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(Announcer)
Major funding for Second Opinion is provided by the Blue Cross and Blue Shield Association, an association of independent, locally owned and community-based Blue Cross/Blue Shield plans, committed to better knowledge for healthier lives. Additional funding provided by...
{background music}
(Dr. Peter Salgo)
Welcome to Second Opinion, where each week our health care team solves a real medical mystery. When we close this file in a half an hour from now, you'll not only know the outcome of this case, you'll be better able to take charge of your own health care and doctors will be able to listen to patients more effectively. I'm your host, Dr. Peter Salgo, and you've already met our special guests who are joining our primary care physician, Dr. Lisa Harris. No one on this team knows this case, and we're going to get right to it. Let me tell you a little bit about Donald. Donald is 65 years old, he's been married for 34 years, he and his wife are avid ballroom dancers, and most of their social life revolves around ballroom dancing. But, Donald's right knee has become increasingly painful due to a disabling, degenerative joint disease, so he recently had elective knee replacement. We meet Donald right now in his primary care doctor's office. It's six weeks after his knee replacement and he's come in with the chief complaint of knee pain and, significantly I think, he says it doesn't feel that it's from the surgery; it feels different. Lisa, what are you going to do? He's in your office.
(Lisa)
I'm really going to try to get a better handle on what he means by 'it's different'. What's the quality of the pain? What's the character of the pain? What makes it worse? What makes it different? What's been going on?
(Peter)
I can tell you that his doctor does a physical exam and I can tell you it shows a red, tender, inflamed knee but no evidence of a wound infection - no evidence of pus or anything from the actual incision line - so the doctor decided to get some tests. What tests would you have run, by the way?
(Lisa)
A CBC, a SED rate, and a CRP.
(Peter)
Okay. The actual numbers - his SED rate is up, that's his erythrocyte sedimentation rate, his white blood cell count is up, his CRP is up, and they did take his temperature and he does not have a fever. Lisa, what does that mean to you?
(Lisa)
Well, I'm worried that he has some sort of infection going on. His white count is up and he doesn't have anything else going on anywhere else in his body.
(Peter)
Donald, I can tell you, was sent to the hospital with a presumed infection and specifically an infected prosthesis - his artificial knee was infected. They did an aspiration culture that came back positive for MRSA. What exactly is MRSA?
(Betsy McCaughey, Ph.D.)
MRSA stands for methicillin resistant staphylococcus aureus. It's a drug-resistant form of the bacterial infection staph, and we've seen a rapid increase in drug resistance in the last 30 years. In 1974, only about two percent of staph infections were drug resistant; by 1995, 22 percent, and now almost 70 percent, about eight percent of all hospital infections right now in the US are MRSA.
(Peter)
How do these bacteria, all bacteria - and we hear about this all the time on the news today, the super bugs, resistant bacteria. How do they become resistant to antibiotics?
(Dr. Ed Walsh)
They become resistant by use of antibiotics; in other words, in nature organisms have to replicate. By administering antibiotics, they can replicate in an environment where the only survival will be by becoming resistant.
(Peter)
So, if I understand you, there are bacteria of all sorts out there; some are resistant to antibiotics. You give me antibiotics, you kill off all the killable ones, and what are left are the nasty ones.
(Kathy Kastan)
It's more related than to the amount of usage of antibiotics that we've have over the past few decades.
(Ed)
Overuse of antibiotics for patients with simple viral infections, for instance, is a major problem.
(Dr. Peter Salgo)
So we're giving folks antibiotics, some of them don't need them. How does somebody then catch one of these resistant bugs? How do you do that?
(John)
Usually, it's from a healthcare worker is the most common cause, and in the hospital. And that's usually associated with not washing their hands or having bacteria on equipment that the patient would be exposed to.
(Peter)
I thought I heard you say 'not washing your hands'.
(Dr. John Onate)
Or not washing properly.
