Wednesday, April 10, 2013

Hospitals are Hazardous to Your Health! (Part 3)

Dirty hospital rooms a top concern for Canadians
One-third of respondents to CBC survey say patient room, bathroom not clean
By Kazi Stastna,
CBC News
Posted: Apr 9, 2013
Barbara Martin recalls her distress the day she walked into a Kelowna, B.C., hospital to learn her 72-year-old mother had been left lying in bed sheets soiled with feces overnight.
Visit the CBC News home page on Wednesday, April 10, to see how your local hospital fared in the first-ever Canada-wide hospital report card and watch a special report on the fifth estate this Friday
"They couldn't keep up with the amount of time she had to go to the washroom [so] she'd have an accident," said Martin, who lives in Angus, Ont., and travelled to B.C. with her husband last fall to take care of her mother. "I came in one morning, and she'd been sitting in it all night long. She had called for help, and it just didn't come."
Martin's story is disturbingly similar to many of the 3,500 submissions to an online survey about patient experiences done by the fifth estate as part of Rate My Hospital, a sweeping week-long series on the state of Canada's hospitals.
Nearly a third of respondents, who included patients, health-care workers and relatives and friends of patients, said hospital rooms and bathrooms were not kept clean.
Stories shared by respondents from across the country described soiled bathrooms, patients left lying in their own waste and pleas to seemingly harried nurses that went unanswered.
A nurse's world Where stress is status quo
Karl Rinas, 61, who was treated for a bleeding ulcer at a Leamington, Ont., hospital last February, says he ended up wiping down the bathroom himself after his complaints about the dried liquid waste he found on the floor and toilet seat failed to get a reaction, but he worried about older, less mobile patients.
"If I was a little sicker, I would have walked through that slop," he said. "I wouldn't have wiped the seats off. I would have been in the goo, and that's what's so sad."
Patients, relatives doing cleanup
Martin says she, too, brought her own sanitizing wipes to the hospital where her mother, who suffers from Lou Gehrig's disease, was being treated after she discovered urine on the floor and the toilet seat. She said she always cleaned the bathroom before her mother used it, changed her mother's soiled bed sheet after a request for new sheets went unheeded and gave her mother sponge baths because she found showers were infrequent.
Despite all her efforts, Martin says she has no doubt that the antibiotic-resistant superbug Clostridium difficile infection her mother contracted soon after surgery was related to the hospital's level of cleanliness.
Surfaces such as door handles, bed rails and nurse call buttons are common sites of bacteria transmission. (Bernice Kim/CBC)
"I know everybody nowadays has to work more with less, but to me, a hospital should be absolutely clean," she said.
Of the respondents who wrote into the fifth estate's survey about being harmed in hospital, most said the harm was a hospital-acquired infection such as MRSA and C. difficile.
MRSA develops on the skin and is transmitted through skin to skin contact with an infected person or a surface they've touched. C. difficile is spread via surfaces or skin that have come in contact with feces infected with the bacteria.
About one in 10 patients admitted to hospital in Canada contract hospital-acquired infections, and between 8,000 and 12,000 die from them each year.
No federal tracking of infectionsCanada doesn't track infections federally, and provinces vary in which infections they require hospitals to report.
The Canadian Nosocomial Infection Surveillance Program is the closest thing to a federal overview that Canada has, but it relies on voluntary reporting by only 54 hospitals in 10 provinces, most of them teaching facilities, which, according to infection control experts, generally have higher infection rates than other acute care hospitals because they tend to see more seriously ill patients.
A World Health Organization report that compared Canada's infection data with that of 12 other wealthy countries found that Canada had the second-highest prevalence (11.6 per cent) of hospital-acquired infections after New Zealand — much higher than that of Germany (3.6 per cent) or France (4.4 per cent).
C. difficile infections, in particular, which generally afflict patients who are already vulnerable and are fatal in about five to 10 per cent of cases, have been on the rise not just in Canada but in the U.K. and the U.S. as well.
In the last 10 years, there have been several high-profile outbreaks of the superbug in hospitals in Quebec, British Columbia and Ontario that resulted in patient deaths. Those three provinces continue to have the highest prevalence of C. difficile.
Is outsourcing to blame?
Those who work in hospitals have pointed to the increased outsourcing of housekeeping in recent
years as one reason behind the decline in hospital cleanliness that patients and hospital workers have observed.
