Hospital Safety and Patient Deaths

A new study conducted by researchers from Cincinnati Children’s Hospital explored how hospitals determine the schedules for administering drugs to patients. Researchers found that the driving force behind such timing is not patient need. 

Instead, the researchers learned that many hospitals tend to give patients drugs on a schedule that best matches up with their employees’ schedules, though this is oftentimes to the detriment of patients.. 

“For every drug, order times were time-of-day dependent, with morning-time surges and overnight lulls,” the researchers wrote. “These rhythms correspond to shift changes and rounding times.” 

Prioritizing patient care

To get a better idea of how hospitals are creating schedules for doling out medications, the researchers analyzed drug orders and administration for over 1,500 patients in a children’s hospital in 24-hour intervals between 2010 and 2017. The study included data on nearly half a million doses of 12 different drugs. 

Overall, the researchers learned that there was no universal solution here; each patient is unique and responds more positively to different drugs at different times. The finding emphasizes the importance of healthcare professionals checking in with patients to determine what time best suits their needs. 

The study revealed that the hospital tended to wait until morning to dole out most drugs to patients -- once staffing changes had been made -- and this isn’t always the most effective strategy. 

While some drugs are better administered during the patient’s waking hours versus right before bed, other patients need quick pain relief in the middle of the night. The researchers say it’s important for hospitals to take these factors into consideration. 

Listening to what patients need, ensuring that they can avoid painful side effects, and that they are able to rest comfortably throughout the night are essential, and it can be done rather easily in hospitals. 

“There is great potential here to align what we know about drug timing from the last 60 years of research and implement this knowledge in hospitals,” said researcher Dr. David Smith. “There are immediately actionable steps.” 

Being admitted to a hospital ranking lower for preventing accidents, injuries, errors, and infections could greatly increase your chances of not getting out alive.

That’s a principal takeaway from the Leapfrog Group’s annual Hospital Safety Grades. It found that patients in hospitals receiving a “D” or “F” grade were 92 percent more likely to die from an avoidable cause.

The report also found that patients in hospitals receiving a “C” grade were 88 percent more likely to have a patient die an avoidable death. The risk drops to 36 percent for institutions receiving a “B” grade.

While hospitals awarded an “A” grade are not perfectly safe, the researchers found they are getting safer with each passing year. Their report concludes that if every hospital protected against avoidable death at the same rate as “A” hospitals, it would save 50,000 lives annually.

160,000 avoidable deaths

The report found an estimated 160,000 lives were lost in the U.S. in 2017 from avoidable medical errors that are accounted for in the Leapfrog Hospital Safety Grade, a big improvement from 2016, when researchers estimated there were 205,000 avoidable deaths.

"The good news is that tens of thousands of lives have been saved because of progress on patient safety,” said Leah Binder, president and CEO of the Leapfrog Group. “The bad news is that there's still a lot of needless death and harm in American hospitals."  

She points to the report’s underlying conclusion, that U.S. hospitals don't all have the same track record when it comes to keeping patients alive.

“So it really matters which hospital people choose, which is the purpose of our Hospital Safety Grade," Binder said.

Very few received a failing grade

The latest study graded more than 2,600 U.S. hospitals, with nearly a third earning an “A” grade. Fortunately, only 1 percent got a failing grade, while 6 percent were rated “D,” or poor. The states with the highest percentage of A-rated hospitals are Oregon with 58 percent, Virginia with 53 percent, Maine with 50 percent, and Massachusetts and Utah with 48 percent.

There were no A-rated hospitals in Wyoming, Arkansas, Washington, DC, Delaware, or North Dakota.

The Leapfrog Hospital Safety Grades are an independent, nonprofit grading system administered on behalf of employers and other purchasers of healthcare services. They rate institutions on their ability to avoid errors, accidents, injuries and infections and receive guidance from the Johns Hopkins Armstrong Institute for Patient Safety and Quality.

When it comes to certain life and death circumstances, hospital patients are often left with little choice when it comes to the care they need to receive. For example, being put on a ventilator to maintain breathing function can be the only real option for someone who has been in a serious accident.

Unfortunately, using these devices often comes with a risk of its own. Experts say that blood clots, lung damage, and ventilator-associated pneumonia – one of the most pervasive and deadly hospital-acquired infections – are all too common. But a group of researchers from Johns Hopkins Armstrong Institute of Patient Safety say there are ways that consumers and medical staff can reduce the risks.