(Peter)
Are you telling me that doctors, healthcare workers, hospital workers in the hospital, going from patient to patient don't wash their hands?
(Lisa)
People don't wash their hands.
(John)
Yeah
(Betsy)
I think it's really important to underscore that these drug-resistant bugs are everywhere and they're carried on people's skin, but in a hospital the situation changes because in the hospital patients have a urinary tract catheter, an IV, a ventilator, a surgical incision, so suddenly there are ways for these very deadly drug-resistant bugs to get inside your body and that's when you get an infection. That's why unclean hands, inadequately cleaned equipment, contaminated clothing on healthcare workers makes such a difference because those are the vectors that carry these nasty bugs to the patient and allow them to get inside the patient's body.
(Peter)
Jeanine, does this sound at all familiar to you?
(Jeanine Thomas)
Yes it does.
(Peter)
Why?
(Jeanine)
Because I got a surgical site infection during surgery.
(Peter)
Tell me about it.
(Jeanine)
I had broken my ankle; the skin was not broken. I went in and had hardware put in...
(Dr. Peter Salgo)
They put a plate on your ankle.
(Jeanine)
Yes, they put a plate and two screws. I was in the hospital for two days and I came home and in two days I had terrible pain. I didn't have a fever and because there was a splint on it, I couldn't see it. I called my surgeon; he said, 'Either the cast is too tight or you have an infection' and I went in and both the incisions were black. It was hugely swollen and pus coming out of it; it was the most horrible thing I've ever seen.
(Peter)
And they cultured that pus?
(Jeanine)
Yes they did.
(Peter)
And they grew what?
(Jeanine)
MRSA.
(Peter)
So you're a MRSA victim, if you will. The bugs got to you, however they got to you, they did.
(Jeanine Thomas)
Yes.
(Peter)
Let's go over this again because I think the common view of a hospital is that it's a shining sterile white tower somewhere where everything's clean and doctors are all washing their hands. What is the environment in a hospital like day to day? Is it really this Ben Casey type of place or is it different?
(Ed)
Well, hospitals are very crowded and very busy; very intensive places these days. Patients stay for half the time they used to stay; the throughput is high and the intensity of care is very high. Patients move in and out of rooms frequently, go to the OR, have procedures, and then very quickly exit the hospital and another one takes their place. This puts a lot of pressure on the hospital systems.
(Peter)
Let me just state something that's so obvious that people may lose sight of it: hospitals are for sick people. That's where people go when they have infections, so far from being sterile, isn't it full of infectious material?
(Jeanine)
It's a toxic waste dump.
(Betsy McCaughey, Ph.D.)
I think that's so well put, and there's been much too little emphasis on hygiene in hospitals. For example, Boston University researchers examined 49 operating rooms in four New England hospitals and found that over half the surfaces in the operating room that are supposed to be disinfected were left untouched by the cleaners. A follow-up study of 1100 patient rooms all the way from Washington, DC to Boston found that once again, over half the surfaces in patient rooms that are supposed to be cleaned when one patient is discharged and another patient is placed in the room were untouched by the cleaners. The bed rails, the call buttons, the telephones, and the faucets - the toilet seats were actually much cleaner than the faucets.
(Peter)
I don't want to go there, and with the exception of toxic waste dump, how much of this is something you agree with? Or maybe you do agree with toxic waste dump?
(Dr. John Onate)
Well, I think the issue is - the acuity is much higher now.
(Dr. Peter Salgo)
What does that mean?
(John)
People are more ill and the - how ill they have to be in order to be admitted is much more intense than it has been in the past. That puts a pressure where you have people more susceptible to illness.
(Betsy)
As a bypass survivor who was in the hospital for a week...
(Peter)
Bypass surgery?
(Kathy)
Yes, and in the intensive care unit and the whole thing, and then obviously as a patient advocate, I think it's just so scary to listen to what you're telling us.
