Hypermetabolism and Nutritional Status after Surgery: A Poorly Understood Hospital Danger

According to a study published in the American Journal of Health-System Pharmacy April 1, 2004; 61(7):672-82), patients who have had major surgery or postoperative complications may require a longer time than most before resuming an oral diet. Presumably, they receive at least maintenance saline fluid through an IV, with or without added glucose. Still, this may not meet the increased nutritional needs of the patient in dealing with surgical wound healing and the hypermetabolism that often accompanies recovery from surgery. The authors of this study point out that the result of inadequate nutrition include “muscle wasting, immune dysfunction, and declining visceral protein status.

Although it seems intuitive that adding parenteral nutrition (by injection or infusion) could help avoid the consequences of a weakened nutritional state, apparently this subject has not received much study in the medical literature. Those articles that do exist provide contradictory results. Some report high dose supplementation might decrease the number of complications from infection and shorten hospital stays, yet not really reduce the mortality rate after surgery.

This seems a surprising lack in medical research, particularly when reports point out how important the nutritional status of patients is when it comes to the course of their recovery and the length of their stay in the hospital. It does not even require rigorous study to see the obvious danger: the longer someone remains in a hospital, the greater the risk of acquiring a nosocomial (hospital-acquired) disease and other complications.

Malnutrition, particularly among the elderly, adds another dimension to the dangers. A Brazilian study, reported in Nutrición Hospítalaria, 2010; 25(3):468-470), found malnutrition, based on the body-mass index (BMI), present in 14.1 percent of all patients in the study. Classified by age, only 2.9 percent of adults aged 59 or less were malnourished, while 36.6 percent of those aged 60 or greater were malnourished. Malnourished patients spent, at a median, three more days in hospital than those who entered or remained well-nourished. Studies from other countries, including the U.S. clearly link increased length of hospital stay with a worsening of nutritional status.

A few articles in the medical literature do recommend nutritional screening upon admission, based on specific questions. For example, Clinical Epidemiology, October 21, 2010; 2:209-216, described a four-question initial screening questionnaire: 1) BMI less than 20.5; 2) Weight loss in the past three months; 3) reduced diet in the past week; and 4) whether the patient is seriously ill.

A “Yes” answer to any of these four questions triggers a more detailed second level. The results provide a point-based score with recommendations for nutritional requirements based on anticipated treatment. If the patient answers “No” to the four initial questions, then re-screening should be repeated each week.

How many readers of this blog were asked those four screening questions or a variant thereof during the hospital admitting process?

An unaddressed area of research, only covered in anecdotal reports on the Web, is the continuance of a hypermetabolic state after hospital discharge, leaving patients in an underweight status, unable to regain healthy weight and muscle mass despite more than adequate calorie intake. This can be a dangerous condition if it persists, since even something as simple as a flu infection may leave the patient no reserves. The obvious question is why more attention is not paid to this possibility? Why are there no generally approved and medically-based recommendations available other than, “Eat more?”

How to Find Safer Hospitals for Specific Operations

You may not have a choice about which hospital to use for a particular operation.  Options often are limited because you may need to use a specific surgeon or specialist. Geography may limit your choice if you live in a less populated area with only one hospital. If you are fortunate enough to live in a larger metropolitan area and are not locked into a specific physician, you may be able to avoid some dangers inherent in hospital care by being selective in where you go for treatment.

You can do that by doing some research on the web into hospital rating services. For one example, visit www.healthgrades.com. Check out specific hospitals and procedures in your area and the results may surprise you.

To illustrate, a person living in a populous area like Seattle is fortunate to have a number of hospitals within easy driving distance. For example, check out some hospitals in a situation where the patient has been told they need to have a gallbladder (Cholecystectomy) operation. Their primary care doctor has recommended three surgeons who practice with three different hospitals in the area. How does the patient make the best choice? The first step is to check out the reputation of the doctor through traditional methods. Ask for opinions from others who may have some knowledge of the doctor. Arrange consultation appointments with each doctor, asking questions like how many operations like this have you done, what is your success rate, and what problems have you encountered. Then use ratings services like the one above to check for more information about the doctors.

