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Critical Issue Report Cleanliness might solve the "med-mal" mess Proper hygiene could significantly reduce infections By Bruce D. Hicks, CPCU, CLU The mere mention of medical malpractice is likely to immediately raise emotions in any gathering of medical, legal or insurance professionals. Any discussion is also likely to revolve around the need for reform, with someone inevitably pointing out the problems of runaway jury verdicts, the lack of placing caps on lawsuit awards, predatory attorneys, and an errant tort system. Just as likely to be mentioned are the problems of finding affordable medical malpractice coverage and the fact that many medical specialists continue to abandon their practices. Many of us might like to wash our hands of the whole mess—and that might be the best action we could take. As difficult as it may be to believe, a critical strategy for attacking this crisis may be to heed some of the earliest advice we’ve ever received: “Wash your hands.” Yes, medical lawsuits are often fueled by allegations of surgical error, misdiagnoses, improper distribution of prescribed medicine (including dosage and interaction errors); however, a major cause of litigation involves simple (and neglected) hygiene. Patients often suffer serious health complications, including death, because of the insufficient level of hygiene practiced by health care personnel. It is very possible that strict adherence to proper hygiene could reduce litigation from a crisis level, to a volume that was contemplated by once affordable medical malpractice premiums. Even more important, rigorous hygiene could save lives and reduce suffering for persons who, ironically, are in hospitals for care, not for picking up potentially fatal infections. Various studies indicate that, each year, more than 100,000 persons die from infections they pick up during hospital stays. Many thousands more have their care (and hospitalization) substantially prolonged by hygiene-related infection. Hygiene and patient safety Hygiene is critically important to the safety of hospital patients—and patient safety in the United States is a huge problem. A 2005 study published in the Journal of the American Medical Association reports that the nation’s hospitals were making little progress toward meeting patient care standards recommended by the Institute of Medicine. Dr. Daniel Longo (who led the study) remarked: “This report calls attention to the fact that there are systemic problems. We are not talking about bad apples.” In essence, the systemic problems revolve around too few hospitals making the effort to enforce proper hygiene. In many instances the danger to patients from infection is far greater than from the circumstance that resulted in the hospitalization. Current studies show that patients are still highly vulnerable to infection due to easily correctible problems such as physicians and nurses who fail to wash hands before touching patients, hospital staff transferring infection via their clothing, or improper use of gloves (including putting them on with dirty hands and/or not changing gloves as they contact different patients). A number of medical organiza-tions, including the Centers for Disease Control, the American Medical Association and the Institute of Medicine, create and publish information on hygiene and hygiene practices that should be used in health care facilities. For instance, the Veterans Health Administration encourages the use of the CDC’s hygiene recommendations. While hospitals do take care to ensure that surgical procedures are performed in a sterile environment, it is every other aspect of care that lacks this attention to hygiene. An item that makes this issue even more disturbing is that the stakes are incredibly high. We all face situations where disease is spread, at home, at work, in day care, at school, and while using public transportation, for instance. However, these are locations where, typically, the result is a pesky cold or, perhaps, the flu. At worst, we may end up just feeling lousy and spend a day or two in bed. On the other hand, catching something in a hospital can be far more serious. Data show that there are increasing incidents of spreading staph infections and other microbes that are very resistant to antibiotic treatment. There are a number of reasons why so many people suffer from poor hygiene at our nation’s hospitals … but none is good. For some reason, flying in the face of the Hippocratic Oath (to do no harm to patients), health care workers in the United States routinely act in a manner that is at odds with their sole purpose of providing quality care. Spend any time at most hospitals and you likely witness: • Unwashed, uncovered hands alternately handling bed pans and food trays (infections involving fecal matter in food are a common incident) • Doctors and nurses visit/treat a number of patients without intervening washing or disinfecting • Waste cans are infrequently emptied • Counters, toilets, and sinks are irregularly and insufficiently cleaned • Water and water/cleaning solutions in cleaning/mop buckets are not frequently changed • Stethoscopes are not disinfected before use • Gloves, when used, are put on and worn over unwashed hands • Health care workers performing work in contaminated clothing • No use of disposable garments • Infrequent cleaning/disinfecting of hospital curtains which easily become contaminated Is anyone listening? It is both unfortunate and puzzling why health care personnel are so resistant to the adoption of practices that would substantially increase the quality of patient care and, simultaneously reduce costs, both direct (additional hospital expense for treating complications) and indirect (reduced legal expense and insurance premiums). Yet significant evidence of health care workers adhering to their facilities’ respective hygiene protocols is rare. When considering this situation, an outsider might guess that there may be a problem with workflow or access that contributes to poor hygiene. It would be a poor guess. Most hospital facilities are designed in a manner that makes healthy hygiene practices convenient. Most patient care areas include strategically located sinks and antibacterial dispensers. Further, many hospitals also make pocket-sized antibacterials available. In recognition of the number of times that protocols would require washing/decontamination (possibly promoting