"These complications prolong the duration of mechanical ventilation, and they keep patients in the hospital longer," said Dr. Sean Berenholtz. "This, in turn, leads to higher complications, higher mortality, higher lengths of stay and higher costs. So decreasing these complications is a national priority and helps our patients recover sooner."

Reducing risks

In a study involving 56 ICUs at 38 hospitals in Maryland and Pennsylvania, researchers attempted to provide medical staff with the most recent and effective evidence-based therapies for protecting patients from ventilator-associated complications. The interventions included:

• Elevating the patient’s head in bed;
• Suctioning the patient’s mouth tube;
• Performing oral care, including tooth brushing and using chlorhexidine mouthwash;
• Performing spontaneous awakening and breathing trials by reducing narcotics and sedatives; and
• Implementing a five-step culture change intervention program focused on reducing harm to patients.

Over the two-year study period, the researchers found that these interventions drastically reduced ventilator-associated events in ICUs by 38%, with infection-related events dropping by over 50%. Cases of ventilator-associated pneumonia also dropped by an astonishing 78%.

Complications are preventable

The study findings give hope to patients and medical professionals, many of whom believed that these dangerous infections and events were unavoidable.

"When patients are sick, complications can happen, and, in some cases, health care-associated infections are thought to be inevitable. . . This is the largest study to date to show that these complications of mechanical ventilation, or ventilator associated events, are also preventable," said Berenholtz.

The full study has been published in Critical Care Medicine.

When people are seriously ill or injured, they are usually admitted to a hospital. But it turns out that a hospital may not exactly be the safest place to find yourself.

In the past, hospitals didn't always have access to the latest treatments. Today, most have excellent capabilities, but they don't always have the resources or systems to handle the patient load. This can lead to breakdowns in safety that can result in patient injures and infections.

According to Leapfrog, which conducts annual hospital reviews, hospital mishaps kill over 200,000 Americans each year, making hospital mistakes the third leading cause of death in the United States.

Making the grade

Since not all hospitals are alike and some have much better safety records than others, it might be prudent to consult the data before selecting a hospital. In the latest Leapfrog Hospital Safety Grade, which judged 2,633 hospitals and assigned letter grades, 844 earned an "A," 658 earned a "B," 954 earned a "C," 157 earned a "D" and 20 earned an "F."

That means 57% of hospitals were ranked as either “excellent” or “good,” and only 6% were found to be “poor” or a “failure.” Of course, that's small comfort for patients admitted to that 6% of hospitals.

Leapfrog found that geography sometimes plays a role, with some states able to attract the best hospital administration and best medical talent. North Carolina is a prime example. It was ranked 19th in spring 2013 for the number of “A” rated hospitals. In the current ranking, it's number five.

Idaho has moved from number 45 – the the bottom of the list in 2013 – to number two today, one reason that the state has begun to attract more retirees. At the same time, Alaska, Delaware, North Dakota, and Washington, D.C., have no “A” rated hospitals.

Not equally competent

"In the fast-changing health care landscape, patients should be aware that hospitals are not all equally competent at protecting them from injuries and infections,” said Leapfrog President and CEO Leah Binder. We believe everyone has the right to know which hospitals are the safest and encourage community members to call on their local hospitals to change, and on their elected officials to spur them to action.”

You might think with hospital errors causing so many deaths each year, health policymakers would carefully keep track of them. However, they don't. The 200,000 figure is only an estimate.

As we reported earlier this year, researchers at Johns Hopkins have called on the Centers for Disease Control and Prevention to create a category for hospital errors, much as it has for other health threats. The researchers say cancer and heart disease tend to get most of the attention. They say that since "medical errors" isn't an official category, it doesn't get the funding it needs.

You can find out how hospitals in your area ranked here.

When you go into the hospital, you trust the medical staff will do everything in its power to make sure you leave alive.

But Johns Hopkins researchers calculate that more than 250,000 people in the U.S. die each year because of medical errors. The researchers say it is difficult to know for sure, however, because the Centers for Disease Control and Prevention (CDC) does not have a category for “medical errors” on death certificates.

If the researchers are correct, mistakes made by health care professionals would be among the most common causes of death. The CDC's third leading cause of death, respiratory disease, kills a far fewer 150,000 per year.

The problem, says Dr. Martin Makary, professor of surgery at the Johns Hopkins University School of Medicine, is medical mistakes have never been recognized in a standardized way of collecting statistics.