(Lisa)
But toxic waste dump, I don't think it's any more toxic than the restaurant we ate at last night or the day before or breakfast.
(Jeanine)
Well, it is if you have a surgical wound...
(Lisa)
But I'm saying this is a comment on society; people do not wash their hands and that includes healthcare workers.
(Peter)
But let's get some numbers on the table over here. How big a problem, how common, hospital acquired infections? Is it getting worse? Is it getting better? Is it staying the same? Do we have any data on this? I bet you do.
(Betsy)
Well, the Centers for Disease Control and Prevention claims that two million patients contract infections in hospitals in the US each year, but in fact, the truth is several times that number, and this is why. The CDC is relying on a six-year old number from a sliver of data. We know from a survey that was done by the Association for Professionals in Infection Control in 2007 that 2.4% of hospital patients acquired hospital-acquired MRSA while they're in the hospital. That means 880,000 patients a year, and we know that MRSA infections are about eight percent of all hospital infections so we can see that quite a few million patients contract these infections each year.
(Peter)
Are hospital-acquired infections going up in the United States, staying stable, or going down? Do we know this?
(Betsy)
We know that they're going up, and more importantly, that the danger is worsening because increasingly, the infections cannot be cured with commonly used antibiotics. It's the drug-resistant nature of them that makes them more dangerous than in the past.
(Peter)
So, what are the most common sites in a hospital for hospital-acquired infections? Do we know this?
(Ed)
Sure. It's related to surgical procedures - certain ones, much more than others, but it's also related to the intensity of care. So for instance, your risk of an infection is going to be to a large extent how sick you are when you come in, or how sick you become say, after a procedure.
(Kathy Kastan)
And this is all about washing our hands?
(Ed)
No, it's not as simple as that.
(Lisa)
It's like taking that Ben Casey analogy that was thrown out earlier. You would come in, lay in this nice little bed with these clean sheets and you didn't have anything invasive done to you. Now you might get your blood drawn two or three times in a day; you might have a catheter placed - there are more invasive things that are done to you.
(Dr. Ed Walsh)
You know, we are seeing far more infections, as you pointed out, because of the things we're doing to patients.
(Betsy)
I would accept that rationale if there weren't compelling evidence that 90 percent of these infections are preventable through rigorous attention to hygiene and proper procedures, but we have so many examples now. At the University of Pittsburgh, Presbyterian reduced MRSA infections 90 percent in the intensive care units. So it's not that the patients are sicker; there's been inattention to hygiene.
(Peter)
Is it fair to say - we've got what? Two million cases or more?
(Betsy McCaughey, Ph.D.)
More.
(Dr. Peter Salgo)
Is it fair to say that they're getting more cases per year or fewer?
(Betsy)
More.
(Peter)
And is it fair to say that patients are getting harmed by hospital-acquired infections?
(Betsy)
Yes.
(Peter)
What is the leading cause of death in hospitals today? Is it infection?
(John)
I'd say its infection.
(Peter)
Is that fair?
(Ed)
I don't think it is infection; I don't know the statistics. I think...
{Multiple voices speaking simultaneously}
(Betsy)
Let's put it in perspective. It's the fourth leading cause of death in the United States anywhere, right after...
(Peter)
Before you say that, you mean hospital-acquired infection?
(Betsy)
Hospital-acquired infection is number four, after heart disease, cancer and stroke.
(Peter)
So the question again: Hospitals - leading cause of death? We're not sure it's infections or we are?
(Ed)
I'm not sure, but what we can agree on is a major problem that something needs to be done, and about which, if we do certain things, we can reduce it.
(Dr. Peter Salgo)
Major problem - I think we can all agree on the word 'major'.
(Ed)
Yes.
(Peter)
It may be the last thing we agree on for the next five minutes, so let me stop and sum some of these things up. Of all the illnesses in hospitals, infections are among the most common cause - is that fair? - Among the most common cause of deaths; infections are now recognized as a major cause of sickness and death in hospitalized patients. Are we all happy with this? Nobody's jumping out of their seat.
