Articles Posted in Hospital-Borne Infection/Disease

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Miscommunication Among Hospital Staff Can Lead to Serious Patient Infections 

Researchers from the University of Michigan investigated infections caused by catheters (urethral or suprapubic) showing that the devices may cause unnecessary infections to patients due to poor communication of health care professionals. The findings were first published in the July 2019 volume of the American Journal of Critical Care, mimicking what previous studies have said and agreeing that when catheters remain in too long, infection is more likely to follow.

Indwelling catheters are a type of catheter commonly used in both hospital and long-term care settings as a urinary assistance device that collects urine from the bladder and disposes of it through a drainage bag. A nurse, or another trained healthcare provider, is the person responsible for performing a safe catheter insertion or removal through the urethra or sometimes through a tiny hole in the abdomen.

“To know that this happens is our country, that’s unacceptable.” 

-Sue Sheridan, patient safety advocate, in To Err Is Human

The medical malpractice attorneys of Levin & Perconti recently watched To Err Is Human, a newly released documentary showing the frequency and impact of medical errors upon American families. To see the facts relating to the frequency and severity of medical errors combined with the heart wrenching story of a family forever changed by these mistakes has left a lasting impression on all of us.

The Leapfrog Group, a nonprofit group dedicated to hospital safety, has released their biannual Leapfrog Hospital Safety Grade report, showing an overall improvement in Illinois hospitals since the spring. According to Leapfrog, the survey measures hospital patient safety by the number of “errors, injuries, accidents, and infections.” Participation by hospitals is optional and this fall, 110 Illinois hospitals agreed to take part. According to the data collected, Leapfrog rated Illinois hospitals as #13 overall, an improvement from #15 this past spring.

In a time where the increasing problem of medical errors is finally being given the platform it deserves, the survey is more relevant now than ever. The Leapfrog Group, citing an often quoted 2016 Johns Hopkins study, notes that medical errors are now the third leading cause of death in the United States. Patient safety and healthcare provider accountability is essential for all hospitals and healthcare organizations. Below is our analysis of the Fall 2018 Leapfrog Hospital Safety Grade report for participating Illinois hospitals.

Illinois & Metro Chicago Hospital Results

The parents of an infant girl are suing Children’s Hospital of Philadelphia (CHOP), alleging that hospital’s failure to follow standard infection prevention controls led to their daughter’s death. She is one of 23 infants who were sickened during a 2016 hospital outbreak of adenovirus. Recent reports have indicated that there is a second infant who died, also allegedly due to the same viral contamination.

Melanie Sanders was a premature baby receiving treatment in the neonatal intensive care unit at CHOP, the 3rd best children’s hospital in the country according to U.S. News and World Report. Melanie, along with 22 other infants in the neonatal intensive care unit (NICU), became ill after receiving an eye exam. Each of the infants was diagnosed with adenovirus, a group of viruses that cause respiratory symptoms and can lead to pneumonia, an infection that can prove fatal to vulnerable hospital patients, especially children, those with compromised immune systems, and the elderly.

Of the 23 infants sickened by the virus, all showed respiratory symptoms, while 5 of these infants developed pneumonia. The hospital reported in the June 2017 issue of the American Journal of Infection Control that 12 of these patients “required increased respiratory support.” In addition to the 23 infants, 3 parents and 6 hospital employees acquired the virus.

Ratings from the annual Hospital Safety Grade Report from Leapfrog Group are now available and 15 Illinois hospitals have lost their ‘A’ rating since last year. This year, Illinois has 30 hospitals who received an A, down from 45 just last year. The Hospital Safety Grade Report “scores hospitals on how safe they keep their patients from errors, injuries, accidents, and infections.” According to the Leapfrog Group, the focus is to bring patient safety information to the public and reduce the number of hospital mistakes and injuries, incidents that are responsible for 440,000 deaths each year.

Data is collected from hospital surveys, the Centers for Medicare and Medicaid Services (CMS), and secondary sources, including the American Hospital Association’s Annual Survey. In all, 27 different patient safety measures are evaluated, the data is weighted and then each hospital is given a rating (A-F). It is important to note that free standing pediatric hospitals, long term care facilities, and specialty centers (such as cancer treatment hospitals) are not included in Leapfrog’s annual Hospital Safety Grade Report.

Of the 27 measures, 12 related to Process and Structural Measures (everything from ‘Hand Hygiene’ to ‘Identification and Mitigation of Risks and Hazards’) and 15 related to Outcome Measures (from MRSA and CDiff infections, all the way to death during surgery). To view the 27 measures, please click here.

