MRSA infections in hospitals - who bears the responsibility?

Following from the previous post, I was wondering who actually bears the financial burden of an MRSA infection... or any other hospital acquired infection?

If we consider SGH (not picking on poor SGH, but simply 'cos there are stats available for me to play with), in 2008, the MRSA rate was 0.6/1000 patient days. Since SGH clocked about 440,000 patient days in 2008, there were 0.6x440 MRSA infections..... about 260 MRSA infections in that year alone. In absolute terms, that's quite a significant number. Now, for each of these 260 patients who picked up an MRSA infection while in hospital, there are increased bed stay charges, expensive antibiotics etc. Since the infection was caused by the hospital, shouldn't the cost of managing the MRSA be borne by the hospital and not the patient....?

MRSA infection rates in Singapore hospitals

TODAY newspaper published a nice article on the efforts made by hospitals to control MRSA infections. The overall infection rates (over 6 public hospitals) have fallen from from 0.4/1000 patient days in 2007 to 0.3/1000 in 2009. Whoohoo...!!

errrmmmm....

Need to look at this in a bit more detail....

Here are the figures across 6 hospitals (2007-2009):

Year 2007 2008 2009

Overall: 0.4 0.4 0.3

AH 0.2 0.3 0.2

NUH 0.4 0.3 0.1

TTSH 0.5 0.5 0.3

CGH 0.2 0.3 0.2

KKWCH 0.1 0.1 0.1

SGH 0.6 0.6 0.4

Seems like not a clear pattern here. Yes, 3 hospitals showed a drop especially between 2008 and 2009. But a couple of hospitals had numbers bouncing around. And it is unclear if the overall improvement was heavily biased by NUH's spectacular drop in 2009. (I am actually quite appalled that our SGH is the dirtiest....

Actually part of the problem looking at these numbers is the lack of clarity in the definitions used in the collection of data. An earlier report by Straits Times had pointed this out, i.e. if the bug is on the skin when patient is admitted, and an infection occurs, it is not counted as an infection....

I looked at a MOH report by Dr Helen Goh in 2007. She had then defined the rate as being based on the CDC-NNIS methodology:

"The National Nosocomial Infections Surveillance (NNIS) system defines a nosocomial infection as a localized or systemic condition that a) results from adverse reaction to the presence of an infectious agent(s) or its toxin(s) and b) was not present or incubating at the time of admission to the hospital. For most bacterial nosocomial infections, this means that the infection usually becomes evident 48 hours (i.e., the typical incubation period) or more after admission5. The diagnosis of nosocomial infection is thus a combination of clinical findings and results of laboratory and other tests."

Assuming the definitions haven't changed and are consistent across all hospitals (of which I am doubful) ....... we should be able to splice her data with TODAY's info:

Year 2002 2003 2004 2005 2006 2007 2008 2009

Overall: 0.6 0.5 0.5 0.5 0.5 0.4 0.4 0.3

AH 0.3 0.3 0.3 0.2 0.3 0.2 0.3 0.2

NUH 0.8 0.8 0.9 0.8 0.7 0.4 0.3 0.1

TTSH 0.6 0.6 0.6 0.6 0.5 0.5 0.5 0.3

CGH 0.1 0.1 0.1 0.1 0.1 0.2 0.3 0.2

KKWCH 0.1 0.03 0.1 0.1 0.1 0.1 0.1 0.1

SGH 1.0 0.9 0.7 0.8 0.7 0.6 0.6 0.4

Yes, overall the improvement is to be applauded. SGH still looks incredibly filthy. KKWCH looks too good to be true, and CGH actually getting worse.

Hospital errors - more action needed

Salma Khalik of the Straits Times picks up the thread again today on hospital errors in a report entitled "Make hospital and docs more accountable". Well done.

I had posted a comment on this previously.

The restructured hospitals have generally done well in making their systems and procedures more accountable. But not necessarily more transparent. Much of the accountability, unfortunately, appear to have been put in place only for accreditation purposes.

The vogue at the moment is to seek accreditation with the US based Joint Commission International (JCI). In this accreditation exercise, reduction of hospital errors is one of the parameters assessed. It therefore became important that the hospitals have systems in place to deal with hospital errors. Or at least have the semblance of being able to deal with errors. But do the hospitals really want to know? If they really want to know they must have in place s system not just for reporting, but one also to audit the reporting, and not just expect to randomly uncover cases of non-reporting.