(Kathy)
No.
(Peter)
What's the no?
(Kathy)
Because I'm not happy with that. I think patients should be protected; they go into hospitals....
(Peter)
I didn't mean happy with the death. I meant happy with the statement.
(Kathy)
What you were saying was fine; I'm still thinking about all these people going into hospitals thinking they're going to get well.
(Peter)
Let's get back to Donald, shall we? Because Donald - remember Donald? He came into the hospital with a hot knee. He has MRSA. What are you going to do?
(John)
A lot of it will depend on the resistance, the culture results from the type of MRSA he has, and his health, of course.
(Lisa)
He can do a localized removal of infected tissue. You may want to take his surgical hardware out, you might just want to give him IV antibiotics and observe what his course is - there are, there's a wide variety of options.
(Peter)
So let me tell you, Donald is treated with four weeks of intravenous antibiotics in the hospital. Let's have a show of hands; did that work?
(Ed)
No, that's not going to work, nor would I recommend that.
(Dr. Peter Salgo)
Want to know what happened? It didn't work. You guys have been reading your crystal balls just right. He had four weeks of antibiotics, the infection was still there, so they went in and they operated. In this case, they decided to take out the hardware because they decided that while the hardware was there where the bacteria were living, they would never be able to eradicate the bacteria. They put something called 'spacers' in, which I'm assuming is a surgical deal that takes the space which was previously occupied by the artificial knee to keep the anatomy sort of straightened out, and then their plan was to continue antibiotics, get him infection free for six months, and then try to replace the knee again. So Janine, how was your MRSA treatment? Does it sound like his?
(Jeanine Thomas)
I had in a total of two months seven surgeries to save my leg from amputation. They couldn't stabilize it and I was on Vancomycin IV almost a month in the hospital, but I went septic. I had sepsis.
(Peter)
That means it went into your blood.
(Jeanine)
Yes. It went into my bloodstream so I was very sick for a long time. My leg, I went home on oral antibiotics for six months in bed, and my leg did heal.
(Peter)
At this point, Donald knows he's got MRSA, he knows he needs surgery, he's had his prosthesis removed, he's got spacers in his leg, they're continuing his antibiotic therapy. You work with people with terrible infections that are difficult to treat; what is life like for Donald right now?
(John)
It's a big effect on the quality of his life. Before this, he was a ballroom dancer and he was - it sounds like he was fairly independent. If he's not able to have the knee replacement done or if he becomes disabled because of that, then it could become a major impact on his quality of life.
(Lisa)
And that's terrifying. I'm sure he's wondering, 'If I got this in the hospital, what are you going to give me now?'
(Betsy)
Right. What am I going to get - ((VRE)), C-Diff, pseudomonas, or...
(Peter)
Because they're all nasty bugs.
(Betsy McCaughey, Ph.D.)
All nasty bugs that are in the hospital, and so often we see patients who contract one, and then they get so many their body is literally ravaged by these infections.
(Kathy)
How do you learn to trust after an experience like this?
(Peter)
What choice does he have, I guess is the question.
(Jeanine)
You have no choice.
(Lisa)
Well, do you go back to the restaurant that gave you salmonella, gastroenteritis after that?
(Kathy)
Well, do you get another doctor? You don't know where he got it from, though.
(Lisa)
No, you don't know.
(Peter)
Donald has another question too, which I'm sure I'll ask to our MDs over here. I've got MRSA. You told me it's resistant. I got antibiotics for four weeks; it's still there, though I'm sure you took the hardware out. How on earth are you going to get rid of this thing? I've got a drug-resistant bacterium; now you're giving me a drug. How's that going to work?
(Ed)
Well, in a patient like this, generally speaking, once the prosthetic devices are removed, we can be successful in eradicating the infection from the knee. Not in every case, but in the vast majority we can.
