Sunday, Aug. 8, 2010 | 2 a.m.
Do No Harm: Hospital Care in Las Vegas, Part 2
- A hidden epidemic
- Hospital stay will stay with her always
- VA system stanching MRSA
- Hospital’s sanitation promises quickly forgotten
- Billing codes key to data analyzed on infections
- Where I Stand: Rise in infection rates, hospitals’ reticence are troublesome
- Editorial: Hospitals should do more to protect patients from deadly bacteria
- ‘We’re the ones who are in there. Our lives are entrusted to them.’
- Health board backs limits on disclosure of infections
- How best to stem spread of infection?
- St. Rose breaks ranks with disclosure on quality of care
See the results
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Las Vegas hospital officials say they are doing enough to protect patients from becoming infected with deadly bacteria.
But hospitals are failing.
Just ask Ruth Lepper, whose 74-year-old husband, Darwyn, had hip surgery in 2008 and died within months of complications from infections. Or Julie Rich, who is 69 and relies on an oxygen machine because of an infection she contracted after outpatient surgery. And Marcia Friedman, whose 91-year-old mother, Eleanor, was recovering from a blood clot when she got infected and died.
What they say: Going to the hospital puts you in harm's way. Hospitals know this and avoid talking about it. And until now, the details have not been publicly known.
The Sun has spent two years investigating hospital safety in Las Vegas, including analysis of hospital billing records on file with the state.
Among the findings: In 2008 and 2009, patients became infected with lethal, drug-resistant "superbugs" in area hospitals 2,010 times.
Two hundred thirty-nine died — although it's impossible to tell from hospital billing records how or whether the infections factored in the patients' deaths.
The microbe Methicillin-resistant Staphylococcus aureus, or MRSA, was responsible for 647 cases of hospital-acquired infections during the two-year period. In the same span, Clostridium difficile, or C. diff, triggered 1,363 infections in Las Vegas hospitals.
No health agency tracks these cases. In fact, hospitals derailed proposed legislation in 2009 that would have required them to publicly report cases of MRSA in their facilities.
However, hospitals are required by law to submit to the state billing records based on each patient visit. The Sun obtained that information from 1999 to 2009 and analyzed the 2.9 million hospital billing records as part of its two-year investigation, "Do No Harm: Hospital Care in Las Vegas."
Because of how the records are coded, the Sun was able to identify the number of infections by the two bacteria, and for the years 2008-09 further identify the cases in which the records say the patients acquired the bacteria while hospitalized.
Jeanine Thomas, founder of MRSA Survivors Network, an Illinois-based national advocacy group, applauded the effort to draw attention to an epidemic that's being hidden from the public. She said MRSA should be reported to public health agencies because it's communicable, infectious and a national problem. That it's not reported "is shocking," she said.
"There should be transparency," Thomas said. "People have a right to know this information."
Not even Nevada State Epidemiologist Dr. Ihsan Azzam knew how many patients have been stricken by the infections until learning it from the Sun. He called the newspaper's analysis a wake-up call to the health care community to be more aggressive in preventing infections.
"Such a significant increase in these rates coupled with the threat of emerging resistant organisms in the health care setting should sound the alarm for all clinicians, hospitals, infection-control specialists and epidemiologists," Azzam said.
A COSTLY, DEADLY PROBLEM
Health care-acquired infections have long been the bane of hospital infectious-disease experts nationwide, costing $30 billion annually and being responsible for the deaths of about 100,000 people. That puts them among the leading causes of death in the United States.
University Medical Center was the only hospital in Las Vegas to accept the Sun's invitation to discuss its findings.
The other dozen hospitals in the valley provided a statement through their trade organization, the Nevada Hospital Association. None disputed the Sun's findings or its methods of identifying the cases.
The statement proclaimed an adherence to national standards that are intended to prevent the spread of bacteria among patients. All screen high-risk patients for MRSA when they are admitted, isolate infected patients and require anyone who enters their rooms to don gowns, gloves and face masks to prevent the spread of the bacteria. The hospitals also stress washing hands and cleansing surfaces with bleach to kill C. diff spores.