dermatitis), cleaning products now contain either moisturizers or separate creams and oils are made available. In spite of these actions, U.S. hospital culture ignores the convenience of proper hygiene. Consider the impact that this attitude would have in the event of a bio-terrorism attack or the avian flu pandemic. Hospital administrators traditionally offer arguments that establishing and enforcing strict hygiene protocols would be expensive and time consuming. However, data don’t support this argument. Patients who are infected in hospitals during their regular treatment often receive additional care at the hospital’s expense, creating substantial direct and indirect cost. The expense of additional treatment and prolonged use of hospital resources (beds, food, care, etc.) is far greater than the cost of gloves, disposable garments, and increased labor (for proper cleaning procedures and routines). Health care executives also, typically, fight against efforts to publicize the situation by, for example, opposing efforts to share information on infection rates. One allegation they make is that such rankings are inaccurate because of the different levels of care provided by different facilities. In this case, infection rates are affected by the amount of care given to high-risk patients. The result of the resistance is that only a handful of states have laws that require hospitals to publicize their infection rates. Advocates argue that it is the public’s right to know how well or poorly a facility addresses infections. They also offer the countering argument that prospective patients should definitely be allowed to use infection rates as a basis for choosing a facility. Sources that are capable of providing rankings say that the information would be accurate after making adjustments for the types of patients served by various facilities. Since, when left on their own, health care workers neglect hygiene, it would be a tremendous boost to public health if facilities could be held accountable via publication of infection rate info. Publishing such information would allow consumers to direct their care to facilities with lower rates of infection. In turn, this could put pressure on all facilities to put a priority on cleanliness. Semmelweis Reflex Perhaps the U.S. health care industry still collectively suffers from Semmelweis Reflex. The term refers to any instance where an idea is abruptly or automatically rejected without considering its merits. The reflex is named for Dr. Ignaz Semmelweis, a Hungarian physician, and the way his breakthrough discovery about hygiene was received by the medical community. In the mid-19th century, many European women in hospitals suffered illness and death from puerperal (aka “childbed”) fever. In 1847, Semmelweis discovered a way to attack the problem. He found that, if physicians would wash their hands with a chlorine solution before attending to birth mothers, the disease rate and mortalities would plummet. As it turned out, the fever was spread by an easily prevented infection. It seems that the same doctors who delivered babies did not wash their hands between performing other tasks, including performing autopsies. At the time of Semmelweiss discovery, the healing community had not yet discovered and accepted the germ theory of disease. Semmelweis’s discovery created a great deal of animosity among his peers and it was not accepted. (Ironically, midwives routinely washed their hands before assisting mothers and such deliveries were not complicated by childbed fever.) More than 150 years have passed since the discovery, and no intelligent health care professional would argue about the connections between germs and the spread of disease. Unfortunately, many health pros definitely would argue about the need to correct the situation by increasing their attention to hygiene. Animosity toward a request to wash hands? Yes! In “Unclean Hands: How Patients Can Prevent Blatant Medical Malpractice” (published on Findlaw.com on 06/14/2006), attorney and article author Sherry F. Colb describes a personal incident. It occurred while she and her husband were present as their young child was receiving medical attention. “I asked (the nurse) to please wash her hands before inserting a catheter into my child. Her face was stone as she insisted, ‘I washed my hands before.’ This is, sadly, the sort of response that one expects from a toddler, not a medical professional. I responded, ‘Did you wash them after you saw your last patient?’ At this point in the conversation, the nurse glared at me, ripped off her gloves, dramatically pitched them into the garbage, and stomped out of the room.” Colb remarked that the experience illustrated the lack of proper hygiene as well as the hostility that may result when a patient (or parent) tries to address the issue. So now what? Organizations routinely provide guides and recommendations to health care workers regarding hygiene. Studies have been and continue to be conducted in this area. Data indicate that a higher than average concern with hygiene occurs when that concern is demonstrated by doctors—and then everyone else in the pecking order follows suit, or when there is an increased danger of being infected and health care workers protect themselves more carefully. The former instance is rare and the latter does not help the public since gloves worn as a defensive strategy may be highly contaminated, protecting only the health care worker. As daunting as the thought may be, perhaps we would serve the situation best by sharing our concerns with the health care workers with whom we deal. That’s what we can do on an individual level. But we have much more chance to have an impact as an industry and it is time to address this serious issue. If we discussed hygiene as frequently as we discussed tort reform, perhaps we could get the results we desire without a need to reform anything except health care worker attitudes. Or, there also seems to be another, equally simple strategy that is creating some buzz. It also appears to be effective in reducing medical litigation. The idea is to have doctors quickly acknowledge a problem and, when appropriate, to apologize to the affected persons. (See “Could It Really Be This Easy?” in the November 2005 issue of Rough Notes.) Hmmm, keeping your hands clean, and quickly “coming clean”—ironic how simple things can help prevent complicated problems. * |
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