“The medical coding system was designed to maximize billing for physician services, not to collect national health statistics, as it is currently being used,” Makary said.

How do they know?

But if that's true, how can the Hopkins researchers claim that medical mistakes kill a quarter million people each year?

The researchers say they looked closely at four different studies of the medical death rate from 2000 to 2008. Using hospital admission rates, they concluded that 251,454 deaths were caused by a medical error, translating into 9.5% of all U.S. deaths.

That would make medical mistakes the third leading cause of death in the U.S., behind heart disease and cancer.

Previous warnings

The Johns Hopkins researchers are not exactly the first to suggest medical mistakes are a significant health and safety issue. ConsumerAffairs, in fact, has a Hospital Errors and Patient Safety category for articles we've written on the topic over the years.

A study as far back as 2004 projected at least 200,000 annual deaths from medical errors. In 1999, when in-hospital deaths were estimated to be half that, the Institute of Medicine called medical error deaths a national epidemic.

Makary says there is a very practical reason to begin acknowledging, and counting, deaths related to medical errors. Cause of deaths statistics, he says, set public health priorities.

“Right now, cancer and heart disease get a ton of attention, but since medical errors don’t appear on the list, the problem doesn’t get the funding and attention it deserves,” Makary said.

The researchers say most deaths caused by medical errors are not due to the quality or skill of medical personnel. Rather, they suggest poorly designed and inefficient health care systems are a threat to patient health and safety.

The antiobiotic-resistant staph infection known as MRSA is a huge problem in hospitals but a new study finds a simple solution that reduces bloodstream infections in intensive care unit patients by up to 44 percent.

The solution: treat every ICU patient as though they carry the infection. In a study involving 74 ICUs and more than 74,000 patients, it was found that providing germ-killing soap and ointment to all ICU patients reduced MRA by 37 percent and bloodstream infections by any germ by 44 percent.

MRSA -- short for methicillin-resistant Staphylococcus aureus -- is often present on the bodies of incoming patients. Besides infecting those patients when they are exposed to needle sticks and other skin punctures, it can also be spread to other patients in the ICU.

The study, REDUCE MRSA trial, was published in the New England Journal of Medicineand took place in two stages from 2009-2011, involving a multidisciplinary team from the University of California, Irvine, Harvard Pilgrim Health Care Institute, Hospital Corporation of America (HCA) and the Centers for Disease Control and Prevention (CDC). It is the largest study of its kind to date.

Three practices studied

Researchers evaluated the effectiveness of three MRSA prevention practices: routine care, providing germ-killing soap and ointment only to patients with MRSA , and providing germ-killing soap and ointment to all ICU patients.   The study found:

• Routine care did not significantly reduce MRSA or bloodstream infections.
• Providing germ-killing soap and ointment only to patients with MRSA reduced bloodstream infections by any germ by 23 percent.
• Providing germ-killing soap and ointment to all ICU patients reduced MRSA by 37 percent and bloodstream infections by any germ by 44 percent.

"This will save lives, and sets a new standard for preventing bloodstream infections in the intensive-care unit," said Jonathan Perlin, president, clinical and physician services group and chief medical officer at HCA. HCA said it is now implementing the protocol in all of its hospital ICUs. 

The folks in a position to know say the workload may be be having an adverse effect on the safety and quality of patient care at the nation's hospitals.

More than one-quarter of hospital-based general practitioners across the U.S. who take over for patients' primary care doctors to manage inpatient care say their average patient load exceeds safe levels multiple times per month, according to a new Johns Hopkins study. Moreover, the study found that one in five of these physicians -- known as hospitalists -- reports the workload puts patients at risk for serious complications, or even death.

The research, reported in JAMA Internal Medicine, comes as health care systems anticipate an influx of new patients generated by the Affordable Care Act -- also known as Obamacare -- over the next few years; as restrictions on resident-physicians limit their duty hours; and as one in three physicians is expected to retire or otherwise leave medicine over the next 10 years, cumulatively resulting in increased patient care needs coupled with stressed staffing demands.

Impact on quality of care

"As perceived by physicians, workload issues have the significant potential to do harm and decrease quality," says study leader Henry J. Michtalik, M.D., M.P.H., M.H.S., an assistant professor in the Division of General Internal Medicine at the Johns Hopkins University School of Medicine. "It is the elephant in the room that cannot be ignored. We have to find that balance between safety, quality and efficiency."

