Constantly beeping alarms from devices that monitor the vital signs of the critically ill have "desensitized" hospital workers who sometimes ignore the noise, leading to at least two dozen deaths a year on average, a hospital accrediting group said Monday. 

And these cases are probably vastly underreported, said the Joint Commission in an alert to hospitals calling attention to the problem. 

The beeping devices include those that measure blood pressure and heart rate, among other things. Some beep when there's an emergency, and some beep when they're not working. That can lead to noise fatigue and the delay in treating a patient can endanger lives, the accreditation commission says. 

Complicating the situation is the abundance of technology, with no standardization for what the beeps mean, said Dr. Ana McKee, the commission's executive vice president and chief medical officer. 

The commission's estimate of possible deaths related to the problem is considerably lower than the reports it found in a U.S. Food and drug Administration database. The FDA lists more than 500 deaths potentially linked with hospital alarms between January 2005 and June 2010. But that includes mandatory reports of malfunctions and in some cases the connection to a death is only tenuous. 

The commission's own database reports 80 deaths and 13 severe injuries between January 2009 and June 2012. Hospitals voluntarily report these to the commission, which reviews them and in these cases determined there was a clear connection to the device, said McKee. 

There likely are far more problems than have been reported, partly because ignoring or misinterpreting an alarm may have set off a chain of events that led to an injury or death, she explained. But tracing back to that first oversight can be difficult, McKee said. 

Alarm-system events included patient falls, delays in treatment and medication errors that resulted in injury or death, the Joint Commission said. 

The most common factor was "alarm fatigue." But other problems included misinterpreting alarm signals, too few staffers to respond to alarms, and equipment malfunctions. 

"With the proliferation of technology, alarms, and a lack of standardization," it's more challenging for doctors and nurses to respond adequately, McKee said. 

The commission said hospital leaders need to address the problem and train staffers in safe alarm management. 

The organization accredits more than 10,000 U.S. hospital and health care organizations. Hospitals covet accreditation and following commission advice is key to maintaining it. 

McKee said the alert will help raise awareness and lead to hospital changes that may save lives. 

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Fewer patients may be dying in hospitals, but that doesn't necessarily mean they are getting better. More may be dying in hospices or nursing homes or even at home, experts say.

The number of people who died in the hospital has fallen just 8 percent over 10 years, despite a big emphasis on letting people die in hospice or even at home, new federal statistics show.

And a lot of the decrease appears to be from an overall drop in many types of death, the new report from the National Center for Health Statistics shows.

“People don’t want to die in the hospital – yet a lot of them are,” says NCHS’s Margaret Jean Hall, who led the study with colleagues Shaleah Levant and Carol DeFrances.

The study found another trend – deaths in the hospital from sepsis, an overwhelming immune response to infection or injury, rose 17 percent over those 10 years. Other data shows sepsis cases overall more than doubled over that time.

Hall and her colleagues pulled their data from an annual survey done by the Centers for Disease Control and Prevention on nonfederal, noninstitutional, short-stay hospitals and general hospitals.

“The number of inpatient hospital deaths decreased 8 percent from 776,000 in 2000 to 715,000 in 2010,” they wrote in their report. “At the same time, total hospitalizations increased 11 percent, from 31.7 million in 2000 to 35.1 million in 2010.”

People with several conditions were far less likely to die in a hospital , the team found. “Hospital death rates decreased for patients hospitalized for respiratory failure by 35 percent, for pneumonitis due to solids and liquids by 22 percent, for kidney disease by 65 percent, for cancer by 46 percent, for stroke by 27 percent, for pneumonia by 33 percent, and for heart disease by 16 percent,” they wrote.

“We know that overall death rates are down for some of these conditions … for example, the cancer death rate, the stroke death rate,” Hall said in a telephone interview.

“But it doesn’t necessarily mean we are better at getting people well in the hospital. They could just have gone to a post-acute setting like a nursing home…or even home and they could have died soon after,” she added.

It’s well established that hospitals are not necessarily the best place for people who are dying. They are very expensive places to get care, and staff may be less focused on making patients comfortable than on keeping them alive – even if they are ultimately almost certainly going to die soon.

“Sometimes they get care that is more intensive than what they would have requested,” Hall said.