"There's no question there's been an impact on the quality of cleaning, and you can see that throughout the years as various hospitals have struggled with very high-profile superbug outbreaks," said Margi Blamey, spokesperson for the Hospital Employees' Union (HEU), which represents 41,000 hospital cleaning and support staff in B.C.
Hospital cleaners in Canada are a mix of public sector workers who work for the hospital or health authority and private contractors. Some say outsourcing of cleaning services has led to fewer cleaners and lower standards.
(Bernice Kim/CBC)
A decade ago, B.C. passed legislation that allowed hospitals to outsource previously unionized cleaning and food service jobs to large multinationals like Aramark and Sodexo. The move that has been replicated by hospitals in other provinces.
But health authorities in other countries are moving away from private cleaning services. Four years ago, Scotland reversed its decision to allow outsourcing of cleaning and catering services because it felt private contractors were not doing a good enough job keeping the spread of infections in check.
Blamey says as long as housekeeping is done on a for-profit basis, employers will reduce the number of staff and cut corners on staff training and cleaning supplies.
"Keeping a hospital clean is contingent on the number of people doing that job, so when you cut that down, you have to make choices on what areas get cleaned [and] how often they get cleaned," Blamey said.
Unlike in the food industry, there are no standardized inspections for cleanliness in hospitals.
B.C. instituted housekeeping audits to verify whether hospitals meet industry cleaning standards, but they have not proven a very accurate measure because they rely heavily on a visual assessment.
The Nanaimo Regional Hospital on Vancouver Island and Burnaby Hospital in Metro Vancouver both exceeded the industry benchmark in their audits in years when the hospitals had fatal C. difficile outbreaks with infection rates three to four times the Canadian average. A BC Centre for Disease Control investigation found that during a 2008 outbreak, the Nanaimo hospital had insufficient numbers of cleaning staff to meet its basic daily needs.
Source of infection hard to pin down
Michael Gardam, who oversees infection prevention and control at the three hospitals that are part of Toronto's University Health Network, agrees that hospitals have fewer resources for housekeeping these days and have to concentrate cleaning on areas that are most likely to transmit bacteria — primarily the surfaces that multiple patients touch.
"I probably get more emails about dust bunnies in the stairwells than anything else in the hospital, and yet, we've done that for a reason. You're not going to catch anything from a stairwell, but you're going to catch it from your bed rails," Gardam said.
A more humane hospital
While cleanliness was a major cause for concern for those who answered the fifth estate patient survey, many respondents also talked about feeling alienated by the hospital system and getting the brush-off when they tried to raise issues of concern with staff.
Most respondents said they sympathized with nurses and doctors who seemed rushed and overworked but wished these professionals would communicate more openly and sympathetically with patients and family members.
"She lost her quality of life in hospital," wrote one respondent about her 91-year-old mother, who was blind and who died in a Kingston, Ont., hospital. "I think she lost her dignity as well because everyone talked about her but not with her."
Many people said they left the hospital feeling demoralized and disillusioned with the health-care system.
"We wait hours to be seen with no explanation why," wrote a survey respondent from Fergus, Ont. "The entire emergency room staff desperately needs training on how to work with people. I always leave angry and wishing we had just stayed home instead."
"We also don't care that much about the floor, because it's less likely you're going to pick something up off the floor than you're going to pick something up off your bed rails or your bedside table or your bedside telephone or your call bell."
About two-thirds of hospital-acquired infections are preventable, Gardam said, but making a direct link between cleanliness and infection is not as straightforward as it might seem.
Some hospital-acquired infections such as ventilator-associated pneumonia or central line-associated bloodstream infections have little to do with the hospital environment and can be controlled through proper protocols around equipment use. But a superbug like C. difficile is a lot trickier because it is hard to pinpoint its source.
"If you're a patient sitting in a bed, and that bed hasn't been cleaned properly, and you pick up C. difficile, and you eat your lunch, and you swallow C. difficile and get colonized, how am I going to say you got it that route versus me not washing my hands and coming in and checking your blood pressure?"
Ontario hospitals' rate of compliance with handwashing protocols for health-care workers has risen dramatically in recent years but has not brought about a commensurate decrease in infections, says Gardam. That might indicate that hospitals need to focus on the other means of reducing the spread of infection such as patient handwashing, the use of private rooms and keeping occupancy below a hospital's full capacity.
Increasing cleaning staff on nights and weekends could also help. A typical medium-sized B.C. hospital that contracts out cleaning services has 24 cleaners by day but only four at night, says Blamey, and workers are often not backfilled when ill or on vacation.