The Johns Hopkins study comprised a survey of 890 hospitalists across the United States, 506 of whom responded. Twenty-two percent of the respondents reported ordering costly and potentially unnecessary tests, procedures or consults because they didn't have time to properly assess patients assigned to their care.

"If a hospitalist is short on time and a patient is having chest pains, for example, the doctor may be more likely to order additional tests, prescribe aspirin and call a cardiologist — all because there isn't adequate time to immediately and fully evaluate the patient," Michtalik says.

Voice of experience

For the study, Michtalik, a hospitalist at The Johns Hopkins Hospital in Baltimore, and his colleagues electronically surveyed self-identified hospitalists enrolled in an online physician community, QuantiaMD.com. Of those who responded over the course of four weeks in November 2010, the average age was 38 years and more than half worked in community hospitals.

Among other questions, physicians were asked to report what they felt was a safe number of patients to see in a typical shift. Most physicians reported that they could safely see 15 patients in a shift if they could focus 100 percent on clinical matters. When the average actual workload was compared with the perceived safe workload, 40 percent of physicians exceeded their own reported safe level.

Michtalik says that JHH's hospitalists typically stay below that number, while hospitalists at community hospitals often see more than 15 patients per shift.

"Hospitals need to evaluate workloads of attending physicians, create standards for safe levels of work and develop mechanisms to maintain workload at safe levels," he adds.

Remember when most minor surgeries resulted in a two- or three-day stay in the hospital? Today, with the cost of hospital beds, many of these operations are now done on an outpatient basis.

Those surgeries that do result in a hospital stay are usually short – shorter than they should be, according to a pair of logistical studies conducted by researchers at the University of Maryland's Robert H. Smith School of Business.

The studies show a correlation between readmission rates and how full the hospital was at the time of discharge, suggesting that patients went home before they were healthy enough. They further suggest that revenue drives the decision about when a patient is discharged.

Better planning

The researchers recommend better planning and other logistical solutions to avoid these problems.

"Discharge decisions are made with bed-capacity constraints in mind," said University of Maryland Professor Bruce Golden, who conducted the research with Ph.D. student David Anderson and other colleagues. "Patient traffic jams present hospitals and medical teams with major, practical concerns, but they can find better answers than sending the patient home at the earliest possible moment."

In the studies, Golden and Anderson tracked patient movement at a large, academic medical center located in the United States. They found that patients discharged when the hospital was busiest were 50 percent more likely to return for treatment within three days.

This indicates recovery was incomplete when patients were first released, the researchers say. The study tracks occupancy rates, day of the week, staffing levels and surgical volume.

Incentive-driven

Golden says surgeons and hospitals are incentive-driven to perform as many surgical procedures as feasible. The more surgeries, the more revenue.

"The hospital has to maintain revenue levels to meet its financial obligations,” Golden said. “Surgeons are working to save lives and earn a livelihood. It's what they do, If the hospital says 'sorry there are no beds available,' there's a lot of tension and pressure from both sides to keep things moving."

Golden says big hospitals tend to have these problems more than smaller ones. Larger hospitals tend to provide more advanced, specialized surgeries not accessible at smaller, community institutions,the researchers say. Patients often have to travel a great distance for the procedures, so hospital delays become expensive for both them and the care providers.

Ask more questions

Part of the problem can be resolved with better planning, the researchers say.

They suggest that surgeons use checklists before discharging the patient, asking more question about the patient's readiness to go home.

Also, the studies suggest that hospitals increase the flexibility of where patients go post-surgery. Allowing them to be moved to units with empty beds, for example, could also lessen premature discharges.

Though this may increase costs in the short run, discharging patients who then quickly return to the hospital offers no long-term savings, and decreases the quality of care, Golden said.  

The higher the occupancy rate at your hospital, the less likely you are to leave alive.

That's the conclusion of a new University of Michigan Health System study that shows you have a 5.6 percent higher risk of dying in a hospital operating at near capacity.

For the study, published in the March issue of Medical Care, researchers evaluated a set of critical factors that can affect hospital deaths: hospital occupancy, nurse staffing levels, weekend admission and seasonal influenza.

Having more nurses made patients safer, decreasing risk by 6 percent. But weekend admission raised the risk by 7.5 percent and admission during widespread seasonal flu had the greatest impact by increasing the risk of death by 11.7 percent, according to the study.