Hospice care aims to keep patients comfortable when it’s clear that their conditions are incurable. Other alternatives to the hospital for patients who may not necessarily be dying include nursing homes, long-term care facilities and home care.

Theresa Forster, vice president for hospice policy at the National Association for Home Care & Hospice, says while an 8 percent reduction in hospital inpatient deaths over 10 years may not be a huge number, it’s at least moving in the right direction.

“This could be the beginning of significant change,” Forster said in a telephone interview. 

“We are getting a whole lot better but we still have a long way to go,” she added. “I think the American public very much desires there to be more discourse around this whole area, and they want to be talking more with their doctors.”

Forster noted that Congress and the federal government have only recently created financial incentives for hospitals to move dying patients to other facilities, as part of efforts to reduce what are called readmission rates – when patients are discharged, and then wind up right back in the hospital a few days or weeks later.

Last month, CDC reported more people are dying at home. The study looked at Medicare patients – a different population of people than Wednesday’s report covers. It found that 33.5 percent of Medicare patients died at home in 2009, compared to 23 percent in 2000.

As for the findings on sepsis, also known as septicemia, Hall says it’s not clear how much of the rise is due to more cases occurring.

"More people are recognizing sepsis," says Dr. Clifford Deutschman of the University of Pennsylvania, a past president of the Society of Critical Care Medicine. Deutschman says hospitals are doing a better job of classifying deaths from sepsis, a still mysterious condition in which the body's immune system gets out of whack, often killing patients in just hours or days.

Hall and colleagues reported in 2011 that both the number and rate of people hospitalized with sepsis more than doubled from 2000 through 2008, from 326,000 in 2000 to 727,000 in 2008. But if deaths only went up 17 percent over a period two years longer, that could indicate that hospitals are doing a good job of saving sepsis patients. Quick recognition and treatment is key, says the Surviving Sepsis Campaign.

Related:

• Fewer Americans die in acute care hospitals
• What you should know about end-of-life care
• New guidelines stress fast treatment for sepsis
• Device speeds ID of sepsis bacteria

Patients can refuse a flu shot. Should doctors and nurses have that right, too? That is the thorny question surfacing as U.S. hospitals increasingly crack down on employees who won't get flu shots, with some workers losing their jobs over their refusal.

"Where does it say that I am no longer a patient if I'm a nurse," wondered Carrie Calhoun, a longtime critical care nurse in suburban Chicago who was fired last month after she refused a flu shot.

Hospitals' get-tougher measures coincide with an earlier-than-usual flu season hitting harder than in recent mild seasons. Flu is widespread in most states, and at least 20 children have died.

Most doctors and nurses do get flu shots. But in the past two months, at least 15 nurses and other hospital staffers in four states have been fired for refusing, and several others have resigned, according to affected workers, hospital authorities and published reports.

In Rhode Island, one of three states with tough penalties behind a mandatory vaccine policy for health care workers, more than 1,000 workers recently signed a petition opposing the policy, according to a labor union that has filed suit to end the regulation.

Why would people whose job is to protect sick patients refuse a flu shot? The reasons vary: allergies to flu vaccine, which are rare; religious objections; and skepticism about whether vaccinating health workers will prevent flu in patients.

Dr. Carolyn Bridges, associate director for adult immunization at the federal Centers for Disease Control and Prevention, says the strongest evidence is from studies in nursing homes, linking flu vaccination among health care workers with fewer patient deaths from all causes.

"We would all like to see stronger data," she said. But other evidence shows flu vaccination "significantly decreases" flu cases, she said. "It should work the same in a health care worker versus somebody out in the community."

Related stories:
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Bioethicist says: Don't be selfish, get the shot

Cancer nurse Joyce Gingerich is among the skeptics and says her decision to avoid the shot is mostly "a personal thing." She's among seven employees at IU Health Goshen Hospital in northern Indiana who were recently fired for refusing flu shots. Gingerich said she gets other vaccinations but thinks it should be a choice. She opposes "the injustice of being forced to put something in my body."

Medical ethicist Art Caplan says health care workers' ethical obligation to protect patients trumps their individual rights.

"If you don't want to do it, you shouldn't work in that environment," said Caplan, medical ethics chief at New York University's Langone Medical Center. "Patients should demand that their health care provider gets flu shots — and they should ask them."