What do hospitals and the MOH do with these numbers? Do they really want to know the true incidences of errors? Just because there are reporting processes in place, and we can crank out statistics of some sort, shouldn't lull us into thinking that risks of hospital errors have been adequately mitigated.

Anecdotally, I know of cases of obvious practice errors, that go unreported. Recently, a wife of a friend of mine had to be wheeled back into theatre because of an error committed during surgery. I am quite certain the incident was not reported.

Reporting systems need to be audited, and the audit findings made public. Otherwise it will remain a sham. So should it be for hospital reporting - be it for surgical errors, medication errors or nocosomial infections.

Condolences to Richard Stanley's family - question for Mt Elizabeth - was this an avoidable hospital infection??

DBS CEO Richard Stanley passed away yesterday. My heartfelt condolences to his family. It's never ever easy to lose someone, a loved one, at the prime of his life, and in such a sudden unexpected manner.

Unexpected? Yeah... though he had leukemia, the disease for a large part can be managed reasonably well. He didn't die of the leukemia .... it should be recognized that he died of an unexpected hospital infection.

Acute Myelogenous Leukemia (Wikipedia)
Acute Myelogenous Leukemia (Leukemia-net.org)

In sharing in the family's grief, we must not neglect to ask the crucially important question .... one that the family in their moment of grief may be too 'pai seh' to ask...:

Was this death avoidable?

True, he had leukemia. And it's true that at this stage of the disease, he was prone to infections.... but was the infection really unavoidable? We had discussed hospital infections recently, and we had people protesting that hospitals have been doing all they could to control the problem, but Mt Elizabeth Hospital had been rather quiet.

So my question to Mt Elizabeth is this .... "Have you done all you could in reducing the risk of hospital infections...especially in a situation like this when the patient is ultra-susceptible to infections?"

It's a bit like in superclean Singapore, where we have a reputation of being able to eat off the pavements .... suddenly finding out that our famous food courts are little more than cess pits.
Quite malu, lah.

Hospital infections

Not so long ago a friend of mine, an active young lady who tore her meniscus during some games was operated on in one of our major hospitals. What started as a simple surgical procedure, turned out to be a painfully distressing, protracted and expensive journey because she picked up a septic arthritis following the operation. What was worst for her was the callous way the hospital shrugged off the incident as part of the risks of surgery.

Really? Should it be part of the accepted risks of surgery?

I was bemused by the letter that appeared in today's Straits Times from Drs Lee and Hsu from the Society of Infectious Diseases, Singapore vigorously defending the hospitals' efforts in this direction. I was curious about the society because I didn't know of it's existence, so I looked them up online. (BTW, The SID ought to know that their website hasn't been updated since 2007). The membership of the SID really comprises the Infectious Disease consultants I know in the hospitals. :)

Anyway, I am glad they responded. They are right of course in pointing out that Denmark took 10 years and UK took 4 years. They are also right in that we can't expect to turn this around overnight.

My question to SID is: So why are we waiting? We were aware of this problem 10 years ago. When did we actually make this 'commendable start', and this 'move to share data and knowledge'? How do we actually share data when we are tip toeing around hospital sensitivities about who is doing better and who's worse, and case-mix ratios and what not?

Can we move a bit faster please, and take some definitive concrete action? We don't really want to wait another 10 years to actually start.

Hospital infections - the saga continues

I am glad that following Salma Khalik's report that there have been a flurry of hospital and MOH responses appearing in today's Straits Times. If nothing else it would appear that they have taken cognizance of the groundswell of public concern.

It would appear that some sort of 'awareness' had arisen at their level back in 2007, and that there were some (albeit kinda half-hearted) attempts then to deal with the problem. That was back then. Hopefully this display of public angst may provoke them to adopt more concrete and enduring solutions.

So far, they seem only to be playing with numbers. Sure, there is a problem with definitions. But to sit back and wring their hands for 2 years knowing the stats are not meaningful because of a non-harmonised approach towards data collection smacks of a fairly large dose of a 'boh chap' attitude. I mean, if you are really interested in the data, it doesn't take too much effort to standardize the definition regardless of the limitations. And why not provide the public with a tracking of this problem over the years? Don't just tell us the comparisons between the worst year and the best. Don't fudge by playing with the denominator to make the numbers look miniscule (per patient days? errmmm...why not per patient seconds?). Is the situation really getting better as every hospital seem to suggest? If really so we shouldn't need to worry and these discussions would be totally unnecessary. But I suspect not, so give us the real news.

