The Change We Need: Avoiding Harm in Hospitals

I first posted this on OccupyHealthcare September 10,2012.

The Institute of Medicine (IOM) recently published a substantial report on the healthcare system in the US.  According to the report, in the US 1/3 of patients are currently harmed during their stay at a hospital.  These harms are called Hospital Acquired Conditions (HACs).

In a 2012 article in the Journal of Health Care Finance, Nero, Lipp and Callahan analyzed 2007-2008 patient data from the New York State Department of Health’s Statewide Planning and Research Cooperative System.  Of the 4,853,900 patients whose discharge information was included in the analysis, the most frequent hospital acquired conditions was bedsores, also known as pressure sores or the technical name “decubitus ulcers.”  Their annual cost estimate for New York alone was nearly $680 million and 376,546 days of hospital care.

For the US, estimates of cost range between $6 and $15 billion annually (Markova & Mostow, 2012).  The costs in human suffering are also significant.  When Ailman et al (1999) conducted a comparison of patients who developed bedsores and those who had not; they found significant increases in hospital-acquired infections (45.9% vs 20.1%) and other complications.  Hospital costs and length of stay were greater for those who developed these ulcers.

My interest in decubiti is personal.  In the 1980’s and 1990’s my mother worked part-time in a hospital in North Carolina in quality control.  When researching cost and quality issues, she found that a significant amount of money and time was spent on a problem that patients were getting in the hospital, that was preventable, that was painful and could be life threatening.  This was the problem of bedsores.

She spent an enormous amount of time trying to educate the hospital administration, nursing staff and fellow physicians in the need to prevent and treat bedsores.  She made some inroads:  the hospital hired a skin care expert who trained the staff.  But in the end, budget cuts reduced or eliminated jobs in quality control at that hospital.

One of the saddest and most disturbing ironies of her story is that, in 1999, when she was a patient, dying of metastatic breast cancer in that hospital, she got a bedsore.  Because training had been discontinued, the nursing staff did not know how to prevent this ulcer from occurring, nor did they know how to treat it. Thankfully, my mother was still able to help my sisters and I find the skin care expert that had been hired previously.  Through that expert, we got the type of dressing that mother needed to promote healing.  We took over, turning mother, changing her dressing, giving her bed baths and doing “bedpan duty”.  We were there with her, night and day, for two months.

There was a patient in the next room over who had no family.  He also had a bedsore and we could hear him crying, suffering from the treatment he received.  My mother’s bedsore healed up as we took care of her, despite her cancer.  We showed the nurses what we were doing and asked if they could use the dressing on the man next door.  Sadly, we were told that if his physician did not order the dressing, there was nothing that could be done for him.

The name of the IOM’s report is “Best Care at Lower Cost: The Path to Continuously Learning Health Care in America.”  In my view, continuously learning healthcare means that just because there is improvement in quality, efforts to maintain quality control cannot be stopped.  It means continuous training and monitoring.  It means dealing with this very real problem.  Getting bedsores is preventable.  Patients in hospitals and nursing homes do not have to acquire these life-threatening ulcers.  But it requires awareness, intense devotion, continuous monitoring and education.  It also requires enough people.  People who are willing and able to do the physical work, people who have the energy, time and devotion to care and people in power who remember that the patient in that hospital bed could be their mother, sister, brother, father, child, aunt, uncle, grandparent or friend.  Patient safety must be at the center of all the care we provide and it is imperative that we actively work to prevent avoidable complications in care.

References:

Ailman, R., Goode, P., Burst, N., Bartolucci, A., & Thomas, D. (1999). Pressure ulcers, hospital complications, and disease severity: impact on hospital costs and length of stay. Advances in Wound Care. 12(1):22-30.

Markova, A. & Mostow, E. (2012).  US skin disease assessment: ulcer and wound care.Dermatological Clinics. 30(1):107-11, ix.

Nero, D., Lipp, M. & Callahan, M. (2012). The financial impact of hospital-acquired conditions.Journal of Health Care Finance. 38(3):40-9.

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“It’s the Neighborhood, St***d”

“Life is like riding a bicycle. To keep your balance, you must keep moving.” Albert Einstein

A study just published in the September 20 issue of Science gives a whole new meaning to moving.  The study comes from the data of over 4,500 low income families who participated in a large-scale randomized social experiment called Moving to Opportunity.   The poor neighborhoods were in 5 cities, Baltimore, Boston, Chicago, Los Angeles and New York.     Moving to Opportunity used a random lottery to offer vouchers to around 2,000 extremely disadvantaged families who were living in distressed public housing projects .  These vouchers  allowed them to move to mixed income neighborhoods, that is, better neighborhoods.  The study was done to determine the impact of where one lives on one’s health.   The research published in Science is based on comparative data of those adults who moved and those that stayed in the neighborhood.  It is longitudinal data, data obtained 10 to 15 years after the move took place.

