http://www.consumerreports.org/cro/magazine/2012/08/how-safe-is-your-hospital/index.htm

Our new Ratings find that some are riskier than others

Consumer Reports magazine: August 2012

What we foundWhat we found | Deadly infectionsDeadly infections | ReadmissionsReadmissions | Unclear instructionsUnclear instructions | Radiation overloadRadiation overload | What needs to happenWhat needs to happen | Hospital safety: Highest and lowest scoresHospital safety: Highest and lowest scores | Why some hospitals succeedWhy some hospitals succeed | When bad things happenWhen bad things happen | Hospitals respondHospitals respond

Patrick Roth of Dartmouth, Mass., can’t walk unassisted because of surgical complications.

Hospitals should be places you go to get better, but too often the opposite happens.

Infections, surgical mistakes, and other medical harm contribute to the deaths of 180,000 hospital patients a year, according to projections based on a 2010 report from the Department of Health and Human Services. Another 1.4 million are seriously hurt by their hospital care. And those figures apply only to Medicare patients. What happens to other people is less clear because most hospital errors go unreported and hospitals report on only a fraction of things that can go wrong.

“There is an epidemic of health-care harm,” says Rosemary Gibson, a patient-safety advocate and author. More than 2.25 million Americans will probably die from medical harm in this decade, she says. “That’s like wiping out the entire populations of North Dakota, Rhode Island, and Vermont. It’s a man-made disaster.”

Related Topics

• Hospital Ratings
• Your hospital survival guide

Some hospitals have responded to the crisis with safety initiatives such as electronic prescribing to help prevent drug errors and checklists to prevent infections, with some success. Rates of central-line bloodstream infections, for example, have dropped by 32 percent since 2008, according to the national Centers for Disease Control and Prevention.

But more needs to be done. “Hospitals haven’t given safety the attention it deserves,” says Peter Pronovost, M.D., senior vice president for patient safety and quality at Johns Hopkins Medicine in Baltimore. Nor has the government, he says. “Medical harm is probably one of the three leading causes of death in the U.S., but the government doesn’t adequately track it as it does deaths from automobiles, plane crashes, and cancer. It’s appalling.”

That lack of information not only makes it difficult to define the extent of the problem but also makes it challenging for patients to know about the safety of the hospitals in their communities.

To address that problem, Consumer Reports has for the first time rated hospitals for safety, using the most current data available to us at the time of our analysis. It includes information from government and independent sources on 1,159 hospitals in 44 states. For this article, we also interviewed patients, physicians, hospital administrators, and safety experts; reviewed medical literature; and looked at hospital inspections and investigations.

‘Medical harm is probably one of the three leading causes of death.’ — Peter Pronovost, M.D.

Still, our Ratings include only 18 percent of U.S. hospitals because data on patient harm still isn’t reported fully or consistently nationwide. “Hospitals that volunteer safety information, regardless of their score, deserve credit, since the first step in safety is accountability,” says John Santa, M.D., director of the Consumer Reports Health Ratings Center. “But the fact that consumers can’t get a full picture of most hospitals in the U.S. underscores the need for more public reporting.”

Despite that limitation, our safety Ratings provide a unique way to compare hospitals in your community. And they yield important insights into the state of hospital safety nationwide—and what you need to do to protect yourself, or someone you care for, when entering a hospital.

Get hospital safety Ratings

 

Click on the map at right to find Ratings of hospitals nationwide (available to subscribers). The Ratings include those hospitals for which we have a safety score, as well as some information on performance for more than 3,000 other hospitals.

What we found

We focus on six categories in our safety Ratings: infections, readmissions, communication, CT scanning, complications, and mortality. (Read more about how we rate hospitals.)

Some experts question those measures. Readmission rates, for example, might be higher among hospitals that care for patients with little home or community support, says David M. Shahian, M.D., professor of surgery at Harvard Medical School and associate medical director at the Center for Quality and Safety at Massachusetts General Hospital in Boston. But our Ratings are “based on the best data we have about what happens to patients in hospitals,” Santa says.

Even the highest-scoring hospital in our safety Ratings got just a 72 on our 100-point scale.