The MOH provides weekly stats of the reporting of of all kinds of infectious diseases. Why can't the MOH tell us the yearly-hospital incidences and let us judge for ourselves if the situation is really under control, and which hospital is really biting the bullet where this is concerned?

Hospital (nosocomial) infections - an 'invisible' disease

Salma Khalik, Health Correspondent for the Straits Times had a good write up today (pg 2 ST) on stamping out hospital infections. Her comments resonated with what I had posted earlier, and points the finger at bottom line issues affecting the hospitals. She suggested an interesting solution. Make the hospitals liable for hospital (nosocomial) infections. She's right, of course. They should be. Why should patients have to pay extra if hospitals are responsible for infections inflicted upon the patients. It's like asking patients to pay for the extra surgery required if surgeons botch up their routine surgery (oooops...that happens too doesn't it?). Problem is hospitals will just pass on the costs of litigation, and of insurance back to the patients. And then up go health care costs.

This really underlies the difficulty in implementing solutions which we all know are required. Hospitals don't want to track nosocomial infections and don't really want to know about it no matter what they profess. And MOH also doesn't really want to track the problem, nor seriously deal with it. Ministry of Health needs to keep health care costs down, or else pay the political price.

It's all lip service at the moment, because the numbers are still manageable. Many patients are not even aware they have picked up nosocomial infections, or that their hospital costs are high because they needed that expensive special antibiotic, or that extra long stay to deal with an unnecessary superinfection by a resistant bug. It is really one of several 'invisible diseases'....ailments that doctors pretend not to see, and for which patients willy nilly accept as part of their hospital experience. And pay for it. What choice do they have?

So as long as patients happily pay the cost of their superinfections, its really "hush everyone...don't tell anyone the problem exists".

Ultimately it is a problem that Ministry and hospitals have to take responsibility for. No doubt health care costs will go up because of it, but someone has to pay for it...and someone other than the patient who was really an innocent victim of dirty facilities.

Scrubbing out the superbug? Yeah...sure....

Today's Straits Times also carried a report entitled "Scrubbing out the superbug". It's no easy task, and we are dealing with a smart bug (Staphylococcus aureus) that's able to develop resistance as fast as we are able to produce drugs against it.

The problem is set to get worse, with no real end in sight. I am not so hopeful it can be scrubbed out.

Reading the report I was particularly struck by the apparent reality that we actually know what needs to be done, and yet mysteriously are not able to do what needs to be done to "scrub out" this bug. NUH says it wants to have more MRSA (methicillin resistant Staphylococcus aureus)-free wards but are constrained by a "tight bed situation". Good hand hygiene of health care providers is paramount, yet compliance is low, and there is no process in place to check compliance. Doctors drape stethoscopes around their necks like ornaments to be brought to public areas. NUH's Prof Tambyah says MRSA infections should be notifiable. But it is not.

It struck as me as odd that hospitals 'try' to tackle this community problem at their level while keeping a half-cocked eye on their bottom lines. The Ministry of Health knows what needs to be done, yet seems to by pussyfooting around with 'guidelines' to the hospitals they 'regulate' - guidelines which nobody reads and nobody enforces. It seems to me more than a bit odd.... a bit like asking Jurong Town Corporation to 'regulate' worker's safety in the factories of their tenants. I was wondering of MOH's apparent softness arise from this 'conflict of interest'.

Perhaps it is time for an external regulator to be overseeing this process. Control of infectious diseases (not only this superbug, but others that affect the community such as SARS and the dreaded and anticipated avain flu) should perhaps be delegated to an authority external and independent of the Ministry of Health. Perhaps then we can see hard decisions being taken without being affected by bottom line issues.

It's a question of our national health and safety.

See other conflicts of interest posts:
http://gigomole.blogspot.com/2009/01/regulatory-oversight-health-sciences.html
http://gigomole.blogspot.com/2009/01/regulatory-oversight-any-conflict-of.html
http://gigomole.blogspot.com/2008/12/future-of-regulatory-oversight-in_20.html
http://gigomole.blogspot.com/2008/12/future-of-regulatory-oversight-in.html