Thursday, December 15, 2011

Calls for hospitals to reveal more about errors, infections are getting louder; feds plan more data, but hospitals fight state rules

By Tara Kaprowy
Kentucky Health News

LEXINGTON, Ky. -- The stories are hard to hear.

A little girl is taken to the hospital after she turns on the water and burns herself in the bathtub. After being admitted, her mother notices she looks dehydrated but nurses and doctors don't respond to the mother's pleas for help. A few days later, the girl dies.

While in the hospital, a father gets a gastric tube that is mistakenly inserted into his lungs. He soon passes away.

A friend goes into the hospital to get a knee replacement. He gets an infection from which he never recovers.

These scenarios are all the result of medical errors and hospital-acquired infections. The Centers for Disease Control and Prevention report nearly 100,000 Americans die each year from such infections alone. Calls for hospitals to be more transparent about what happens behind the curtain are growing more insistent, and the concern was the focus of last month's Health Watch USA conference in Lexington.

"This isn't a political issue, this is a real human issue," Rosemary Gibson, author of The Wall of Silence, a book about the problem, told those in attendance. "We need to do better here."

For the past several years, Frances Griffin, a faculty member with the Institute for Health Improvement, has been teaching hospitals how to measure harm, which IHI defines as an "unintended physical injury" that requires additional monitoring, treatment or hospitalization. "We're not getting into blame here," she said. "We just counted all the unintended consequences of medical care that required intervention."

For a study published in Health Affairs in April 2011, Griffin and her team reviewed 795 records from three large hospitals. They found 33 percent of patients experienced an adverse event, ranging from temporary harm that required intervention to an event that resulted in death. The findings were eye-opening, showing "adverse events in hospitals may be 10 times greater than previously measured," she said.

And, despite hospitals "pouring a lot of money into patient safety," Griffin said studies show that many patients are still being harmed. "We may not be applying our efforts to the right areas," she said.

Lack of transparency

Though data have been collected from hospitals around the country for many years — either through voluntary reporting or to comply with state laws — much of it has not been available to the public.

The only data on adverse events that is available now for Kentucky is based on Medicare billing claims and can be viewed at It shows numbers about urinary catheterizations, central-line infections, pressure ulcers (bedsores), falls, blood incompatibility and foreign objects left in the body after surgery. But these claims might not tell the whole story, said John Santa, director of the Health Ratings Center for Consumer Reports, because "They're not being submitted to describe what happened accurately; they're being submitted to get payment."

Starting next year, the Centers for Medicare and Medicaid will release data that are collected by the CDC's National Health Safety Network and are based on actual patient records from acute-care hospitals, including ones in Kentucky. Information will be released on central-line bloodstream infections that occur in the ICU. In 2012, hospitals will then be required to collect information about surgical-site infections and catheter-associated urinary infections, which will later be released.

"I think we have gotten to a turning point," said Dr. Kevin Kavanagh, chairman of Health Watch USA. "It's become evident that states need to be engaged in their reporting efforts so the quality of data that's reported to the federal government is as good as it can possibly be and be reflective of what's going on in the states."

In Kentucky, there are no mandatory public reporting requirements for hospitals. In fact, hospitals must only inform the Department of Public Health about infectious outbreaks, but the definition of an outbreak varies from facility to facility based on the number of patients seen in a specific period of time. Though almost 100,000 people die each year nationwide from hospital-acquired infections alone, Kentucky hospitals only reported four outbreaks between Oct. 1, 2009 and Sept. 31, 2010.

"Without data, it's hard to know where our problems are," said Fontaine Sands, who manages the Kentucky Department for Public Health's program to prevent infections associated with health care. "We don't have anything specific on Kentucky and where (problems) are occurring on different levels of care."

Still, Sands isn't necessarily pushing for a state law, which could be overly burdensome. "The thing we don't want to do is put a mandate out there that is, one, too difficult to implement, and, two, doesn't give what the consumer needs."

Hospitals fight state attempts to require reporting

State Rep. Tom Burch, chairman of the House Health and Welfare Committee, is in favor of state monitoring, but said hospitals are generally reluctant to do it. But the Louisville Democrat, who was a quality-control supervisor at General Electric Appliance Park, said "It's just good business that you put out a quality product. If you've got nothing to hide, then why not put it out there?"

Burch introduced a bill last session that would have required reporting of infections acquired in health facilities acquired infections. "I ran into a buzz saw, needless to say," Burch said. The Kentucky Hospital Association was against the bill. "We support reporting but we want a national standard," said Nancy Galvagni, senior vice president of the KHA. "The federal government has already set up a standard, and we see no reason to duplicate it."

She added that most of Kentucky's hospitals have 100 beds or less and can't afford the money it takes to track the data. "We have to be recognizing the limited resources that are out there," she said.

The two hospital systems in Kentucky that have opted to release their own data — Norton Healthcare and Saint Joseph Health System — are large ones. Norton released its data, which are updated on a monthly basis, in October 2005. The move was not without its anxieties. "The fear is: What if we report it and the other guy doesn't?" said Ben Yandell, division director of clinical information analysis for Norton.

Since it started tracking its data, Norton has improved on many measures, Yandell said. Bluegrass Oakwood in Somerset has had the same outcome, with fewer bedsores, ear infections and urinary tract infections. The numbers have improved because the tracking system has improved, Oakwood Medical Director Keith Sinclair said.

Facilities that have full-disclosure policies also tend to spend less on malpractice litigation. After the University of Michigan Health System adopted a full-disclosure policy, "There was a 50 percent drop in medical malpractice suits, a lower mortality and much better, stronger defense when there was litigation," said Helen Gulgin Bukulmez, board member and patient advocate at Health Watch USA.

But there are drawbacks to reporting, which can "lead to hiding flaws instead of tracking them," Yandell said. It also might reduce access to care if providers avoid high-risk patients in order to keep scores up and could lower the quality of care if good care conflicts with what would give a good score.

Still, there is power in knowing how a hospital is performing, Santa said, citing data that was collected by the Society of Thoracic Surgery. As part of the analysis, which looked at such measures as whether patients were getting the correct medicines, the probability of survival 30 days after bypass surgery and the probability of major complications, 10 Kentucky hospitals allowed their data to be released. At Central Baptist in Lexington, there was an 89 percent probability of avoiding complications. At Hardin Memorial Hospital in Elizabethtown, there was a 73 percent probability. "Now ask yourself," Santa said. "Who would you rather go to? Hardin Memorial or Central Baptist?"

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