But examples of hospitals not following their own standards are plentiful — jeopardizing, even, their own employees. A Sunrise Hospital worker who complained to state officials about being infected with MRSA on the job told health inspectors in June, "This problem has been going on for a while, but has surged recently" and could cause an outbreak. The state forwarded the complaint to the Nevada Occupational Safety and Health Administration.
Infected patients, or their survivors, say not enough is being done to stop the spread of bacteria.
"My husband should not have died of a broken hip," said Ruth Lepper, after her husband died after contracting MRSA at a hospital. He also was infected with C. diff at another valley health care facility.
"They're just not as dutiful as they should be," said Rich, who also contracted a MRSA infection at a local hospital. She described the hospital as filthy.
"They killed her," Marcia Friedman said of the hospital where her mother contracted and died of complications related to a MRSA infection.
The Sun found that even as the hospitals focus on eliminating the infections, they proliferate. The combined rate of hospital-acquired MRSA cases at all 13 Las Vegas Valley hospitals increased by 34 percent to 1.74 cases per 1,000 hospital discharges from 2008 to 2009, state records show. The rate more than doubled at four facilities: Desert Springs Hospital, Spring Valley Hospital Medical Center, St. Rose Dominican Hospitals — San Martin Campus and Valley Hospital Medical Center.
MRSA infection rates are declining in some regions of the U.S. It's impossible to compare the Sun's findings of hospital-acquired MRSA and C. diff rates to those elsewhere because of the different ways the information is gathered and reported.
There is no national standard for an acceptable level of hospital-acquired MRSA or C. diff infections. But some facilities have all but eliminated them. In several European countries, rates have been reduced to almost zero, and within the Veterans Affairs Department, some hospitals go for a year or more with no cases.
"We're not satisfied when the rate is any higher than zero," said Dr. Rajiv Jain, head of the VA's MRSA prevention program.
In Las Vegas, the rate of hospital-acquired MRSA infections in 2009 ranged from 0.67 to 3.04 cases per 1,000 discharges at Summerlin Hospital Medical Center and North Vista Hospital, respectively.
The rate of hospital-acquired C. diff infections in 2009 ranged from 1.93 to 5.31 cases per 1,000 discharges at Spring Valley Hospital and Desert Springs Hospital, respectively.
The Sun asked the hospitals to voluntarily disclose their numbers of hospital-acquired MRSA and C. diff cases. UMC officials said they had 86 MRSA and 52 C. diff infections that were hospital-acquired in 2009.
St. Rose Hospitals promised to make the information available on its website soon. The other hospitals declined.
BACTERIA HAVE BECOME MORE RESISTANT
Penicillin was proclaimed a miracle drug when it came into use in the 1940s because it could defeat the deadly Staphylococcus aureus bacterium.
But the byproduct of that achievement was the evolution of more resistant bacteria. That's how MRSA and C. diff became epidemics.
MRSA appeared in hospitals in the 1960s. As it evolved, it spread into the community. Now patients who enter a hospital may carry MRSA but not be infected, which means they show no symptoms and can infect others unknowingly. Victims are infected through contact with contaminated health care workers, patients or medical equipment.
Hospital-acquired MRSA manifests itself as pneumonia or infections in the bloodstream or at surgical sites.
A recent Duke University study found MRSA surgical-site infections lead to a sevenfold increase in the risk of death, a 35-fold increase in the risk of hospital readmission and more than three weeks of additional hospitalization.
MRSA infections are treated with heavy doses of antibiotics — providing an opening for C. diff. The bacterium lives in the human gut and is harmless in healthy individuals because "good" bacteria keep it in check. But when a person is on antibiotics the good bacteria are destroyed, disrupting that balance and allowing C. diff to proliferate. It causes severe diarrhea, abdominal cramping, fever, nausea and blood in the stool.
C. diff spores are so hearty that hospital employees wash high-traffic areas with bleach to kill them. Like MRSA, it spreads through contact with infected patients, health care workers or equipment. Infected patients are supposed to be isolated.
Because of the intensive hospital care and expensive drugs required to treat these infections, the financial costs are staggering. Each MRSA bloodstream infection costs $27,083, according to academic research, and each C. diff case costs up to $7,100 in additional treatment. That puts the cost of hospital-acquired infections in Las Vegas in the millions of dollars annually.
Much of the cost of hospital-acquired infections is borne by taxpayers and the insured, through government insurance programs and private insurers.