Even if a clear top choice in the doctor emerges, unless the others are far below the top choice for the sake of your health check out the hospital in which the surgery will be done again with the rating services. You may find startling differences that either will confirm your first choice or make you rethink some of the other choices.

Here are the results of comparing safety and hazard information in three different hospitals in Seattle all within 20 minutes from a patient’s home. One of the hospitals is a state-owned hospital,  (1), the second is a very large private hospital with multiple locations (2) and the third a small single location private hospital (3). Here is how the www.healthgrades.com rates the gallbladder surgery experience at each hospital.

“Better” ratings mean fewer patients were affected than expected, “Average” ratings mean about the same number of patients were affected as expected, “Worse” means more patients were affected than expected.

1)      Complication rating for gallbladder surgery = One Star (Poor). Survival ratings for gastrointestinal surgeries and procedures while in hospital, one month after hospitalization and six months after hospitalization = Three Stars (“As Expected”). Overall Patient Safety Rating = “Worse” (More patients affected than expected) in the following areas: Collapsed lung due to a procedure or surgery in or around the chest; Catheter-related bloodstream infections acquired at the hospital; Excessive bruising or bleeding as a consequence of a procedure or surgery; Blood clots in the lungs and legs following surgery.

2)      Complication rating for gallbladder surgery = Three Stars (As Expected). Survival ratings for gastrointestinal surgeries and procedures while in hospital, one month after hospitalization and six months after hospitalization= Five Stars (best). Overall patient safety indicator = “Worse” in the following areas: Death following a serious complication after surgery, Collapsed lung due to a procedure or surgery and around the chest, Catheter-related bloodstream infections acquired at the hospital.  

3)      Complication rate for gallbladder surgery = Three Stars (“As Expected”). Survival ratings for gastrointestinal surgeries and procedures while in hospital, one month after hospitalization and six months after hospitalization= Three Stars (“As Expected”). Overall patient safety indicator = “Better” or “Average” in all areas.

While emergencies may not leave time for this kind of research, anyone at all interested in being proactive about their health would be well rewarded if they did some checking on the hospitals in their area before they got sick.

 OTHER SOURCES FOR HOSPITAL INFORMATION

Gram-negative Bacterial Infections—More Dangerous than MRSA

You probably have heard about the dangers of Methicillin-resistant Staphylococcus aureus bacteria. MRSA is a gram-positive type of bacteria, difficult but not impossible to treat because several new drugs are effective. Gram-negative types are more difficult to treat because of their cellular structure and thus potentially more dangerous. Some hospitals with very large patient populations such as in New York have become breeding grounds for some species of gram-negative bacteria.
Bacteria in this latter category like Acinetobacter baumannii and Klebsiella pneumoniae continue to evolve and are becoming immune to present day antibiotics. Exacerbating the situation, the pharmaceutical industry, presumable for business reasons as well as the difficulties of developing antibiotics for this type of bacterial infection, are not pursuing solutions.
Gram-negative bacteria can attack the body in multiple areas, causing dangerous pneumonia, urinary tract and blood infections as well as affecting other parts of the body.  Acinetobacter showed up in soldiers wounded in Iraq. Klebsiella has been around for quite some time. The organism was named after Edwin Klebs, who was a 19th century German microbiologist. The bacterium cell has a capsule that covers the whole surface, making it very resistant against the body’s own defenses.
An excellent article in eMedicine,”Klebsiella Infections,” goes into detail about the harm infections with this bacterial can cause. According to this article, “Klebsiellae account for approximately 8% of all hospital-acquired infections. In the United States, depending on the study reviewed, they comprise 3-7% of all nosocomial bacterial infections, placing them among the top 8 pathogens in hospitals. Klebsiellae causes as many as 14% of cases of primary bacteremia, second only to Escherichia coli as a cause of gram-negative sepsis. They may affect any body site, but respiratory infections and UTIs predominate.”
The Centers for Disease Control and Prevention estimates there are about 1.7 million hospital caused bacterial infections, accounting for 99,000 deaths each year. Costs associated with treating these infections range from $28 to $45 billion. In Europe, a report estimates two-thirds of the hospital acquired bacterial infections are caused by gram-negative bacteria. MRSA remains the most common type in the U.S. and is particularly dangerous because it can spread to people outside hospitals. Although gram-negative bacteria in the U.S. tends only to affect people in hospitals as opposed to community-acquired infections, there is a greater chance for infection even when visiting a patient in hospital, or going to an emergency room for a totally unrelated cause. This happens because bacteria like Klebsiella last a long time on surfaces in hospitals and are relatively easy to attack the body through wounds or hospital treatments such as catheters and IVs. People already with some form of weakened body system, for example perhaps gallbladder problems, may visit an emergency room for an unrelated purpose and come away with a gallbladder badly infected with Klebsiella—in other words, worse off than before their visit.
It is imperative to take every antiseptic method you can when visiting a hospital, including wearing a mask, frequently washing your hands or using hand sanitizing liquids, and ensuring all hospital staff you come in contact with have used sanitary methods before touching you, even for something as simple as taking your temperature.
Hospitals can be dangerous to your health!