For some people, flu causes only mild symptoms. But it can also lead to pneumonia, and there are thousands of hospitalizations and deaths each year. The number of deaths has varied in recent decades from about 3,000 to 49,000.

A survey by CDC researchers found that in 2011, more than 400 U.S. hospitals required flu vaccinations for their employees and 29 hospitals fired unvaccinated employees.

At Calhoun's hospital, Alexian Brothers Medical Center in Elk Grove Village, Ill., unvaccinated workers granted exemptions must wear masks and tell patients, "I'm wearing the mask for your safety," Calhoun says. She says that's discriminatory and may make patients want to avoid "the dirty nurse" with the mask.

The hospital justified its vaccination policy in an email, citing the CDC's warning that this year's flu outbreak was "expected to be among the worst in a decade" and noted that Illinois has already been hit especially hard. The mandatory vaccine policy "is consistent with our health system's mission to provide the safest environment possible."

The government recommends flu shots for nearly everyone, starting at age 6 months. Vaccination rates among the general public are generally lower than among health care workers.

According to the most recent federal data, about 63 percent of U.S. health care workers had flu shots as of November. That's up from previous years, but the government wants 90 percent coverage of health care workers by 2020.

The highest rate, about 88 percent, was among pharmacists, followed by doctors at 84 percent, and nurses, 82 percent. Fewer than half of nursing assistants and aides are vaccinated, Bridges said.

Some hospitals have achieved 90 percent but many fall short. A government health advisory panel has urged those below 90 percent to consider a mandatory program.

Also, the accreditation body over hospitals requires them to offer flu vaccines to workers, and those failing to do that and improve vaccination rates could lose accreditation.

Starting this year, the government's Centers for Medicare & Medicaid Services is requiring hospitals to report employees' flu vaccination rates as a means to boost the rates, the CDC's Bridges said. Eventually the data will be posted on the agency's "Hospital Compare" website.

Several leading doctor groups support mandatory flu shots for workers. And the American Medical Association in November endorsed mandatory shots for those with direct patient contact in nursing homes; elderly patients are particularly vulnerable to flu-related complications. The American Nurses Association supports mandates if they're adopted at the state level and affect all hospitals, but also says exceptions should be allowed for medical or religious reasons.

Mandates for vaccinating health care workers against other diseases, including measles, mumps and hepatitis, are widely accepted. But some workers have less faith that flu shots work — partly because there are several types of flu virus that often differ each season and manufacturers must reformulate vaccines to try and match the circulating strains.

While not 100 percent effective, this year's vaccine is a good match, the CDC's Bridges said.

Several states have laws or regulations requiring flu vaccination for health care workers but only three — Arkansas, Maine and Rhode Island — spell out penalties for those who refuse, according to Alexandra Stewart, a George Washington University expert in immunization policy and co-author of a study appearing this month in the journal Vaccine.

Rhode Island's regulation, enacted in December, may be the toughest and is being challenged in court by a health workers union. The rule allows exemptions for religious or medical reasons, but requires unvaccinated workers in contact with patients to wear face masks during flu season. Employees who refuse the masks can be fined $100 and may face a complaint or reprimand for unprofessional conduct that could result in losing their professional license.

Some Rhode Island hospitals post signs announcing that workers wearing masks have not received flu shots. Opponents say the masks violate their health privacy.

"We really strongly support the goal of increasing vaccination rates among health care workers and among the population as a whole," but it should be voluntary, said SEIU Healthcare Employees Union spokesman Chas Walker.

Supporters of health care worker mandates note that to protect public health, courts have endorsed forced vaccination laws affecting the general population during disease outbreaks, and have upheld vaccination requirements for schoolchildren.

Cases involving flu vaccine mandates for health workers have had less success. A 2009 New York state regulation mandating health care worker vaccinations for swine flu and seasonal flu was challenged in court but was later rescinded because of a vaccine shortage. And labor unions have challenged individual hospital mandates enacted without collective bargaining; an appeals court upheld that argument in 2007 in a widely cited case involving Virginia Mason Hospital in Seattle.

Calhoun, the Illinois nurse, says she is unsure of her options.

"Most of the hospitals in my area are all implementing these policies," she said. "This conflict could end the career I have dedicated myself to."

