Tuesday, November 14, 2006

Hospital-induced Infections

An op/ed appeared in today's New York Times raising the important issue of hospital-induced infections, “which account for an estimated 100,000 deaths every year.” The author, Betsy McCaughey, describes the spread of the deadly Staph infections: “Doctors and other caregivers who lean over an [infected] patient often pick up the germ on their hands, gloves or lab coats and carry it along to their next patient.” McCaughey has apparently given up, however, on the possibility of getting caregivers to wash their hands and change their gowns between patients. Indeed, she notes that “[e]arlier efforts to stop these infections by installing many more dispensers of hand cleanser and conducting a year-long educational campaign on hand hygiene had no effect.” Her current proposal is to screen all patients for the presence of the infection.

I have addressed this issue in two columns, Unclean Hands: How Patients Can Prevent Blatant Medical Malpractice and Hospital-Induced Infections: A Serious Crime Against Our Nation's Patients. In both, I have proposed that such infections continue to spread because many caregivers do not want to – and accordingly don’t – wash or disinfect their hands. The simplest solution is therefore to compel them to use the hand cleansers. Doctors and nurses often prefer to skip the hand-washing, knowing – as they do – that it is virtually impossible to trace a particular infection to a specific individual. Without accountability, in other words, there is no compliance.

But they can and must be held accountable. How? Here’s one possibility: Hospitals can require that before every medical interaction, every patient receive a form that explains to the patient that over 100,000 people a year die in hospitals because of the providers’ failure to observe basic hygiene around patients. The form should accordingly instruct the patient to pay attention to whether his provider washes her hands before touching him. Then, after the patient sees his doctor or nurse, he should be given the same form and asked to respond anonymously to the following questions: 1. Did each of your providers wash or sanitize her hands before touching you? 2. If not, please name or describe by appearance the providers who did not. 3. Did you say anything to your provider at the time about the failure to wash? 4. If so, was the provider receptive to your criticism? Doctors and nurses receiving more than one or two complaints on this score could be warned and ultimately observed by an internal health inspector. A failed inspection could result in suspension and ultimately termination. If the failure to use proper hygiene were treated as the malpractice that it is, then the inexcusably high mortality rates would likely drop.

25 comments:

Jamison Colburn said...

This seems like one pragmatic approach to what is quickly becoming a nightmarish problem. To hear some of the testimonials of people who are contracting the infections that go along with this MRSA bacteria is to make you skiddish of checking into a hospital. But even given the four parts to the form, wouldn't you worry that the forms themselves would be "managed" by staff at hospitals that don't take MRSA and other super bugs seriously enough? It seems like the ones that are moving on this are doing so because they've perceived the bottom line on the issue differently.

Derek said...

My first response was to say that I liked your idea, but was worried it might create a moral hazard (of sorts). Patients might falsely accuse their doctors of not washing their hands if they were dissatisfied with their manner or some other element of the hospital experience. That is, they might be tempted to check the “no hand washing” box because it would be a good way to exercise some power over their doctor without doing anything really harmful, since they might reason that unless others also checked the box, there wouldn’t be any serious repercussions. Of course, if everyone reasoned that way, a lot of boxes would get checked.

But then I thought that even if that’s true it might not be such a bad thing. The forms could kill two birds with one stone, creating incentives to wash one's hands *and* improve one’s bed side manner.

And, anyway, unless the false accusations were really rampant, saving 100,000 lives would be worth it regardless.

David Crowley said...

To respond to Derek, I'd be surprised if patients lied about their doctors' hand washing as a way to punish them for other issues. Unless the lying were widespread, I think administrators would be able to police for this. If a doctor normally gets reported as a hand washer, the rare complaint would probably be brushed aside. Further, the problem could be avoided, I think, by just adding a blank space with "other complaints" next to it. That way the disgruntled patient can honestly evaluate the hand washing while still complaining about the doctor's other issues.

As for the proposal more generally, I like it---I'll like anything that has the chance to reduce this completely unnecessary problem. However, what concerns me is the norm-shaping that is going on. It seems to me like doctors and nurses should be doing this of their own volition, not because they fear being tattled on by patients. Putting this sort of patient reporting mechanism into the examining room has the potential to introduce elements of resentment and suspicion (in both directions), and undermine the relationship of trust that we all want to have with our doctors. I don't want my doctor to look at me as a potential plaintiff, and I don't want to go around tallying the major medical mistakes that my doctor makes. Further, if we use a "stick" against doctors, then there's the risk that only those patients that are credible reporters will get the desired results. In other words, the poorly educated may get worse care because doctors doubt they'll take the survey seriously (or that they'll bother to monitor hand washing). And, realistically speaking, once we're aware of the dangers, who wants to wait to report on the survey the doctor's mistake? I think we'd all be confronted with the uncomfortable "Miss Manners" problem that Professor Colb describes in her findlaw column.