(Dr. Peter Salgo)
Is it possible in the United States, with our hospitals, to get the infection rate down close to where it should be, which should be zero?
(Ed)
I would still argue this is such a complex issue that you really have many points of attack beyond simply screening the hand washing.
(Lisa)
So yes, we should stress and emphasize hand washing. I don't know that it's preventable. You can reduce the risk, but I don't know if we can absolutely eradicate it.
(Peter)
Do we all start with hand washing? Unless we do that, nothing else works as well?
(Lisa)
And educating the public. If there's a sign outside the room, put your gloves on.
(Jeanine)
You need screening, surveillance, isolation and strict adherence to hand hygiene and environmental cleaning. I think you need all of those.
(Kathy Kastan)
I agree with what you're all saying and I think that's something too that has to be done.
(Peter)
Let me see if I can sum this all up, clearly with the caveat that everybody wants to reduce the reducible risk as low as possible, however you do it. Let's talk about hand washing for a minute. Hand washing by hospital staff, patients, and visitors is effective; it's a very effective way to prevent hospital-acquired infections. Screening, environmental cleaning - great, but unless you do the hand washing, they're going to be less effective than they otherwise would have been. Can we agree on that?
(Multiple voices)
Yes.
(Dr. John Onate)
I think one thing this dialogue is showing is that there's a perception from the patient's view where they want as little risk as possible going into the hospital. We certainly would not want people to not go to the hospital for a necessary procedure or severe illness because of a perceived risk that may not, may be disjointed or inflated.
(Peter)
Is there something the hospital could have done so this didn't have to happen to Donald, who after all, just wanted his knee fixed?
(Betsy)
Well, research shows that cleaning and screening are effective in substantially reducing these MRSA post-operative wound infections by as much as 90 percent.
(Peter)
So let's stop and examine that. Hand washing - how many doctors, in terms of percent, wash their hands between patients regularly and routinely? We've got numbers on this somewhere, I know.
(Dr. Lisa Harris)
The data is around 30 to 40 percent.
(Peter)
Let me just stop; 30 percent? That means 70 percent of doctors, nurses, hospital staff are not washing their hands. You know, everything you need to know about infectious disease, you might have learned in first grade.
(Ed)
You know, you might be overstating the point there.
(Peter)
Okay.
(Ed)
Now, there is proper hand washing and then there is washing hands. I think the 30 percent would refer to what we would consider most proper hand washing.
(Betsy)
That's not enough, though. Even when doctors and nurses do clean their hands, their hands become re-contaminated seconds after they clean them because of poor environmental cleaning in the hospital. Their hands become re-contaminated the moment they reach up and pull the privacy curtain, open the drawer, touch the keyboard, touch the patient's bedrail, so these bugs are picked up on the caregiver's hands even if they've just washed and gloved.
(Dr. Peter Salgo)
So, in order to make that work, if I understand you correctly, you've got to clean your hands on the way in, on the way out, clean the beds, clean the curtains, clean the computers, clean the floors, clean the ceiling, clean the walls, and clean the food carts, and then go back and do it again. Is that practical?
(Kathy)
And with all these people coming in and out.
(Dr. Ed Walsh)
It's not simple; it's very complex. It involves hundreds of people and it's really a systematic approach that has to be taken in the entire institution.
(Peter)
Now let me ask you a question, which may not be fair to Donald; is there anything Donald could have done, had he known, to reduce his risk of catching a bug or a hospital-acquired infection?
(Betsy)
He could certainly make sure that he asks every caregiver who comes in to see him if they could clean their hands before touching him, and you know, we're all worried about being too aggressive, but just remember your life could be at stake. Certainly, he could've talked to the surgeon before the day of surgery about being tested for MRSA, he could've asked the doctor about keeping him warm during surgery - for many kinds of surgery, patients who are kept warm resist infection better. He could've made sure they didn't shave his leg before the surgery, right? That's one of the mistakes that's still made at some hospitals. He could've made sure he got his prophylactic antibiotic an hour before the first incision. He could've begged them not to give him a urinary tract catheter; there are many things he could do.