Here are some of the most important findings from our analysis:

• Bad things happen in all hospitals, but they happen a lot in some. The lowest-­scoring hospital, Sacred Heart Hospital in Chicago, earned just a 16 on our 100-point safety scale and reported a rate of bloodstream ­infections that was more than twice the national benchmark. The hospital declined to comment.
• Even high-scoring hospitals can do better. Billings Clinic in Montana was at the top of our list—but it got a safety score of just 72. “The work is hard,” says Mark Rumans, M.D., the hospital’s physician-in-chief. “We are far from perfect.”
• Some well-known hospitals have less-than-outstanding safety scores. That includes Massachusetts General Hospital, Boston, with a safety score of 45; Ronald Reagan UCLA Medical Center, Los Angeles, 43; Cleveland Clinic, 39; New York-Presbyterian, New York, 32; and Mount Sinai Medical Center, New York, 30.
• Our Ratings are an important measure, but they’re not the only source you should consult. They don’t, for example, assess how successful hospitals are at treating medical conditions. So before a planned hospital stay, consult multiple sources, such as Hospital Compare, run by the federal government, and the Leapfrog Group, an independent organization that tracks hospital safety and quality. Some of the data we use come from those sources.

Deadly infections

Despite worsening back pain, Patrick Roth of Dartmouth, Mass., loved to ride his bicycle. But that was before back surgery in 2007 at age 65. The procedure was followed by several complications, including an infection with a potentially deadly bacterium. Roth says he didn’t understand he had the infection until he transferred to a new hospital. Now he rides a mobility scooter instead of a bike and is learning to live with the side effects of daily antibiotics, he says.

About one in 20 hospitalized patients will develop an infection. They can be devastating, deadly even, and many can be prevented. Dirty instruments, improperly sterilized catheters or needles, and the contaminated hands of doctors, nurses, or other health-care workers are common causes.

We rate hospitals on infections that develop after surgery, those caused by central-line catheters in intensive-care units, or both. The catheters are IVs that deliver drugs and nutrients but can also introduce serious infections into the bloodstream. Some states require that hospitals report data for one or both types of infections. And some hospitals volunteer central-line data to Leapfrog.

About one in 20 hospitalized patients will develop an infection.

An estimated 290,000 surgical-site infections occur each year in U.S. hospitals, and Roth’s is an example of the agony they can cause. A few days after his surgery Roth was in so much pain he had to return to the hospital. He was there for 12 days, most of which he can’t remember because of the pain medication he was given. (Roth was initially treated at Carney Hospital in Boston. We don’t have data for the period he was hospitalized. But the hospital received a 61 in our current safety score and top marks for avoiding infections.)

Roth’s wife, Barbara, says he was hallucinating and “would scream for 2 to 3 hours at a time.” A CT scan taken several months later showed that a screw from his surgery had broken, but Roth says his doctors don’t want him to risk another operation. He can no longer walk unassisted. “The pain becomes too intense,” he says. And to this day the Roths have not received “even an acknowledgment or an apology for what he went through,” Barbara Roth says. The hospital said it could not comment on a specific patient.

Only 544 of the hospitals in our Ratings have data for surgical-site infections, from 14 states that require their public reporting. Of those hospitals, 82 reported zero such infections.

Infections linked to central-line catheters may be even more worrisome. They kill up to 16,250 patients a year, research suggests. They’re also almost entirely preventable. Yet 202 hospitals reported infections at rates higher than the benchmark used by the CDC, and only 148 reported zero infections.

“Central-line infections are the canary in the coal mine for patient safety,” says Pronovost at Johns Hopkins Medicine. In one study, 60 percent of hospitals that used an infection-prevention checklist he developed eliminated all central-­line infections in their intensive-care units for at least a year. And follow-up research shows that those hospitals saw a 10 percent drop in their overall death rates.

“Any hospital should be able to get to zero bloodstream infections, or close to it,” Pronovost says. And a hospital that does well in preventing those infections “has something good going on.” On the other hand, he says, be concerned about hospitals that do poorly in that measure.

