating tests and treatment, the records showed.
Officials at Bridgeport Hospital, which settled the suits related to the outbreak for an undisclosed amount, acknowledge they could have been more aggressive in fixing known problems.
The nonprofit, 665-bed hospital has undergone a $30 million remodeling in recent years.
Improvements include updating air-filtration systems in operating rooms; more patient isolation rooms; motion-sensitive sinks with timed release of water to encourage proper hand scrubbing; and waterless-soap dispensers for cleaning hands quickly.
As a result, infection rates that once soared to 22 percent of cardiac-surgery patients have been brought down to nearly zero during most months, according to the hospital.
By the 1950s, the widespread use of penicillin and other antibiotics allowed doctors to overcome once-lethal infections, and over the decades, prevention gradually has become less of a priority.
Within the average U.S. hospital today, about half of doctors and nurses do not wash hands between patients, a dozen recent health-care studies show.
The direct observations of federal and state inspectors in recent years underscore the carelessness that threatens patient health. In Baltimore, inspection records show, a doctor placed his stethoscope on the chest of a sweaty patient in the grip of pneumonia, then walked to another room and placed the unwashed, moist device on the chest of a patient. The patient developed pneumonia.
On their own
All hospitals are required to adopt general infection-control standards to qualify for the federal Medicaid program, but each facility is allowed to draft its own rules. Most hospitals, for instance, leave catheters connected to patients because CDC studies show that even daily removal exacerbates infection rates. But a few hospitals still work under the misguided belief that changing needles every 24 hours avoids infections, studies show.
A checkerboard of local, federal and private health-care regulations does little to force hospitals to step up infection control. Most violations are quickly resolved by a hospital's promise to provide more training, federal records show.
Nurses and other health-care workers complain that it's virtually impossible to wash hands between every patient contact, which could number 150 times or more a day in a busy hospital. A recent study showed nurses would spend 2-1/2 hours each day to wash hands thoroughly with disinfectant and water. Additionally, frequent washing causes the skin to dry out and crack.
Consequently, most hospitals have begun to use a waterless disinfectant that kills germs and instantly dries on hands. However, many nurses fail to adopt even this simple measure, hospital inspection reports show.
The sanitary condition of a hospital also depends on the diligence of its housekeeping staff, but in many facilities those staffs are poorly trained and overburdened.
"What is needed is not more antibiotics," said Dr. Gary Noskin, chief of infection control for Northwestern Memorial Hospital, which has some of the nation's lowest infection rates.
He attributes the hospital's success to rapid detection of germs and aggressive treatment of infections.
"These bugs are so smart," he said. "They have been here a million years before we were here and they'll be here a million years after we're gone."