Alternatively, what if doctors and staff monitored each other, through anonymous reporting systems and/or random spot audits? This would hopefully have the effect of creating strong hand washing norms within the provider community, and thus eventually eliminate the need for any reporting system. In the meantime, doctors and patients wouldn't view each other suspiciously. Of course, there may be issues that develop between doctors and nurses in these cases, but that relationship is less fragile, and more easily manageable by hospital administrators.

Derek said...

Good points, Dave. The "other complaints" space would seem to solve the problem.

Regarding the education point, couldn't we solve that problem by making the forms anonymous? Or do you think there might be some hospitals, as a whole, which might be more or less likely to take the forms seriously (even if they were anonymous) depending on the demographic they primarily serve?

Regarding your proposal, I'm not sure having doctors and staff monitor each other would lead to less problems. I would think that such an environment might become very tense and awkward. Plus, and I think this speaks to your worry about norm shaping, if a doctor/nurse knows that a patient is aware of the importance of hand washing she might be more inclined to wash her hands not just because she fears the patient will turn her in (though this would probably play a role), but because her sense of responsibility toward the patient would be activated. That is, doctors/nurses see themselves as care-takers with respect to their patients and this is possible, psychologically, only if they think the patients do (or at least should) see them as properly fulfilling that role. In other words, they would be motivated to wash their hands, in part, in order to preserve their status/role/image in the eyes of their patients, once they know that the patients know how important hand washing is to their health. This works only because hand washing is something which, as health care providers, the doctors/nurses would have to admit is important to the general goals which define their field. So the same sort of mechanism wouldn't work to ensure that doctors punched a time clock or performed some other administrative duty not essentially related to health. Trying to enforce that sort of practice through feedback forms *would* likely result in suspicion and resentment between doctors and patients.

Anonymous said...

I'm very thankful for this post, but I'm a bit skeptical of the proposed solution of the forms.

Has anyone had an extended stay in a hospital?

One of my previous incarnations was as an admitting clerk for a private hospital in Evanston, IL. One of my responsibilities was to go around to the patients' rooms and attempt to get their signatures for Medicare benefits assignment. Again and again I had to explain that each admission into the hospital required a whole new set of forms to be signed. For the most part I was successful - that is, if I didn't run into doctors, nurses, social workers, relatives and/or friends, maintenance workers...you get the idea...who arrived before me to bombard the patient with a number of questions and issues, or to provide just plain ol' company.

Anyway, the point I want to make is that if there are any changes to be made in the way healthcare professionals care for their patients, the changes need to come from within the "culture" of healthcare - doctors especially - not only from hospital administration. Sure, the hospital can require this-or-that form to be made available, but hell will freeze over before doctors and other healthcare providers will put into practice something that they consider an imposition rather than "organic" to their ongoing practices.

So, you might ask, how to make something as simple and important as washing one's hands "organic" to patient healthcare? Honestly, I have no idea! BUT, perhaps one or more doctors will begin to use those hand sanitizers conveniently located (sometimes) at the entrance to a patient's room, or nearby, and everyone, not just doctors and helathcare providers, who visits the patient's room will also begin to use them. Perhaps a sign posted on the patient's door could say, "Did you remember to wash your hands upon entering and leaving this room?" Less legal requirements and more peer pressure, I think, could get the job done...OR, it just occured to me, instead of requiring washing of hands and sanitizers, why not make gloves mandatory? That is already so in step with the "culture" of doctors and healthcare providers, and it would take no additional time for a helathcare professional to use and then discard them, especially when they have to visit several patients and only have a certain amount of time to do so.

Bottom line: I don't think it's a good idea to make the patient responsible for reporting the practices of healthcare providers. They're in enough discomfort already.

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Unknown said...

cara mengobati penyakit wasir secara jika mendengar kata wasir mungkin anda cara mengobati bab berdarah atau wasir obat herbal wasir wasir ambeien herbal obat wasir obat ambeien atau wasir herbal

Unknown said...

cara mengobati penyakit wasir secara jika mendengar kata wasir mungkin anda cara mengobati bab berdarah atau wasir obat herbal wasir wasir ambeien herbal obat wasir obat ambeien atau wasir herbal

Unknown said...

pengobatan penyakit herpes kelamin cara mengobati herpes kelamin obat herpes kelamin obat herpes kelamin

Unknown said...

bahayakutilyangtumbuhdipenis obatmerontokkankutildipenis menghilangkankutilyangtumbuhdivagina

Arjunane Denature said...

Obat kencing Nanah De Nature Obat Herbal obat Kutil Kelaminpenyebab ujung kemaluan keluar cairan obat kencing nanah pada wanita jenis obat untuk kencing nanah obat herbal mengatasi kencing nanah