Few people would think that a likely time and place to pick up an infection would be in a hospital as they are receiving medical treatment. But alarming statistics now being compiled may turn heads. According to the Centers for Disease Control and Prevention (CDC), as many as 1 in 20 hospitalized patients will pick up an infection in the course of medical treatment. Other sources report that the five most common infections picked up by patients after hospital admittance cost our healthcare system almost $10 billion a year. In fact, hospital-acquired infections have become such a large issue that Medicare now refuses to pay for costs associated with them.

These infections are associated with several risk factors, which include:

· The use of indwelling medical devices, such as bloodstream, endotracheal, and/or urinary catheters · Surgical procedures · Hypodermic injections · Contamination of the healthcare environment · Improper use of antibiotics

A Las Vegas Sun editorial last week blasted the inadequate measures taken by most hospitals to prevent the spreading of hospital borne infections.

As the paper explains, while these infection rates–which are almost always preventable–should be dropping as hospital administrators become more aware of the problem, the rates are actually increasing. In fact, in just the area sampled in the investigation, MRSA cases (one of the most common types of hospital infection) rose by nearly 34 percent in 2009.

The rise in infection rates is all the more disappointing because the methods of eliminating the problem are widely known. It is not too much for patients to ask that their hospitals be clean and safe. The only thing needed is for doctors, nurses, aides, hospital administrators and all other medical personnel to step up and follow the well-known prevention procedures. Too many healthcare workers, however, refuse to follow simple steps and risk the lives of all patients instead. As the editorial reports, “among the most egregious of these practices are when patients with contagious infections are placed in rooms with uninfected patients, rooms are not adequately cleaned between patient stays and medical professionals fail to wash their hands”.

A recent study by the Center for Disease Control (CDC) found that ambulatory surgical centers failed to prevent hospital-borne infections in 46 of the 68 surgical centers that the study examined. Researchers reported lapses in infection control in hand hygiene, injection safety, medication and handling, equipment reprocessing, environmental cleaning, and handling of blood sugar monitoring equipment. The study found that 28% of the facilities used medications in single-dose vials for multiple patients and that 32% of the facilities performing blood glucose testing did not clean and disinfect the blood glucose meters after each use. Additionally, the study found that 6% of the facilities reused items that were packaged and labeled as single-use devices and 21% of the facilities used a single lancing penlet device for multiple patients in blood glucose testing.

Ambulatory surgical centers operate exclusively to provide surgical services to patients who do not require hospitalizations or admission lasting longer than 24 hours. Between 2001 and 2008, researchers found that there was a 50% increase in the number of Medicare certified ambulatory surgical centers in the United States. During that same period of time, researchers also found a significant rise in problems relating to hygiene and safety health procedures at the Centers.

Hospital-borne infections are a serious problem facing hospitals. When a patient suffers further injury or death because of a hospital’s failure to prevent infections, hospitals may be held liable. Hospitals can prevent infections among patients by making sure that both the hospital staff and visitors regularly clean their hands with an alcohol-based hand cleaner. Hospitals should also make sure that if a patient needs an IV that it is inserted and removed under clean conditions and changed every three to four days.

Congressman Murtha’s recent death has raised questions about the complications of gallbladder surgery. Many are left wondering if the influential lawmaker was among nearly 100,000 people who die in U.S. hospitals annually because of medical errors. While Congressmen debate health care on the hill, it is time that they reflect on the death of one of their own. Instead of focusing on issues such as tort reform, it is necessary that they look more closely at how to prevent medical error.

The Washington Post found reported that Murtha had elective laparoscopic gallbladder surgery preformed at the Bethesda Naval Hospital and fell ill shortly afterwards from an infection that has been related to the procedure. Studies have found that the mortality rates for gallbladder surgery is quite low, ranging from .7-2% even in the elderly. So we are left with the question of whether Murtha was an unlucky patient or whether he is yet another victim of medical error. Some argue that a two minute checklist could decrease the death rate. Since Bethesda Naval Hospital is a government institution, organizations that work to prevent medical mistakes cannot confirm whether they do use such a checklist.

The Chicago medical malpractice attorneys at Levin & Perconti support the use of checklists to promote communication between hospital staffers. They believe that this is one step that a hospital can take in lower the death toll that occurs every year from medical error. If you believe that you are a victim of such a medical error, please consult a Chicago medical malpractice attorney. To read more about the devastating lost of Congressman Murtha, please click the link.

A hospital, where officials say a nurse may have exposed more than 1,800 patients to HIV and hepatitis by reusing medical supplies, says that patients are currently being tested for HIV. Officials at the hospital said that 410 of the 1,851 potentially exposed patients have been tested. Earlier this month the hospital discovered that 59-year-old nurse was reusing IV tubing and saline bags during cardiac chemical stress tests. While hospital officials said that the chances of infection are low, it cannot be ruled out. Police are currently investigating this tremendous medical error. To read more about the medical malpractice, please click the link.

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