__

Online:

R.I. union lawsuit against mandatory vaccines: http://www.seiu1199ne.org/files/2013/01/FluLawsuitRI.pdf

CDC: http://www.cdc.gov

The stress and chaos patients experience in the hospital may make them prone to a new illness -- and landing back in the hospital.

Nearly one in five seniors discharged from the hospital will be re-admitted within 30 days with a completely different ailment from the one that originally landed them in a hospital bed, according to a report published Wednesday in the New England Journal of Medicine.  

The phenomenon has even been given a name: post-hospital syndrome.

The point of the new report “is not to trash hospitals,” says the author Dr. Harlan Krumholz, a cardiologist and a professor of medicine at the Yale School of Medicine. “But, it’s to say maybe we haven’t adequately recognized the potential toxicities that can occur during the course of a hospital stay.”

After a hospital stay, patients are often weak from lack of exercise, sleep deprivation or malnutrition. The first 30 days after discharge “are a transient period when the patient is at great risk and is susceptible to many things,” according to Krumholz, but patients are rarely informed how to take care of themselves.

“I kept watching people come back to the hospital with a variety of different problems,” Krumholz says. “I started thinking about what we might be doing in the hospital that weakened people, making them at greater risk when they went home.”

After scrutinizing Medicare data of almost 12 million people from 2003-2004, Krumholz found that the majority of patients being readmitted to the hospital had a different illness from their original diagnosis. Someone who had been treated for pneumonia might be back in the hospital with an infection, heart failure or wounds from a car accident or fall.

Letha Sandweiss was home from the hospital for barely a week when she fell on her way to the bathroom one night.  She’s back in the hospital once more with a painful cracked rib.

“My legs buckled and I couldn’t get up,” Sandweiss says, from her bed at the Yale-New Haven Hospital. “I lay on the floor for four hours.”

Samdweiss, 80,  was originally hospitalized for an infection and didn’t move around very much while there. She says her muscles felt weaker when she got back home.

Dr. Grace Jenq, an assistant professor of medicine and medical director of inpatient medicine at the hospital, says the nurses try to get patients moving.  “It’s one of the things that doesn’t happen as much as we would like,” she says. “It’s not for lack of trying. The patients are usually pretty ill and a lot don’t want to get up. And when they get home they are very vulnerable for falls.”

Often it’s a matter of focus, Krumholz says.

“We tend to be in battlefield mode fighting the acute cause of admission,” Krumholz says. “And everything else is pushed to the side while we focus on that issue to the potential detriment of the patient’s overall well-being. Sleep, doesn’t matter when we’re dealing with your pneumonia.”

At a minimum, patients need counseling, Krumholz says. They might be warned, for example, that they’ll be a little foggy for the next few weeks, “so don’t drive a car and don’t make any important decisions,” he explains.

Along with that, hospitals need to make a greater effort to respect patients’ sleep schedules and to get them moving as soon as possible so they don’t lose so much muscle tone.

Not everyone agrees with Krumholz's diagnosis. 

While being in the hospital is stressful and can contribute to a delay in recovery, Dr. Mark Williams, a professor and chief of the division of hospital medicine at Northwestern University’s Feinberg School of Medicine acknowledges counters that the study “doesn’t seem to recognize the good that has been done for the patient.”

Still, Williams says, researchers should look for ways to better prepare patients for discharge. “A lot of them need physical therapy and occupational therapy,” he adds. “We need to figure out what is the right amount of support.”

Williams pointed out that the patients in the study were older and may have been the sickest ones.

But, Krumholz believes that his results have a much wider application.

"I think this problem affects everyone who is hospitalized to a variable extent," he says.

Related:

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Health insurance: US pay more, for less

A Medicare payment policy designed to push hospitals to cut their infection rates has had no effect in reducing two types of preventable infections among patients in intensive care units, researchers say in the latest issue of the New England Journal of Medicine.

In 2008, the Centers for Medicare and Medicaid Services began denying additional payments to hospitals whose patients became sicker as a result of bloodstream infections and urinary tract infections associated with the use of central lines or catheters.

Researchers looked to see whether denying additional payments would spur hospitals to cut their infection rates, comparing those infections with a type of pneumonia not targeted by the payment policy.

