“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?

Yawn
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.

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?

Think You Know What Happened to You in the Hospital? Think Again!

If your hospital experience resembles most, you have a very limited and probably somewhat confused understanding of your hospital stay based on some comments from doctors and nurses. This represents a tiny fraction of the real record of your hospital stay.
For your own safety, you should obtain a copy of the official file. This will contain laboratory results, reports on any imaging studies (X-Rays, CT scans, MRI’s, etc.), doctor comments, usually called “Chart Notes,” more detailed reports from your doctors, nurses comments about you, often referred to as “Shift Notes,” and any other information accumulated during your stay. Besides these hospital notes, get the the same kind of information on a periodic basis from any health care provider. Keeping your own file of this information makes it readily available to you in an emergency.
Besides learning in detail how you were treated, you can then correct errors in your medical history. Based on considerable experience, both trivial and serious errors probably appear in your record. These could come from transcription errors. Typically, doctors dictate their reports of each encounter to a digital recorder, and a medical transcription later transfers this information to written or electronic format. In an electronic system, the doctor may type in or dictate them information directly. If the doctors do not take time to proofread the end result, perhaps because they are too busy, your history may be flawed. Based on personal experience, errors occur in most records, ranging from trivial to potentially harmful.
Another significant cause of error comes from doctors simply not listening carefully enough during an interview, particularly in emergencies. Whatever the reason, inaccurate information could come back to haunt you. For one example, in an office visit a patient with significant “white coat” hypertension, that is, blood pressure that rises sharply in a doctor’s office, had a doctor check his blood pressure. It was 190 over 96. The patient said, “It is much lower at home.” Later, when the patient obtained a copy of the doctor’s note, he found that according to the doctor, his blood pressure was “much higher” than this at home. It is easy to see how in a later emergency, someone reading this could be misled. In addition, should this misinformation make it into the patient’s medical insurance file, it might affect his coverage options. The HIPAA act gives the patient the right to correct errors in the medical record as well.
Fortunately, the passage of the Health Insurance Portability and Accountability
Act in 1996 granted patients the right to see and obtain copies of their medical files as well as control, in a number of areas, who can see this information. The law provides strict rules about the process of records release including a timetable. In most cases the information must be provided within 30 days unless you are given a reason, in which case the period may be extended for another 30 days. The only reason for refusing to surrender the records at all is when the doctor feels the information might endanger you or others. In this case, the medical provider must give you the name of a third party arbitrator. For more information, see the Health Information Privacy information sheeet on the Health and Human Services Web site.
To get their records, patients complete a form authorizing release. Although standard forms are available on the Web, most medical institutions, clinics, hospitals or private practice situations have their own versions. Request a copy of the form from the office or medical records department in a hospital.You can see a typical release form here. This is provided as an example only. Use an approved form from your provider.
In the section specifying the specific information requested, describe this as broadly as possible or else the medical agency has the right to decline release of part of the information. For example, you might say, “All information covering the dates of treatment including laboratory studies, chart notes, nurses shift notes, specialists reports, imaging studies, and all other information contained in my medical file.” You may have to pay a fee but it is limited to the cost of copying and supplies.
The informed patient will have a better chance of staying healthy and playing an important role in their own health care. Understanding what has been said about you and accurately knowing what happened to you in a hospital or under some other type of medical care is vital to this purpose.

“Let’s Get an IV Started”

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You can hear these lines, or variants thereof, in hundreds or perhaps thousands of hospital emergency rooms even as you read this blog post. IV, or Intravenous, lines provide a fast way to get live-saving fluids, usually a saline solution, to a patient through a tube inserted in a vein. They offer an easy way to inject drugs such as antibiotics or painkillers. IV lines also can make patients very ill or even kill.
When hospitals continue IV fluids such as hypotonic solutions overly long, often when admittance to the hospital follows, or as a patient recovs from surgery, a condition of “over hydration” may occur. Water saturates the body beyond the amount excreted, and the body’s normal sodium level becomes diluted, leading to hyponatremia. Possible results include digestive problems, behavioral changes, brain damage, seizures, coma—even death.
Symptoms may include confusion, drowsiness, shouting, delirium, blurred vision, muscle cramps and twitching. Sudden weight gain occurs from edema, or swelling, particularly in the lower extremities. Less serious cases may show only this swelling and some elevations in systolic blood pressure as well as lowered sodium levels in a blood test called a “metabolic panel.”
According to a study titled, “Avoiding common problems associated with intravenous fluid therapy,” published in the Medical Journal of Australia, 2008 Nov 3;189(9):509-13 (available though the U.S. National Library of Medicine):
“Inappropriate intravenous fluid therapy is a significant cause of patient morbidity and mortality and may result from either incorrect volume (too much or too little) or incorrect type of fluid. Fluid overload has no precise definition, but complications usually arise in the context of pre-existing cardiorespiratory disease and severe acute illness.”
Several similar reports in the National Library of Medicine database put the estimated number of cases of over hydration at 2 percent of hospitalized patients. According to the American Hospital Association (AHA), in 2009 there were 37,479,709 admissions in U.S. registered hospitals (those meeting the AHA’s standards). This does not include short-stay community hospitals. If 2 percent develop hydration problems, this equates to 374,797 people with potentially serious problems.
What follows is a real example of hospital-neglected developing over-hydration, fortunately with only annoying, not lethal results.
Reason for hospital admission: Cholecystectomy (gallbladder removal)

Length of stay: Seven days

Event: Doctor ordered (or simply hospital protocol) for post-operative recovery: IV supplementation with 0.9 percent saline solution at the rate of 150 ml per hour (25.2 liters over seven days.)
Hospital staff awareness of problems developing: Nurse on third day of IV comments, “Are your legs always this thick?” Lab tests show blood sodium level results below minimum levels. Systolic blood pressure rises to 169 from normal 126. Urinary output is significantly below input from IV. However, since the original order for this level of IV supplementation is still in place, staff cannot alter it. Note: Interestingly enough, a typical first line of treatment for newly diagnosed high blood pressure is a diuretic to reduce fluid levels, not add more fluids.

Result: : Patient left the hospital, despite no solid food for seven days, weighing 32 pounds more than on entry and with significant swelling in feet, ankles, legs, thighs, lower abdomen and other appendages. 

Lesson learned: Patients, at all costs, must be more proactive in their own defense, refusing to accept first level staff responses. Insist upon seeing superiors until you get to the doctor who first ordered this level of supplementation and/or a patient representative.