Johns Hopkins Hospital had less than half the rate of infections of the national benchmark. But we couldn’t rate it for safety because Maryland hospitals don’t participate in the standard Medicare payment system that’s also used to collect data for some of the measures in our Ratings.

What you can do

Ask whether the hospital uses a checklist of best practices for inserting and maintaining central lines and how you or someone caring for you can help monitor those lines. In addition:

•  Make sure that all staff and visitors wash their hands before touching you.

•  Ask every day whether any catheters or other tubes can be removed.

• Before surgery ask whether you’re prone to infection because of a chronic disease, such as diabetes. Smoking increases infection risk, so take steps to kick the habit.”

• Ask whether shaving your surgical site is necessary. Nicks can grant bacteria entry.

• Heartburn drugs called proton pump inhibitors increase the risk of intestinal infections and pneumonia. If you’re taking one, ask whether you should stop.

•  Make sure you understand instructions for caring for your wound. If you notice redness and pain at the surgery site or if you develop a fever, call your doctor.

 

Readmissions

Having to return to the hospital soon after going home can be a sign that something went wrong during the initial stay, such as an infection that worsens after you get home. And the more often you enter a hospital, the greater the chance something else will go wrong. Research suggests that up to three-quarters of readmissions may be preventable.

No hospital got top scores for readmissions or communication.

Our readmissions rating is based on data from the Centers for Medicare and Medicaid Services, which tracks patients hospitalized for heart attack, heart failure, and pneumonia who are readmitted to a hospital within 30 days of being discharged.

No hospital earned our highest score for readmissions; 166 hospitals received our lowest score.

What you can do

Usually the sooner you get home the better. But you shouldn’t be discharged if you feel disoriented, faint, or unsteady; have pain that’s not controlled by oral drugs; can’t go to the bathroom alone; have trouble urinating or moving your bowels; or can’t keep food or drink down. In addition, follow these steps:

 

• See a discharge planner well in advance of your departure to arrange for services or supplies you’ll need at home.

 

• Get a written summary of what to do when you get home, including drugs you need, how to care for wounds, how active you can be, and when you can shower, drive, return to work, and eat normally.

 

• Get results of tests done while in the hospital and ask what tests you’ll need after you leave and when you’ll need them.

 

• See your primary-care doctor within 10 days of going home.

 

Unclear instructions

Clear communication in the hospital is hard to come by: Almost 500 hospitals earned our lowest score for communication about new medications and discharge plans, and none earned our top score.

That’s a problem because drug errors in hospitals are common and sometimes serious, and poor discharge planning can lead to readmissions.

The scores are based on questions answered by millions of discharged patients in a federally mandated survey.

What you can do

Take notes during your discharge planning if you can, and bring a friend or relative to serve as an extra set of ears. To prevent confusion about your medication, follow these steps:

 

• Keep a list of all your prescription and over-the-counter medications, including dietary supplements and vitamins.

 

• If you don’t understand why you are taking certain drugs, or how to take them, ask again until you do.

 

• Learn about the potential side effects and what should you do if you have one.

 

Radiation overload

CT scans can provide essential diagnostic information. But they pose risks, too. Radiation from CT scans—which are equivalent to between 100 and 500 chest X-rays—might contribute to an estimated 29,000 future cancers a year, a 2009 study suggests.

Our Ratings report the percentage of chest and abdominal CT scans that are ordered twice for the same patient, once with contrast and once without. Probably less than 1 percent of patients undergoing chest CT scans should get double scans, says James Brink, M.D., chairman of the department of diagnostic radiology at Yale University School of Medicine. Double scans of the abdomen are needed more frequently, often to define abnormalities in the liver, kidney, and pancreas, he says.

But only 28 percent of the hospitals in our Ratings had double-scan rates of 5 percent or less in both categories, which is the cutoff we use for a top rating. Brink says that referring doctors often assume that double scans provide more useful information than single scans. Radiologists should question such orders, he says.

What you can do
If you’re scheduled to get two CT scans of your chest or abdomen, ask whether both are necessary. Also ask whether any CT is really required and whether an imaging test that does not emit radiation, such as an MRI or ultrasound, could be used instead.