Because of the size of the study, which included 166,920 adult patients admitted to 39 Michigan hospitals over three years, the findings can be generalized to hospitals nationwide, authors say.

"The study establishes that there is indeed a connection between hospital occupancy and death rates in U.S. hospitals," said lead author Peter L. Schilling, M.D., a resident in orthopedic surgery at U-M Health System. "It's important to emphasize though that this study does not identify a specific occupancy level above which patient care suffers and deaths abruptly become more common. The key occupancy level may differ for each hospital."

First study to consider all four factors

The findings are considered robust because each factor still had a significant impact even while evaluated in a model simultaneously. While this study is not the first to demonstrate that these factors are associated with in-hospital mortality, the U-M Health System is the first to compare all four at once.

"The study further establishes each factor as a major predictor of hospital deaths but the good news is that each can be modified in some way," said co-author Darrell A. Campbell Jr., M.D., chief of clinical affairs at the U-M Health System.

For instance, generally the peak flu season can be predicted and during those times, hospitals can reinforce the importance of hand washing and covering coughs and sneezes.

The impact of seasonal flu may also be diminished by improving vaccination rates in the community and among health care workers. The rate of vaccination among health care workers and high-risk patients remains surprisingly low nationwide.

Researchers calculated the occupancy of the hospitals every day for the years 2003-2006. On average, patients in the study were admitted while hospital occupancy was 73 percent of full capacity. One-third of patients were admitted on high occupancy days, at average levels of 80 percent or more.

Study patients were admitted after being seen in the emergency department for a heart attack, congestive heart failure, stroke, pneumonia, hip fracture or gastrointestinal bleeding.

"Hospital occupancy changes from day to day, so patients shouldn't try to choose a hospital based on its occupancy level," said co-author Matthew M. Davis, M.D. "But these kinds of study findings should prompt hospitals to look at the flow of patients and processes of their care teams during high occupancy times. Those are more challenging moments when more things can go wrong."

By James Limbach
ConsumerAffairs.com

November 11, 2009
Almost a quarter of heart failure patients insured by with Medicare are back in the hospital within a month after discharge, researchers report in Circulation: Heart Failure, a journal of the American Heart Association.

Each year, from 2004 through 2006, more than a half million Medicare recipients over age 65 went to the hospital for heart failure and were discharged. And each year, about 23 percent returned to the hospital within 30 days -- signaling a need to improve care, researchers said. Readmission rates for all causes were almost identical all three years.

"I was hoping for improvement and was disappointed to find that was not the case," said Joseph S. Ross, M.D., M.H.S., the study's lead author and an assistant professor of geriatrics and palliative medicine at Mount Sinai School of Medicine in New York. "Despite the increased focus on the need to reduce readmissions, about a quarter of patients are back into the hospital within 30 days."

Heart failure occurs when a heart weakened by disease can no longer pump effectively. Before discharge heart failure patients should receive written information on:

• Eating a proper diet;

• Engaging in appropriate physical activity;

• Taking medicines correctly;

• Monitoring their weight; and

• Knowing what to do if their symptoms worsen.

However, the current fee system in the United States doesn't encourage a focus on prevention, researchers said. In their analysis, they report doctors and hospitals are financially awarded more for treating and hospitalizing patients, not for preventing hospitalizations through such strategies as disease management.

"Physicians aren't paid to coordinate care," Ross said. "That physician is busy seeing patients and that's what they're paid to do. If we want to deliver better care, this trend is what we need to address."

Another barrier to optimal care is a lack of communications between doctors who care for patients in the hospital and the patients' regular physicians who help patients manage their chronic disease, Ross said. The disruption to the continuum of care can have a negative effect on the patient.

The average age of patients in the study was 80 years and more than half (57 percent) were women. Most patients had multiple chronic diseases: 60 percent had heart arrhythmias; 73 percent had atherosclerosis or hardening of the arteries; 49 percent had diabetes; and 29 percent had kidney failure.

"Coming back and forth into the hospital isn't good for patients, and it isn't good for the healthcare system," said Ross, who plans to research the reasons heart failure patients are readmitted to the hospital. "This is a tremendous challenge."

Findings of the study are important for patients and hospitals, Ross said.

"Patients should use this information to vet hospitals, to look at the quality of care delivered there and ask questions about the care they receive," he said. "Hospitals should consider the rehospitalization rate a grade which, from these findings, needs improvement."