The costs are also paid by the victims, people such as Carole LaRocca. She almost died from a MRSA infection she contracted at a local hospital in 2003, and was billed $3,676 for antibiotics that insurance refused to cover. It's an overwhelming and stressful debt for a 74-year-old woman on a fixed income. She faithfully pays $25 a month to a collection agency, yet still receives threatening calls.
"It's an awful thing," LaRocca said. "They need to make an effort to prevent their patients from going home with illness."
TESTS AT ADMISSION COST-EFFECTIVE
The Southern Nevada hospital that arguably does the best job combating MRSA is the O'Callaghan Federal Hospital at Nellis Air Force Base. (Because it is a federal hospital, it was not part of the state database examined by the Sun.)
The Veterans Affairs Department, which operates the hospital, has a zero-tolerance policy toward the bacterium. As at other VA facilities nationwide, staff members swab each patient upon admission and determine within two hours whether the person is colonized or infected with MRSA. Patients who are carriers are immediately isolated.
The hospital also tests each patient upon transfer elsewhere in the facility or discharge to monitor whether the bacterium is being contracted inside the facility.
Each test costs about $25, but VA officials say it's cost effective, given that the number of hospital-acquired MRSA infections has fallen to almost zero in many facilities.
No other Las Vegas hospital tests every patient for MRSA at admission, and none tests any patient at discharge. They say their methods — when followed carefully — effectively reduce the spread of bacteria in the hospital.
Still, a few facilities in other states have found universal screening works. In 2005, a three-hospital group in Illinois, comparable in size to the Southern Nevada hospital chains, started a universal MRSA screening program. Evanston Northwestern Healthcare officials discovered 6.3 percent of their patients arrived infected or carrying the bug. The hospital isolated them, a defensive tactic made possible with the screening. The hospitals also emphasized washing hands, decontamination of facilities and equipment, and contact precautions.
The annual cost of the Evanston Northwestern program was $600,000, mostly for laboratory supplies and personnel. The program was cost-effective in its first year, and MRSA bloodstream infections dropped by 80 percent.
The Centers for Disease Control and Prevention takes the lead on infection prevention in American hospitals. But the CDC has failed to prioritize for hospital officials the best prevention practices — from among almost 1,200 recommendations — and has not grasped "the extent of the problem," according to a 2008 report by the Government Accountability Office.
Dr. Bill Jarvis, who worked at the CDC for 23 years and led its hospital-infection program, said the federal government is sending mixed messages to hospitals on MRSA control: The VA system has rigorously attacked the bacterium, while the CDC has yet to give it proper attention.
CDC Epidemiologist Dr. John Jernigan said the agency is revising its guidelines, and he thinks the recommendations, if followed, will prevent MRSA's spread in hospitals. In fact, MRSA rates are declining in some regions, he said.
Jernigan does not recommend other hospitals pursue universal MRSA screening, because there is legitimate scientific debate about its necessity, he said.
In the joint statement they provided to the Sun, a dozen Las Vegas hospitals said screening only high-risk patients — including intensive care patients, anyone coming from another facility and patients who have wounds or are homeless — "is a cost-effective and efficient method to reduce the rate of MRSA in hospitals."
Still, the overall rate of infections at hospitals is rising, the Sun found.
The infection rate more than quadrupled for MRSA and doubled for C. diff from 1999 to 2009. In recent years, MRSA rates have continued to rise, while C. diff rates have leveled.
The Sun's analysis found more than 33,000 cases in which Las Vegas hospital patients suffered from the infections during the past 11 years — 18,563 cases of MRSA and 15,333 cases of C. diff.
Of those cases, 2,582 of the records showed the patient died while hospitalized, although it's impossible to tell how the bacteria contributed to the deaths.
Azzam, the state epidemiologist, was asked whether Las Vegas hospitals have succeeded at reducing infections. He said he thinks local hospitals "are on the right track" but conceded he was not sure.
SIMPLEST PRECAUTIONS OFTEN NOT TAKEN
The rise of lethal bacteria — combined with infection-control failures — has made being a patient, visitor or worker in Las Vegas hospitals increasingly dangerous.