“Don’t Worry; This Is Less Radiation than an Airplane Flight.”

If you have ever had an X-ray, almost certainly you have heard this or a very similar line from a radiology technician. If you hear these reassuring words, particularly if you are in a hospital and have not already gotten a very clear and understandable reason from your doctor for hitting your body with more ionizing radiation, then at least be aware of the following facts about medical radiation.
X-rays include not just the simple “lean against a panel while a big machine makes noises” but CT scans as well. The latter X-ray sends a much larger amount of ionizing radiation into the body than a single airplane flight. Understanding how radiation is measured is important because there are several different terms used. Here are the main measurements:
rad. The amount of radiation energy that is absorbed by the body per unit of mass of matter. It is called the “absorbed dose.” Since there are several types of radiation, some more harmful than others, another measurement is used to create a common measurement among the different kinds.
rem. This is the “dose equivalent,” derived by multiplying the absorbed dose, the rad, by a specific quality factor for the type of radiation.
While therapeutic radiation used to treat cancer may be used in large amounts, most diagnostic radiation is measured in much smaller units, 1/1000th of a REM, called a millirem.
sievert. An alternative way of describing the dose equivalent used as an International Standard and equivalent to 100 rem.
The problem with radiation doses from diagnostic tests is that a) radiation damage to cells and DNA is cumulative; and b) you are far more likely to receive multiple diagnostic scans during a hospital stay unless your case is very simple. For example, patients might be given a simple X-ray either pre-admission if for surgery, or as part of a preliminary diagnosis. If something in the X-ray looks questionable, the physician may feel a more in-depth test through a CT scan is needed.
In the first case, if a chest X-ray is involved, the amount of radiation is usually around 10 millirems. This is equivalent to about 2.4 days of the amount the body receives from natural background radiation. It is also equal to approximately 20 hours of flying time—a bit more than a single flight. A CT scan exposes you to much larger amounts of radiation. For example, a CT of the abdomen can produce anywhere from 800 to 2,000 millirems depending on how it is done. At a minimum this is more like 400 chest X-rays or 2.7 years of normal background radiation. Some CT scans may go as high as 10,000 millirems. Any kind of complicated surgery or re-admission to a hospital may lead to more than one examination using ionizing radiation. It is easy to see how the absorbed radiation can build up.
Patients may well find that hospital staff is not really concerned about cumulative exposure doses, always operating on the assumption that the benefits outweigh the risks. Interestingly enough, labor standards typically limit the amount of exposure for radiology technicians to 5,000 millirems a year.
The use of CT scans in the United States has skyrocketed in recent years. The New England Journal of Medicine, in an article titled “Computed Tomography—An Increasing Source of Radiation Exposure,” (November 26, 2007, pp. 2277-2284) estimates “more than 62 million CT scans per year” in the U.S. “including at least 4 million for children.” In this report 30 percent of patients had at least three scans. There is growing concern over how many of these scans are medically necessary as well as the long-term risk, which is largely unknown at this point.
Sources of Additional Information:
Radiation Dose Chart  (This is a very helpful online calculator that lets you estimate your radiation absorption from all sources.)