"Bacteria don't care what time it is," said Gardam.
The infection expert says it doesn’t matter whether a private or public entity oversees cleaning; both have had problems with cleanliness. The bottom line is that hospitals generally undervalue the importance of cleaning staff, Gardam said.
"People don't really think of them as part of the team, but if you think about how infections are spread in hospitals, they're actually an incredibly important part of the team that goes far beyond just the cosmetic appearance of the room."
10 hospitals rated best in CBC national report
5 provinces represented in top tier of 1st national hospital performance report card
CBC's the fifth estate has awarded 10 hospitals across the country top grades as part of a Canadian national hospital performance report card.
A range of facilities in small towns and urban centres from across the country achieved an overall grade of A+ necessary to make the top hospital list, which is part of Rate My Hospital, a sweeping investigation into Canada's hospitals by CBC-TV's the fifth estate.
Hospitals in Alberta, New Brunswick, Manitoba, Ontario and Saskatchewan are represented in the top 10 in the CBC's rating of acute-care facilities based on patient outcome data.
CBC based its assessment on data collected from hospitals by the Canadian Institute of Health Information (CIHI), a publicly funded, non-profit organization that gathers and analyzes data on Canadian hospital performance. A five-member expert panel advised CBC on the selection and use of the data.
Data used by the CBC included rates of patients who died after major surgeries, who were readmitted after treatment and who experienced unexpected complications, known as adverse events, tied to nursing care during a hospital stay.
4 of 10 top hospitals in Alberta
Four of the 66 hospitals rated in the large-community category achieved A+: Sturgeon Community Hospital, a 143-bed facility just north of Edmonton; Chaleur Regional Hospital in Bathurst, N.B.; and two Winnipeg hospitals, Grace Hospital and Victoria General Hospital.
Only one hospital reached the top rung in the medium-sized community hospital category: Perth and Smiths Falls District Hospital, named for the small eastern Ontario towns in which the two sites of the 82 acute-care bed facility are based.
Alberta dominated the small-hospital category with three facilities: Lamont Health Care Centre northeast of Edmonton; Covenant Health Banff Mineral Springs Hospital, a 22-bed facility in the mountain town of Banff; and High River General Hospital, a 27-bed hospital in a small community south of Calgary.
Of the 25 hospitals in the teaching category, two facilities ranked in the top tier: the 70-bed St. Joseph's Health Care London in London, Ont., and the Saskatoon City Hospital, a 137-bed facility in Saskatchewan's largest city.
An A+ grade means that data reported by the hospital shows its patient outcomes in the areas measured are substantially better than a typical hospital of the same size; a B means they are similar; a C that they are lower and a D that they are substantially lower than a typical hospital of the same size.
The majority of hospitals — 140 in total — received B grades. Twenty hospitals got A's while 34 received a C rating.
Only eight hospitals had the lowest grade of D. They were:
Vancouver Hospital and Health Sciences Centre, Vancouver (teaching hospital).
Burnaby Hospital, Burnaby, B.C. (large community hospital).
Surrey Memorial Hospital, Surrey, B.C. (large community hospital).
Ridge Meadows Hospital and Health Care Centre, Maple Ridge, B.C. (medium community hospital).
Northern Lights Regional Health Centre, Fort McMurray, Alta. (medium community hospital).
Yorkton Regional Health Centre, Yorkton, Sask. (medium community hospital).
Bonnyville Healthcare Centre, Bonnyville, Alta. (small community hospital).
Daysland Health Centre, Daysland, Alta. (small community hospital).

Ratings aim to spark debate
Canadians can find out how their local hospital fared in the CBC ratings by visiting their hospital's profile page on the Rate My Hospital website.
Hundreds of hospitals couldn't be rated because the necessary data wasn't publicly available.
CBC’s the fifth estate tried to get additional data about individual hospitals from the Canadian Institute for Health Information, provincial health ministries and hospitals. However, many hospital leaders and most provincial governments opposed their efforts.
Documents obtained through requests to provincial freedom of information offices show that health ministries from across Canada agreed to block the release of previously unpublished data by CIHI.
They also agreed to ask hospitals in each province not to fill out a specially developed survey the fifth estate sent to the CEOs of more than 600 hospitals in January.
The survey asked about initiatives the hospitals are taking to improve safety and care, such as how often staff wash their hands, how much care is provided by registered nurses and whether cots are provided for people who want to stay with a sick relative or friend overnight.