Some doctors and hospital employees fail to take even the most simple infection-control precautions. Asked if all hospital staff consistently wash their hands, Dr. Eugene Speck, a respected Las Vegas infectious-disease specialist, said, "Of course not." He wasn't being glib. Every health care practitioner interviewed for this story agreed with his assessment, and national studies say the same. Hospital employees are too busy, distracted, apathetic, stressed or short-staffed to keep up with hand washing.
Registered nurse Christina Schofield said she has witnessed poor infection-control practices everywhere she has worked during a 23-year career in Las Vegas.
Schofield was recently assigned to monitor whether UMC nurses were practicing proper hand hygiene. She found nurses were dutiful in washing hands — but said "physical therapists, case managers, physicians, ancillary staff" were not.
Also at UMC, she said, patients known to have contagious infections were placed in rooms with uninfected patients. At St. Rose Hospitals — Siena Campus, she said, technicians who ran the department where intravenous catheters were inserted and angiograms were performed rarely cleaned the room between patients, resulting in contamination by bloody refuse.
"It's a multisystem failure," Schofield said.
St. Rose officials said rooms are always cleaned thoroughly after each patient visit. UMC officials said they did not know of any instances where infected patients were placed in rooms with uninfected patients. Dr. Alan Greenberg, medical director of UMC's infectious disease program, acknowledged that the failure to follow hand hygiene rules is a consistent problem.
Schofield has testified about problems in hospitals before elected officials. No one has followed up on her complaints, she said.
"This is important," she said. "We make an error and they're dead, and there's no changing it."
State health inspectors have documented numerous infection-control problems. A UMC doctor regularly wore street attire — pants and a long-sleeve shirt — while performing colonoscopies, when the hospital's policy requires surgical scrubs. A Sunrise patient infected with C. diff was observed walking the hospital's hallways. A company that did dialysis work at North Vista Hospital had infection-control problems and no oversight by a nurse.
Patients notice the same problems.
Harold Barling, who was infected with MRSA in 2005, said nurses and aides at Valley Hospital, where he was being treated for the infection, often came in and out of the room without masks, gloves or gowns. "I would think they would take every precaution to prevent any possible contamination between me and any other patient they might take care of," Barling said.
Some patients complain that hospital staff is not forthcoming in acknowledging the problem.
When David Spendlove, 51, contracted MRSA at a Las Vegas hospital, where he was admitted June 17 after a heart attack, no one told the family anything specific about the infection, his wife, Pam Spendlove, said.
"Oh it's just a virus they get," she said she was told. "It's common."
During that time, visitors were uncertain what precautions to take to protect themselves, Spendlove said.
"The MRSA was like a deep, dark secret," Spendlove said.
HOSPITALS KEEPING PATIENTS IN THE DARK
Transparency advocates argue that reporting infections by individual facility allows consumers to make informed health care decisions and spurs competition among the hospitals to improve.
But hospital lobbyists have worked for years to keep the information out of the public eye.
When legislation passed in 2002 requiring reporting of sentinel events — unexpected injuries or infections that take place in hospitals — the hospitals fought to prevent reporting by individual facility.
In the 2009 legislative session, Sen. Barbara Cegavske, R-Las Vegas, introduced a bill to require every hospital in Nevada to create a MRSA program identifying colonized patients, isolating them, enforcing hand washing and reporting infections to the state.
The effort took an abrupt turn when Ann Lynch, lobbyist for Sunrise Health System, spoke during a hearing. Lynch informed the senator that the hospitals keep MRSA information internally and have no convenient way of reporting it to state health officials, Cegavske said.
Cegavske, who received $6,500 in campaign contributions from hospitals in 2006, reduced the bill to a simple promise to discuss the subject.
In 2009, lawmakers passed a bill to strengthen reporting requirements for hospital injuries and infections, including more public reporting of hospital-acquired infections.
The hospitals have again lobbied against the information being made public in a way that would be meaningful to consumers.
At a March meeting to discuss implementing Senate Bill 319, Marissa Brown of the Nevada Hospital Association said the infections should be reported as a total for all Nevada hospitals without identifying individual facilities. The association also proposed limiting which hospital units would report infections.
The Nevada State Health Board is scheduled to discuss the matter Friday. As currently drafted, the regulations would not allow the state to report hospital-acquired infections by facility.