Hospital infections and malpractice

The February 10, 2009, Washington Post contained an interesting article by the Medical Director of Medicare's quality improvement organization in Tennessee, an Infectious Disease specialist who is also an assistant professor at the Rollins School of Public Health at Emory University.  The doctor recounts in the article his experience with an innovative program to reduce hospital-acquired infections.  He noted that prior to the initiative (which was created by pediatrician Donald Berwick's nonprofit Institute for Healthcare Improvement) for every 1,000 "device days" in his ICU, seven patients would develop bacterial pneumonia, six would develop blood infections (sepsis) and four would develop urinary tract infections.  Together, these infections made ten percent of ICU patients more ill than they were, and they added on average $25,000.00 to the average hospital bill for ICU patients.  Despite the cost and misery of these infections, the doctor considered them unavoidable and a small price to pay for the enhanced likelihood of survival from life-threatening conditions requiring intensive care.

Under Berwick's IHI program, now adopted by about 4,000 hospitals including the author's, a checklist is developed to assure that every patient recieves every known routine advantage.  As the IHI notes, we don't ask airline pilots to memorize their pre-flight checklist; it isn't unreasonable to expect that the same care be exercised by medical professionals.  Under IHI auspices, "ventilator bundles" of routine orders have been devised, along with "UTI bundles" for the urinary tract, and central line bundles.  These bundles require toutine measures such as raising the head of the bed to control migration of gastric secretions, for example; or administering blood thinners to prevent lower extremity clots.

This kind of routine checklist, first devised by Peter Pronovost, an anesthesiologist from Johns Hopkins Hospital, has been one of the preeminent safety developments in medicine.    Pronovost devised an experimental checklist program instituted in Michigan hospital ICUs which reduced bloodstream infections in central venous lines to virtually zero.

In the author's experience, ICU infections were reduced by fifty percent in two years and there was an average per-patient reduction in cost at ICU discharge of 21 percent.  Despite these dramatic results, the author noted some "resistors", primarily autonomous doctors who refused to adapt to the routine, absent firm hospital support of the guidelines and of employees charged with compliance. 

In Michigan, and probably in most other states, it remains very difficult for a patient who suffers an "avoidable" hospital  or "nosocomial" infection to pursue a malpractice claim against the institution or the patient's health care providers.  It is exceedingly difficult for a patient--or her or his survivors--to meet the Michigan Supreme Court's rules regarding proof of causation and identification of fault, even in the context of what are now (prove-ably) avoidable injuries.