The Pervasiveness of Inefficiencies and Ineptitude in U.S. Hospitals*

An article by William Faloon titled “As We See It in the May, 2011 issue of Life Extension,”  a publication of the Life Extension Foundation describes one person’s experience in a brief hospital stay that mimics in a number of ways events described in posts on this blog. Some of these blog posts happened in hospitals in the Pacific Northwest. Mr. Faloon describes events that geographically are about as far away from the Northwest as you can get and still be in the continental U.S. If you think this is just coincidence, then your naiveté may hurt you in the event of a needed hospital stay. Staying healthy requires not leaving your medical care solely to the health industry.

The Life Extension article describes admissions inefficiencies that required hours to move from the Emergency Room to a hospital bed. A patient in Seattle spent 13 hours in an ER waiting for admission. This did earn an apology later from the ER shift chief who said he was ashamed of the delay and admitted patients did occasionally get “lost,” a rare but much appreciated openness in a staff physician.

Mr. Faloon writes about an inordinate five-hour long medication delay including mistaken drugs delivered. A forthcoming blog post will describe the difficulties and time consumed in getting hospital authorization through the bureaucracy in order to take a long-standing and necessary prescription drug he brought from home. Another problem encountered by the “As We See It” author was inaccurate information from an ER doctor who promised to assign a cardiologist who turned out to be a general practitioner. A future blog post deals with hospital staff that ignored an important written request from a patient’s urologist because it was not part of their “protocol.”

The description by Mr. Faloon of how hard it is to sleep in a hospital setting, yet how important restful sleep is for the immune system is mirrored in the April 2 post to this blog, “I Need to Check Your Vitals.”

These events are not random unusual happenings. They are common hospital dangers. The opening post in this blog, “This Will Set the Stage,” presented some statistics on iatrogenic (physician or health establishment) related deaths. Some more recent data published in the Archives of Surgery, October 2010 145 (10): 978 reports on an analysis of an insurance database in Colorado, which contained 27,370 physician self-reported adverse occurrences. Among all these adverse events were 25 wrong-patient and 107 wrong-site procedures including a death from a wrong-site procedure. Although these specific happenings seem small in the total 27,000 iatrogenic outcomes, remember the database only included self-reported problems. An inherent cause of mistakes seemed to involve some form of miscommunication.

Do the best you can to ensure 100 percent two-way communication between yourself and every single medical person you encounter. Do not be a victim of supposed unequal status level between physician and patient. Communication experts know it is all too easy for someone presumed to be in a lower status—in this case, nonprofessional vs. professional to agree with the doctor asks something like, “Do you understand?” Question everything. Do not assume the person you are talking understands you situation. Take charge of your own health! Do not leave it to the medical profession.

*Hospitals in other countries may suffer the same problems, but the data on U.S. hospitals is easier to review.

“I Need to Check Your Vitals”

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Taking Vital Signs is an image from the U.S. Federal Government in the Public Domain

Anyone who has spent at least one night in hospital probably has heard these words or some variant. Depending on a specific hospital’s protocol, you may hear this every three or four hours—day and night. If spared the tender mercies of hospitals up to now, be happy but aware that your time almost certainly will come.

When you are an inpatient at a hospital for anything halfway serious, the rules say staff must check to see how you are doing, usually every three or four hours. Unless you are in a critical state and constantly monitored by electronic devices, this is done by checking your “Vital Signs.” (See the University of Florida Medical Information Server for a good description of Vital Signs.) These signs consist of blood pressure, pulse, temperature and breathing rate. There may be more checks such as the level of oxygen saturation in your blood, read by a little fingertip device and, if diabetic, glucose level, read by pricking a finger with a lancet.

While the intent of these checks obviously are highly desirable, in practice, they can be one of the most annoying and even debilitating events encountered during a hospital stay. During the day, having a nurse or nurse assistant coming into see you every three or four hours to check you out is no big deal. The downfall comes at night.

In the first place, it is very difficult to sleep in a hospital. You may be in pain, worried, uncomfortable from various procedures, recovering from surgery, and buffeted by unusual noises from the hallways. Imagine finally dropping off to sleep and being suddenly awoken by a knock on the door or just a “Mr. Brown?” next to your bedside. This sudden awakening is followed by a voice saying, “I need to check your vitals.” No one can sleep through this process unless rendered unconscious from illness.

