Surgical Site Infections – the Drive to Zero Tolerance

Every year, surgical site infections plague hospitals. It is well known that a hospital is one of the most dangerous places on earth as it can harbor the most deadly, antibiotic resistant pathogens. The risk of a healthcare acquired infection (HAI) is one of the great concerns facing any patient about to undertake surgery. In 2010, the CDC stated that there were an estimated 16 million operative procedures performed in the US1. Hospital acquired infections affect about 5% of these patients. Surgical site infections represents the lion’s share as they account for 31% of the total HAI count2 or 1.9% of patient procedures. Surgical site infections therefore affect over 300,000 patients annually in the US. At an average cost of over $20,000 3 per surgical site infection case, the means that the cost of surgical site infections is over $6 billion annually before the cost of the loss of employment days or quality of life factors on the patient or their families.

The CDC also suggests that a significant portion of HAIs are preventable, possibly as much as 30%. Given the enormous financial burdens to health care systems and negative consequences to the patients’ quality of life, it is disappointing that more work is not undertaken to make a serious dent in reducing these infection rates. The culprit, I will suggest, is the silo’d budgeting process of most health care systems today. Infection control is often a separate budgetary entity. Prevention measures usually result in additional costs accruing to these departments, while the cost savings accrue to other departments e.g. drugs, nursing, beds etc. There is often the wrong incentive system in place to generate the kinds of HAI prevention potential from being realized. Incentives however will not change unless there is greater public pressure on public and private health care providers to reduce their rates of infections. In fact, a case can be made that US hospitals actually make more money per patient if these patients acquire infections and require further hospitalization days (which can be on average up to 9 more days).  If we ever truly hope to reduce or eliminate surgical site infections and other hospital acquired infections rates, then we need to both promote a ‘zero HAI tolerance’ across patients and clinicians alike, as well as implementing appropriate systems of compensation, rewards and penalties.

Sources:
1 Data from the National Hospital Discharge Survey. Retrieved from http://www.cdc.gov/nchs/data/nhds/4procedures/2010pro_numberpercentage.pdf.
2  Magill SS, Hellinger W, et al. Prevalence of healthcare-associated infections in acute care facilities. Infect Control Hospital Epidemiol 2012;33(3):283-91.
3 de Lissovoy G, Fraeman K, Hutchins V, Murphy D, Song D, Vaughn BB. Surgical site infection: incidence and impact on hospital utilization and treatment costs. Am J Infect Control. 2009 Jun;37(5):387-97. doi: 10.1016/j.ajic.2008.12.010. Epub 2009 Apr 23   http://www.ncbi.nlm.nih.gov/pubmed/19398246

The Crime Boss, Part 3: Rethinking Crime

The standard criminal law paradigm goes something like this. Big Louie walks into a bar and bops somebody on the nose, for which he could end up in jail for a year. If the guy is hurt bad enough, Big Louie could face a 5 year stretch in the pen. If he uses a deadly weapon, a pool cue, say, he can be put away for 15 years. And if the guy dies, in any of the 3 scenarios, Big Louie is looking at life behind bars.

The essence of this centuries-old paradigm is the emphasis placed on harm: the more damage you do, the greater your sentence will be. That very analysis is what led prosecutors to seek criminal charges in this case. Imagine, for example, if Big Louie put something in the water supply that caused 9 deaths and severe pain to 714 people, mostly children and the elderly (i.e., the amount of harm caused by the poisoned peanuts). We would have no problem imagining the public outcry to to lock him up and throw away the key, or worse.

So why isn’t there such a public outcry over the deeds of Stewart Parnell? In part it’s because we have a hard time imagining men in suits organized in corporate form being thrown in prison for something they did at work: it’s just not something we see very much. In greater part, however, it’s because of the state of mind we require of a wrongdoer before we think about locking them up: we require that they intend to cause harm. But in this case Parnell neither intended to cause harm nor even seemed to realize that harm had in fact occurred. So the Department of Justice is dramatically shifting gears with this prosecution: they’re going after him because (1) he knew he was breaking food safety rules, and (2) therefore, he should have foreseen that serious harm, even death, could have occurred, as, indeed, it did.

This is not the first time the criminal law has staked out new territory for itself. Beginning in the 1990s, for example, prosecutors started going after perpetrators of domestic violence. It took a long time to get to where we are today, but the new rules are now well understood by both the public and the justice system. We are no longer surprised when a man is behind bars for battering his wife; indeed, that is what we now expect. A similar shift in thinking — the precise contours of which will be worked out over the ensuing decades — has taken place with this prosecution.