“The financial penalty did not further reduce infection rates, which were already going down because of multitude of (infection control) campaigns and interventions that were already ongoing,” said the study’s lead author Grace Lee, associate professor, Harvard Pilgrim Health Care Institute and Harvard Medical School.

Infections picked up by hospitalized patients are an area of growing concern. It is estimated that about one in 20 hospitalized patients get an infection, resulting in up to $33 billion in additional costs each year. Efforts to reduce the rate of infections include public reporting requirements and the payment policy in Medicare, which is now being expanded into state Medicaid programs.

Other studies have found the payment policy resulted in increased attention by hospital leaders, sometimes at the expense of other infections not targeted by the policy.

As policy efforts expand, the researchers say “careful evaluation is needed to determine when these programs work … and when they have unintended consequences.” They did give did give some caveats about their findings: The study looked only at patients in the ICU, for example, so it can’t say if infection rates in other parts of hospitals changed. Researchers tracked data reported to the National Healthcare Safety Network by 398 hospitals from January 2006 to March 2011.

Many of those 398 hospitals were voluntarily reporting that data even before the payment policy was implemented, which means they may have been further ahead in their infection control efforts than others, thus resulting in no additional slowdown after the penalties, says Lisa McGiffert of Consumers Union, publisher of Consumer Reports.

She and others say efforts to affect hospital payments and to publish infection rates do work.

“When you start affecting payments and publishing results, it does get the attention of leadership in a hospital,” said McGiffert. “This study shows it’s enormously difficult to connect a singular policy with progress.”

The study is consistent with data from other studies, including one recently completed by the American Hospital Association, said Nancy Foster, vice president for quality and patient safety policy at the association. Those studies have shown an ongoing decline in infections that pre-dated the payment policy.

Still, Foster said a key piece of any effort to reduce hospital infections is not just to count the number of patients who have problems, but to have a specific, detailed prevention strategy. Preliminary results from the association study found a 40 percent reduction in central line-associated bloodstream infections in intensive care units when they used a team-based approach.

“With infections, you need a series of things you’re doing right each and every time. Not just washing hands, although that is important. Not just the right antiseptic, not just the right antibiotic. But all of those things together,” said Foster. “That’s the shift in perspective hospitals have gained.”

CMS spokesman Brian Cook did not address the study results directly, but said the 2010 federal health care law strengthens policies to reduce infections in hospitals.  ”We’re confident that these polices will improve health care quality and reduce costs,” Cook said.

Related stories: 

• Burned-out nurses linked to more infections in patients
• Surviving sepsis: New device speeds ID of dangerous bacteria
• Calif. lab worker who died from meningitis identified

© 2012 This information was reprinted with permission from KHN. Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

By Michael B. Sauter, Alexander E.M. Hess and Lisa A. Nelson
24/7 Wall St.

According to the National Institutes of Health, nearly 50,000 to 100,000 patients die in U.S. hospitals each year as the result of lapses in safety. Recently, the Leapfrog Group, a nonprofit promoting transparency and safety in hospitals, released its first-ever Hospital Safety Score. The study analyzed data from 2,652 hospitals from across the country based on 26 different safety-related measures. Each hospital received a score of A, B or C. Grades for hospitals receiving D and F have not yet been finalized.

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Some states have much safer hospital systems than others. In several states, 40 percent or more of reporting hospitals received the best possible score. In others, not one hospital scored better than a B. Based on Leapfrog’s report, 24/7 Wall St. identified the states with the largest percentage of hospitals receiving an A.

In an interview with 24/7 Wall St., Melissa Danforth, Interim Senior Director of Leapfrog’s Hospital Ratings, explained the importance of the report compared to other national hospital rankings. “The Hospital Safety Score is unique,” according to Danforth, because Leapfrog only considers what puts a patient’s safety at risk, instead of “looking at the reputation of the hospital.” Danforth said, “We’re really looking to, and wanting to draw attention to, things that could happen to you in a hospital that could kill you.”

Danforth explained that hospitals that received an A grade tended to have close to perfect scores for particular safety measures. Incidence of patient falls, trauma, including broken bones or injuries that occur during a patient’s stay, and the likelihood of receiving a central-line associated bloodstream infection (CABSI) -- a dangerous infection that can occur during certain procedures -- are particularly low among the safest hospitals.