Update to February 27, 2011 Post Regarding Hospital Records.

Be forewarned about possible costs for these records. The HIPAA Privacy section, codified in 45 CFR 164.524(c)(4)    allows hospitals and other “covered entities” to levy a charge for copying your records. The Federal language states:
“(4) Fees. If the individual requests a copy of the protected health information or agrees to a summary or explanation of such information, the covered entity may impose a reasonable, cost-based fee, provided that the fee includes only the cost of: (i) Copying, including the cost of supplies for and labor of copying, the protected health information requested by the individual; (ii) Postage, when the individual has requested the copy, or the summary or explanation, be mailed; and (iii) Preparing an explanation or summary of the protected health information, if agreed to by the individual as required by paragraph (c)(2)(ii) of this section.”

However, some states have passed laws increasing the allowable maximums, in some cases quite in excess of the Federal mandate. Even though you would think a Federal Statute would trump a State law, you may find that copying charges, particularly if a third-party service is used, may be in excess of $1.00 or more per page. The prices vary widely. There can be a significant difference between the Federal “supplies and labor of copying and a flat fee per page no matter how little labor is involved.
The Law Offices of Thomas J. Lamb, P.A. has compiled links to the medical records charge regulations of most states. This is information that the Medical Reference Departments in whatever institution you are querying may or may not share with you. Check out this link to avoid an unpleasant surprise.

Potential Hazards in Hospitals

What better and more authoritative source for information on hospital dangers than the Occupational Safety & Health Information (OSHA). Surely, if this government organization is aware of potential employee hazards in hospitals, then people who spend any time at all as inpatients probably are exposed to some of these dangers as well, if not on the same level as everyday staff. Here is a list from an OSHA web site titled “Categories of Potential Hazards Found in Hospitals.”

Category
Examples
Biological
Human immunodeficiency virus (HIV), vancomycin resistant enterococcus (VRE), methicillin resistant staphylococcus aureus (MRSA) hepatitis B virus, hepatitis C virus, tuberculosis
Chemical
Ethylene oxide, formaldehyde, glutaraldehyde, waste anesthetic gases, hazardous drugs such as cytotoxic agents, pentamidine ribavirin
Psychological
Stress, workplace violence, shiftwork, inadequate staffing, heavy workload, increased patient acuity
Physical
Radiation, lasers, noise, electricity, extreme temperatures, workplace violence
Environmental, Mechanical/Biomechanical
Tripping hazards, unsafe/unguarded equipment, air quality, slippery floors, confined spaces, cluttered or obstructed work areas/passageways, forceful exertions, awkward postures, localized contact stresses, vibration, temperature extremes, repetitive/prolonged motions or activities, lifting and moving patients

Please note an interesting hazard (boldfaced by your blog editor) listed under examples of psychological hazards, “Increased patient acuity.” OSHA considers increased acuity (keenness/awareness) on the part of patients a hazard. In other words patients with more knowledge of health information and potential problems, particularly in hospitals, may be a psychological hazard for hospital staff. This implies that what you might think is of value for patients, and is even pushed by some hospitals who tout their “patient centered” care where the patient is considered an important part of treatment, may not be of value to hospital staff.
Putting it another way, the more you know about what should be going on in hospitals, the more of a danger you may be to staff. By this, does it follow that hospital staff, doctors and nurses, are more leery of the informed patient? Seems somewhat ironic, doesn’t it?