(Peter)
Okay, let me tell you about Donald a little bit. His medical team tried several different treatments, including different types of antibiotics, different lengths of treatments. A year after the removal of his prosthesis, he is still waiting to be well enough to have his knee replaced. John, what's he going through right now?
(John)
It depends on how stable his knee is with the spacers and what his level of function is.
(Peter)
He came in to get the knee so he could dance; he's not dancing right now.
(John)
That's right.
(Peter)
What's his mental status like? Is he depressed?
(John)
It's possible, and certainly the more medical illnesses you are, the higher at risk you are for depression. It depends on his hospital course; if he was severely ill at death's door, he may have some post-traumatic symptoms.
(Lisa)
That's why it's vital you get a team approach and hopefully you have a social worker or a psychotherapist involved once you've gotten past a week's worth of hospitalization because it's possible that he may have lost his job, that his benefits may have expired, that he now is applying for Medicaid or Medicare or whatever other type of stop-gap insurance, that now the surgeon that did the surgery may not be able to provide the surgery for him anymore. Absolutely he should be on an anti-depressant.
(Peter)
You had your ankle done and you describe some horrific course. What is it like and what are you like right now?
(Jeanine)
Well, I stopped treatment so - I went through treatment...psychological treatment.
(Peter)
Psychological treatment.
(Jeanine)
Yes, because I knew I was depressed, I was clinically depressed and I couldn't get myself out of it. I'd never been depressed before. I was angry, I had anxiety - I had to be on anxiety medication when I was really sick - and I think it's a long process. I had nightmares and flashbacks of my near-death experience. You know you can wake up any day with another infection.
(Dr. Peter Salgo)
Well, let me sum up a little bit of what we've been talking about up to this point. While the burden of decreasing the number of infection cases lies, predominantly, with the healthcare system, patients can also take steps to protect themselves. Fair enough? We can agree on that? All right.
At this point, you've taken a bad experience and you've tried to turn it into a positive one. What have you been doing?
(Jeanine Thomas)
Yes. I was the first advocate, consumer advocate in the US and the
Hospital Report Card Act passed in Illinois. I became an advocate on that, a consumer representative on the advisory board, and I started ringing the alarm in 2003. I got my state health department involved, the hospital association, and a lot of other groups too.
(Peter)
You've been busy.
(Jeanine)
Yes, and now federal legislation.
(Peter)
Where do you find the time?
(Jeanine)
Well, I'm dedicated because I don't want anybody to do through what I went through; it's preventable, and that's why I do the work I do.
(Peter)
Well, thank you so much for being here. It's refreshing to hear somebody launch into a problem like that and make some progress. Thank you so much for being here. Thank you all - tremendous discussion.
Let's just sum up here, shall we? Of all illness, infections are among the most common cause of death in US hospitals. Hospital-acquired infections are now recognized as a major cause of sickness and death. Hand washing by hospital staff, patients and visitors is an effective way to prevent hospital-acquired infections. Screening and environmental cleaning are very important, but they are less effective without proper hand washing. While the burden of decreasing the number of hospital infection cases lies with the health care system, patients can also take steps to protect themselves. Remember your mother was right: Wash your hands. Our final message is this: Being in charge of your health means being informed and having honest communication with your doctor. I'm Dr. Peter Salgo and I'll see you next time, for another 'Second Opinion'.
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Search for health information and learn more about doctor-patient communication on the Second Opinion website. The address is pbs.org.
(Announcer)
Major funding for Second Opinion is provided by the Blue Cross and Blue Shield Association, an association of independent, locally owned and community-based Blue Cross/Blue Shield plans, committed to better knowledge for healthier lives. Additional funding provided by...
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