Similarly, the states with the highest percentage of hospitals receiving an A performed better on these important measures compared to the national average. For most of the states on this list, incidents of falls, trauma and CABSIs are below the national average. In Massachusetts, one of the states with the safest hospitals, incidence of particularly bad bedsores -- another critical safety measure -- is one-third the national rate.

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States with the healthiest hospitals do not necessarily have healthy populations. In addition to the safety scores provided by Leapfrog, 24/7 Wall St. also considered a variety of health-related metrics from statehealthfacts.org, part of The Henry J. Kaiser Family Foundation. Life expectancy, incidence of cancer and diabetes, and heart disease mortality rates were no better in the states with the safest hospitals than the national average.

These are the states with the safest hospitals.

1. Massachusetts 

•  Hospitals with A grade: 76 percent
•  Number of hospitals with A grade: 47
•  Life expectancy at birth: 80.1 years
•  Cancer death rate per 100,000: 186.6

Massachusetts has one of the healthiest populations in the country. Average life expectancy from birth in the state is 80.1 years, the sixth-highest in the country. The state also has one of the best -- and most expensive -- medical systems in the country. The state’s university system produces some of the most prestigious hospitals in the country. More than three-quarters of the state’s hospitals in Leapfrog’s survey received A grades. Just 20 of the of the state’s 62 reporting hospitals failed to record spotless records for pressure ulcers, and two-thirds had a better-than-average percentage of patients receiving the correct type of antibiotics.

2. Maine

•  Hospitals with A grade: 74 percent
•  Number of hospitals with A grade: 14
•  Life expectancy at birth: 78.68 years
•  Cancer death rate per 100,000: 199.7

Citizens of Maine have lower levels of death as a result of heart disease -- 12 percentage points lower than the national average -- but a higher rate of deaths from cancer than the U.S. average. After surgery, patients in Maine hospitals are less likely to experience breathing difficulties or respiratory failure than they would in the average hospital in the United States. All of the 19 Maine hospitals reporting averaged exceptional scores in hand hygiene and care for patients on ventilators. Only three of the state’s 19 graded hospitals received a C.

3. Vermont

•  Hospitals with A grade: 50 percent
•  Number of hospitals with A grade: 3
•  Life expectancy at birth: 79.7 years
•  Cancer death rate per 100,000: 179.7

Though only six Vermont hospitals reported information to Leapfrog, three of these earned A grades. Brattleboro Memorial Hospital received above-average ratings for all Surgical Care Improvement Project (SCIP) measures. The hospital also recorded perfect scores in preventing complications related to air embolisms and pressure ulcers. Southwestern Vermont Medical Center and Central Vermont Medical Center similarly recorded a strong performance, with each receiving above-average SCIP ratings. The quality of medical care in the state may well have major benefits for its residents as heart diseases resulted in just 138 deaths per 100,000 people, far less than the nationwide average of 186.5 deaths.

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4. Illinois

•  Hospitals with A grade: 48 percent
•  Number of hospitals with A grade: 51
•  Life expectancy at birth: 78.76 years
•  Cancer death rate per 100,000: 191.3

Leapfrog surveyed 106 Illinois hospitals. While nearly half received an A grade, the reviewed state hospitals actually performed worse than the national average on many of the key safety metrics, including the frequency of central-line associated bloodstream infections. However, in many other measures Illinois hospitals performed well, including having a low average of the number of deaths from treatable medical complications after surgery. However, many of the state’s 51 hospitals that received an A scored much better than the national average in preventable deaths and ulcers. 

5. Tennessee

•  Hospitals with A grade: 48 percent
•  Number of hospitals with A grade: 31
•  Life expectancy at birth: 76.2 years
•  Cancer death rate per 100,000: 206

With higher rates of cancer death and infant mortality than any other state on this list, as well a lower life expectancy, Tennessee needs hospitals that are both good and safe. Fortunately, 48 percent of the state’s hospitals receive A grades from Leapfrog, while only about 33 percent of hospitals receive C grades. For all of Leapfrog’s safe practice measures, Tennessee’s hospitals receive above-average score. One hospital performing especially well is Vanderbilt University Hospital, which received high scores for its surgery-related antibiotic regimens, as well as for its handling of urinary catheters and prevention of blood clots following surgery.

Click here to read the rest of 24/7 Wall St.'s The States with the Safest Hospitals