Too many lessons in Tragedy
By Thom Wellington
This first appeared in the August 2016 issue of DOTmed HealthCare Business News
For the last four months, I have spotlighted different ideas in this column on how to reduce costly health care-acquired infections (HAIs). Each column began with statistics outlining the cost of HAIs both in lives and in dollars and how legislation is focusing on quality outcomes. In this column, rather than rehashing those facts, I am going to focus on the real-life stories. These are disastrous outcomes related to HAIs that will make you cringe. Keep in mind the purpose is to spotlight the real need to educate hospital teams and outside vendors on the importance of working safely and how small mistakes can cause tragedy. Names have been changed, but the legal case is researchable.
When 2-year-old Lauren, who suffered from acute lymphoblastic leukemia, was finally in remission, her treatments were successful and she was in the hospital for routine follow-up diagnosis. Her room was along the same route that construction workers were taking for a project they were working on in the same hospital. The dust they created from moving equipment and supplies down her hallway had a dangerous but common fungus hitching a ride on the dust: Aspergillus spp. Even in remission, Lauren’s condition was immuno-compromised due to the successful aggressive medical treatment. The fungus invaded her system and within two weeks she died. To make matters worse for the hospital, Lauren was not the only patient who died due to the Aspergillus spp. Five other children located along the same route died due to the common mold fungus.
While two of the children were in remission from leukemia, the pathology report stated Aspergillus was the cause of their deaths, not leukemia. All this ended up in a courtroom with grieving parents stunned by an outcome few could comprehend. Children that so bravely fought through painful leukemia treatments and won, now dead from fungi brought in by construction crews. According to a study in the American Journal of Infection Control, just one colony-forming unit of Aspergillus can cause infection in immuno-compromised patients. Shouldn’t the hospital have known this can happen? And if it didn’t, how would the contractors know?
Aspergillus is not even on the list of the most common types of HAIs. Even more common HAIs include bloodstream infection, ventilator-associated pneumonia, urinary tract infection and surgical site infection. Most of these are nosocomial infections caused by equipment or people that already have some type of medical training, such as nurses, aides or even doctors. Infections can also be spread by maintenance and construction workers who roam the facility on a daily basis.
To compound the problem, most facilities are operating with minimal in-house maintenance technicians and more work is being outsourced to specialty contractors. Manufacturers of specialized equipment used in hospitals often require their own technicians to perform maintenance. For instance, no-touch automatic door openers require maintenance by the manufacturer. All this adds up to more people working in the hospital with no medical training and no idea of how their work can cause problems for patients. The table on this page points out quantitative examples of how routine maintenance or construction work can cause infections and even lead to death.
Two years ago I gave a presentation on HAIs to the maintenance department at a large metropolitan medical complex. I explained how bacteria and fungi hitch a ride on migrating dust and how its migration can affect patients with low immune tolerance conditions. We discussed simple things like vibrations from drilling, opening ceiling tiles and cutting into drywall. Afterward, a few of the maintenance attendees mentioned they had been working in the hospital for more than a decade and no one ever took the time to explain how their work could cause an HAI.
My father died due to an infection. His routine operation turned into a more complicated one when his arm swelled due to an IV insertion. Rather than getting back to work as planned, he returned to the hospital where they opened the infected wound the entire length of his forearm. Complications continued to develop and he was alive for only six more days. This is a case where an accident occurred under the direction of medically trained personnel. It happens and it impacts families.
About the author: Thom Wellington is the CEO and a stockholder in Infection Control University, a company that provides staff training programs and control processes for infectious microorganisms in hospitals, clinics, long-term care facilities and other health care-related institutions.
By Thom Wellington
“This first appeared in the August 2016 issue of DOTmed HealthCare Business News”