If the DOJ wins and Parnell is convicted and sent to prison, a critical question will become, Who else could end up in prison? We know, for example, that the law in this case applies to anyone in the food or pharmaceutical industry, from manufacture to point of sale. But we don’t know if the operative criminal law principles of knowledge and foreseeability will be applied more broadly to someone in the healthcare field – to hospital or nursing home executives or to doctors. So far, these people have been subject only to civil lawsuits. But that’s the significance of this case against Parnell: the DOJ is sending a message to all those people who were formerly subject to civil liability that they, too, could be subject to criminal indictment.

And neither is this a salmonella case per se. It’s a case about a pathogen that made its way to the public that shouldn’t have, if people had done their jobs properly. So whether the offending substance is salmonella, MRSA, C. difficile, or E. coli, the operating legal principle is the same: if you’re in a position to keep it from the public and you don’t, and as a result people get hurt, the law may look at you just as it would if Big Louie had he done the damage the old fashioned way. The law is looking at the quantum of harm, not so much how they got harmed or whether the bad guy meant to do it.

During the Congressional hearings looking into the salmonella outbreaks of 2008 – 2009 (referred to in Part I of this series), Congressman Greg Walden of Oregon, asked Parnell a question. He held up a large clear jar of peanut products made by PCA and asked Parnell if he would like to try some, just as the people who lost lives or were sickened had done. Parnell again invoked his right to remain silent and refused to answer the question.

But what Walden did was meaningful: he was asking someone who held the public trust to step into the shoes of the very people whose trust he once held. And that’s the point: either we, the goods or service provider, learn to put ourselves in the shoes of the people we serve, and let that guide our actions — or we risk putting ourselves in the shoes of Big Louie.

That’s the lesson in Parnell’s case.

 

The Crime Boss, Part 2: The Victims

Shirley Mae Almer

Just after Thanksgiving, 2008, Shirley Mae Almer, 72, a mother of 5, and a grandmother, checked in to the Good Samaritan Society-Bethany nursing home in Brainerd, Minnesota. This was going to be a temporary stay, to help regain her strength and recover from a urinary tract infection, which, given her recent history, was only a minor inconvenience.

And Christmas was coming. It would be spent with her children and grandchildren. There were presents to buy, and she was looking forward to getting a second puppy. Shirley was due to get out of the nursing home the Monday before Christmas – barely enough time to get ready for the Holidays.

Only the year before, Shirley had successful surgery to remove lung cancer. And in July 2008, she had not one, but two, brain seizures. After undergoing radiation therapy and rigorous rehabilitation she recovered from that, too, leaving the hospital just 3 months later. Shirley had excellent medical care, a large and loving family, and she had something else too, what her son calls sisu, a Finnish word, which reflects their family ancestry and means a person with spunk, fortitude, and determination.

Things were coming along as planned at the Good Samaritan nursing home until mid-December. Sometime around the 14th of the month, a week before her planned release, Shirley engaged in an utterly innocent act – she ate some peanut butter toast. Then, slowly at first, she began to notice changes: stomach cramping, nausea, fever, and diarrhea. The staff couldn’t figure out why this was happening to her and because she seemed to be getting worse she was taken to the University of Minnesota Hospital.

A few days later, on Sunday, December 21 – the day before her scheduled release from the nursing home – Shirley went into shock. By then her blood was severely infected and multiple organs were failing. Her family was called to the hospital and told she had only hours to live. Later that day, surrounded by her children, she died.

Eight more people, mostly children and the elderly, died throughout 2008 and 2009. And across the country in all but 4 states, 714 were sickened, hundreds requiring hospitalization. Some were less than 1 years old, 21% were less than 5, half were less than 16, and the oldest was 98. The crucial characteristic shared by all of these people was more than just being vulnerable and unprotected; rather, it’s that they were all utterly and absolutely innocent. Not one of them did anything to bring this on themselves: they might as well have been shot in a drive-by shooting.

It got Christopher Meunier, 7, who screamed, “Mommy, mommy, it hurts so bad I want to die.” Eleven year old Kristen Brugh was given dialysis in her home every night by her father. Her condition, however, became so severe that she needed a transplant. Kristen got lucky because she found a donor – her dad. Three year old Peter Hurley was poisoned too, but the family didn’t know how. He seemed to be getting better though, so his father asked the family pediatrician if his son could have his favorite snack- a peanut butter cookie. The doctor said sure, that couldn’t hurt; but Peter stayed ill for 11 more days.

What happened to these children brings us to the deeper story: the pain and suffering caused in these cases reached beyond the people who caught the salmonella.

Shirley Mae Almer had a kitchenette in her room at the nursing home. Ginger Lorentz, her daughter, who reminds you of a young Loretta Lynn, dropped by as much as she could. One such visit took place around December 14, just shy of her mother’s release date from the home and the much-anticipated family Christmas. Life, it seemed, could be fair after all. Ginger went into the kitchenette and put some bread in the toaster. When it was ready she came back into the living room and gave her mother her favorite snack — peanut butter on toast.

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