Assume you finally got to sleep around 9:00 PM. The vital signs alert, in this particular hospital on a three-hour cycle, jumpstarts you from a fitful sleep, waking you up anytime between 11:45 PM to 12:15 AM the first time. The random time happens because the nurse or assistant assigned to your ward overnight cannot possibly check each patient precisely on the dot of three hours. Once you finally get back to sleep, you cannot even count on the next awakening to be exactly three hours later because either the shift has changed or the staff chooses a different sequence from one room to the next. As the night proceeds, it is very likely that your actual sleep periods will continually reduce as the intervals between the planned routine and the reality shorten.

The result is typical of any other form of regular sleep deprivation: Behavioral changes including irritability, a weakened immune system, exhaustion, impaired coordination and hypertension. To make matters worse, the elderly are more susceptible to sleep deprivation than the young are. Yet is the elderly who are more likely to be hospitalized.

Think about it. Isn’t it bad enough to be sick and in the hospital without being awaked every three or four hours? Does this even make sense?

Is there an illogical premise underlying this practice? If the point is to verify the patient is doing as well as expected with no deterioration, on what is the assumption based that nothing will go wrong, for example, between a check at 12:00 AM and another three or four hours later? A patient actually could die during such an interval. Are there statistical studies showing that the likelihood of any deterioration in the patient’s state at a shorter interval than the standard vital check routine timing is very low?

Who is the real beneficiary of this practice? Is it really the patient, who almost certainly is having a great deal of difficulty in getting any restful and healing sleep? Is the real beneficiary the hospital and its staff, who, in the event of a mishap or unfortunate outcome, can at least say, “Well, he was fine when we last checked on him.”

Is this repetitious intrusion another example of a hospital rule that focuses not on patient-centered care but on administrative efficiency?

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Original and photo reproduction both in the Public Domain (Wikimedia)

The More Things Change, the More They Are the Same


On December 16, 2001, Mary Beth Nierengarten, MA, updated an article originally published January 17, 2001 titled “New Guidelines for IV Catheter-Associated Infections.” This article refers to a study by a Dr. Leonard A. Mermel at the Brown University School of Medicine, which claimed “more than 80,000 in central line–associated bloodstream infections occur each year in the intensive care unit alone in the United States.”

Nierengarten went on to note these infections lead to both morbidity and mortality as well as increased medical costs and pathogens becoming more resistant. Her article reported on some guidelines developed and published by the Infectious Diseases Society of America in coordination with the American College of Critical Care Medicine and the Society for America for Healthcare Epidemiology of America. These guidelines updated ones previously published in 1996. They are found at the Centers for Disease Control website under the title “Guidelines for the Prevention of Intravascular Catheter-Related Infections.”
In an interesting and important addendum to the estimated 80,000 IV problems in intensive care units, the guidelines reported,”A total of 250,000 cases of CVC-associated BSIs have been estimated to occur annually if entire hospitals are assessed rather than ICUs exclusively. In this case, attributable mortality is an estimated 12% to 25% for each infection, and the marginal cost to the health-care system is $25,000 per episode.”

The guidelines are lengthy, but the most important section is,”Strategies for Prevention of Catheter Related Infections in Adult and Pediatric Patients.” They include recommendations on such things as the site where an IV catheter is inserted, the kinds of catheter material used, how often the catheters should be replaced (which you may find differs from typical routines used in hospitals), and many other important rules. Reviewing this document is well worth the time of anyone who is expecting a hospital stay or is caring for a loved one in a hospital.

Despite these guidelines, which have been available for over a decade, we still see stories now like the one reported on ABC news and multiple websites, “Nine Dead After IV Infections at Six Alabama Hospitals.”

IS ANYBODY LISTENING?

For some interesting anecdotes about hospital-caused infections see the following:

The Plumber Did It!” (And Other Strange Tales of Nosocomial Outbreaks.) From infections in the hospital during LASIK surgery, when the doctor, using ice from an ice machine with a contaminated drain infected multiple patients to a nursery where measles infections were passed between several wards by a nurse, this article includes links to other unusual happenings in hospitals. [Note: the link requires a registration. However, registration is free and you will find much helpful information on this site.]

See also the post “Gram-negative Bacterial Infections—More Dangerous than MRSA” in this blog on March 14 2011.