Most of the households in the study were headed by African-American or Hispanic women, most of whom had not completed high school.   According to participants, their motivation for moving was to find better schools, have better apartments and get away from gangs.

Findings from the study are interesting.  First, those who moved to better neighborhoods increased their physical and psychological health. They had lower rates of diabetes, obesity, anxiety, depression and stress than those who stayed.

In addition, movers in this study had gains in happiness and well-being compared to those who stayed.  In fact, although the movers did not see any income increases, they experienced the same gains in degree of happiness as would be found in people who have $13,000 family income gain.

Poverty and poor surrounding take a toll on people. Researchers have surmised that  in the the poor are severely impacted by decision fatigue.    Abhijit Banerjee and Esther Duflo note in their book Poor Economics, decision fatigues cost for the poor.

There are”…many things that…[those who are not poor]  take as given. We live in houses where clean water gets piped in — we do not need to remember to add Chlorine to the water supply every morning. The sewage goes away on its own — we do not actually know how. We can (mostly) trust our doctors to do the best they can and can trust the public health system to figure out what we should and should not do. … And perhaps most important, most of us do not have to worry where our next meal will come from. In other words, we rarely need to draw upon our limited endowment of self-control and decisiveness, while the poor are constantly being required to do so.”

In other words, making difficult decision after difficult decision takes a  toll on mental energy.   The more choices one has to make through the day, the harder each one decision becomes for the brain.  As decision fatigue sets in the brain looks for shortcuts: either becoming reckless,  impulsive, or making no decision at all and doing nothing.

Racial neighborhood segregation is decreasing in the US but economic segregation is increasing.  The findings in Science point to health improvements due to decent, safe housing.   When in stressful, difficult situations–like living in unsafe neighborhoods–much mental energy is used.  Important decisions based on health recommendations, like healthy eating or doing physical activity,  for personal or family health, are either neglected or ignored.  In other words, perhaps when the movers in the study didn’t have to decide the best time to go to the grocery store based on when gangs were roaming the neighborhood, they had more mental energy to make the “healthy” choices at grocery stores that are recommended.

No matter the mechanisms, one thing is certain from the research on Moving to Opportunity:  moving from extremely poor, violent neighborhoods to  better neighborhoods improves health.  Shouldn’t making neighborhoods safer and easier to live in be a national public health priority?

 

Patient Safety: Costs in Healthcare

For many years my mother worked part-time in a hospital in North Carolina in quality.  In researching cost and quality issues, she found that a significant amount of money and time was spent on a problem that was preventable.  It was a problem that patients got in the hospital.  It was painful and could be life threatening.  It was bed sores also known as pressure sores.

She spent an enormous amount of time trying to educate the hospital administration, nursing staff and fellow physicians in the need to prevent and treat bedsores.  She made some inroads:  the hospital hired a skin care expert who trained the staff.  But in the end, budget cuts reduced or eliminated jobs in quality control at that hospital.

One of the saddest and most disturbing ironies of her story is that, when she was a patient, dying of metastatic breast cancer in that hospital, she got a bedsore.  Because training was discontinued, the nursing staff did not know how to prevent this, nor did they know how to treat it. My mother was able to help my sisters and I find the skin care expert that had been hired.  Through her, we got the type of dressing that mother needed to promote healing.  We took over,  turning her, giving her bed baths and doing “bedpan duty”.

There was a patient in the next room over who had no family.  He also had a bedsore and we could hear him crying, actually suffering from the treatment he received.  My mother’s bedsore healed up as we took care of her, even though she had cancer.  We showed the nurses how we were caring for her and asked if they could use the dressing on the man next door.  Sadly, if it was not ordered by his physician, there was nothing that could be done for him.

The Institute of Medicine has just put out a substantial report, 45o pages, which describes what is wrong with healthcare in America.  It is called “Best Care at Lower Cost: The Path to Continuously Learning Health Care in America.”  Continuously learning healthcare means that just because there is improvement, efforts in quality control cannot be stopped…it means continuous training and monitoring.  According to the report, in the US 1/3 of patients are actually harmed during their stay.

There are efforts to help.  Campaign Zero is an effort to “provide safety strategies to patients and their family-member advocates to prevent medical errors.”  OccupyHealthcare supports promoting patient safety to reduce healthcare costs.  Take a look at their websites and take this survey.