But in many cases, hospitals and health officials ignored the pan-Canadian decision. The Ontario Hospital Association agreed to a request from the fifth estate to encourage Ontario hospitals to consider completing the survey. CEOs for 132 facilities, most of them in Ontario, responded.
Prince Edward Island, New Brunswick and Nunavut also bucked the Canadian trend and released some of the previously unpublished information the fifth estate requested.
About 630 acute-care hospitals have a profile page on CBC's Rate My Hospital website, which features a variety of hospital-specific data — from parking costs to the rates of hospital-acquired superbug infections.
Extensive details about hospitals were gathered from provincial ministries and health authorities and from a first-of-its-kind survey sent directly to hospital CEOs.
The website also features the first Canada-wide hospital ratings tool for patients. On each hospital's page, patients can score the facility on four key aspects — cleanliness, friendliness, timeliness and communication — plus give an overall recommendation.
The Rate My Hospital project aims to arm Canadians with hard-to-find, hospital-specific information and seeks to prompt broad discussion about the country's quality of health care.
Though many hospitals in Canada provide at least some of the information on their own websites, unlike other countries, Canada does not have a centralized, user-friendly way for patients to review the type of care individual hospitals provide.
"I would love to be able to check up on a hospital or medical professionals' record before hiring them," said Don Osbourn, whose wife died in hospital after contracting a C. difficile infection following routine surgery and who spoke to the fifth estate.
"I mean, you get references to a mechanic, a restaurant, and those things don't matter the way the hospital matters. And more importantly, I think if everybody had to show their cards, so to speak, I think it would up their game."
Hospital reports around the world
For nearly a quarter of a century, there have been efforts around the world to evaluate and compare hospital performance.
In the United Kingdom, where the public health-care system has been undergoing reforms and a push
for transparency in recent years, the government publishes NHS Choices, a central clearinghouse of hospital information that allows users to access data on hospitals and enables patients to rank them.
One of the leaders in hospital performance measurement is the U.K. company Dr Foster Intelligence, which published its first hospital guide evaluating patient outcomes in 2001 and continues to put out annual guides.
The London-based company works with the U.K. Department of Health to help hospitals develop tools for collecting and analyzing information on the quality of care and has also worked with hospitals in the Netherlands.
More than two decades ago, the U.S. News and World Report magazine launched a set of annual "Best Hospitals" rankings that have expanded over the years to include more than 5,000 hospitals and 16 medical specialties.
In 2001, the U.S. Leapfrog Group started a hospital survey that now allows users to compare data for about 1,600 hospitals. A hospital comparison website is also run by the U.S. Centers for Medicare and Medicaid Services.
Ireland's Rate My Hospital website, run by a medical publishing company, ranks public and private hospitals in the country based on user reviews.
Public rankings drive change
Hospital report cards can be controversial because of the variety of methodologies and data used and the lack of a standardized approach.
But if done well, they can "focus hospitals' and clinicians' attention on important quality of care issues that need improvement," says Jack Tu, a cardiologist at the Schulich Heart Centre at Sunnybrook Hospital in Toronto. Tu was a member of the expert panel that advised CBC on the Rate My Hospital project.
"Every hospital wants to do well on these reports, and so by making this information public, it can help to galvanize hospital administrators and clinicians into making the necessary system changes to improve their performance," Tu said.
Research to date suggests that patients don't generally use report cards to choose a hospital, said Tu.
"But I think this may change over time as the quality of information in report cards improves and the public becomes more aware of this information," he said.
However, research has shown that health-care providers make efforts to improve when performance information is displayed publicly, said Barbara Rudolph, a senior scientist at the Center for Health Systems Research and Analysis at the University of Wisconsin-Madison who was a member of the CBC project's expert panel.
"The best hospitals will acknowledge that there is much to do, even when they have made big strides," said Rudolph, who has helped to develop U.S. hospital report cards.
The key to making the best use of hospital report cards is to recognize their shortcomings but still learn from them, says fellow panelist Alex Bottle, a senior lecturer in medical statistics in the School of Public Health at Imperial College London who devised the statistical methodology for tracking patient outcomes used by Dr Foster Intelligence.
"Even noisy data and imprecise indicators can make a real difference if people acknowledge that they're flawed but that they may contain important signals among the noise," he said.

Surgery's Dirty Secrets | BBC Medical Documentary
Also See:
Hospitals are Hazardous to Your Health!
(Part 1)
10 September 2010
(Part 2)
21 December 2011