What needs to happen

 

Mary Flowers, M.D., says medical mistakes in the hospital led to her father’s death.

The federal government recently provided funding of $218 million to 26 hospital groups nationwide to improve hospital safety and provided up to $500 million for programs to help Medicare patients transition from hospital to home. And hospitals now have financial incentives to use electronic health records.

But more needs to be done. “Those carrots are fine, but we need some sticks, too,” says Lisa McGiffert, director of the Safe Patient Project at Consumers Union, the advocacy arm of Consumer Reports. For example, Medicare withholds payments for some procedures that lead to patient harm, but it should also require hospitals to pay for the follow-up tests and treatments that those errors lead to, she says.

Consumers Union believes that a national system should track and publicly report medical errors. The Institute of Medicine recommended that more than a decade ago. “The public assumes that someone keeps track of all that goes wrong, but that is just not the case,” McGiffert says.

‘The best cure for medical harm is full disclosure.’ — Lisa McGiffert

Also, Consumers Union says hospital administrators and regulators need to listen more to the people most affected by medical harm: patients. Regulators must investigate those complaints and use them to identify hospitals with patterns of problems. Changes in the courtroom could help, too, by relaxing the gag orders and secret settlements that often prevent harmed patients from telling their stories. “The best cure for medical harm is full disclosure,” McGiffert says.

Mary Flowers, M.D., of Montgomery, Ala., agrees. She says her father entered the hospital for a procedure related to dialysis “and never walked out, because of one error after another.” Problems included a punctured colon, bedsores, and a serious infection.

The biggest problem, she says, wasn’t the mistakes but the time it took for the hospital to acknowledge them. “I’m a doctor—I know we are not perfect,” she says. “But we need to listen to our patients and, when mistakes happen, own up so we can fix them, or at least keep them from happening again.”

Hospital safety: Highest and lowest scores

The 10 hospitals at the top of our Ratings are in 10 states. They are in big cities and small towns. The Mayo Clinic in Phoenix is a teaching hospital; others are small community hospitals. The message: Success can happen anywhere. Bottom hospitals tend to cluster around metropolitan areas, suggesting that urban hospitals face special challenges. Their safety scores in our 100-point scale are shown below. See our full hospital Ratings (available to subscribers).

Top 10 hospitals	Safety score	Bottom 10 hospitals	Safety score
Billings Clinic Billings, Mont.	72	Sacred Heart Hospital Chicago	16
Saint Clare’s Hospital Weston, Wis.	71	Harlem Hospital Center New York	20
Alton Memorial   Hospital Alton, Ill.	71	Lake Regional Health   System Osage Beach, Mo.	22
Central Vermont   Medical Center Berlin, Vt.	71	Kings County Hospital   Center Brooklyn, N.Y.	22
Kadlec Medical Center Richland, Wash.	71	Our Lady of the   Resurrection Medical Center Chicago	23
St. John’s Hospital Springfield, Mo.	70	Kimball Medical Center Lakewood, N.J.	24
Mayo Clinic Hospital Phoenix	70	St. Rose Dominican   Hospitals-San Martin Campus Las Vegas	24
Northern Michigan   Regional Hospital Petoskey, Mich.	69	Clinch Valley Medical   Center Richlands, Va.	25
Bon Secours St.   Francis Health System Greenville, S.C.	69	Westchester Medical   Center Valhalla, N.Y.	25
Memorial Hospital of   Union County Marysville, Ohio	68	Hanford Community   Medical Center Hanford, Calif.	25

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Why some hospitals succeed

Top-scoring hospitals have found different ways to improve safety. Billings Hospital in Montana had our top safety score, in part because it reported very low rates of double CT scans and bloodstream infections. Mark Rumans, M.D., the hospital’s physician-in-chief, says that doctors who practice there are part of an integrated system, which fosters teamwork.

Lancaster General, in Pennsylvania, which had the best readmission score among the hospitals in our Ratings, says heart-failure readmission rates have stayed low for seven years. The hospital says its overall readmission rates have also been low thanks to a strong network of primary-care doctors and a team approach to care.

Baylor University Medical Center in Dallas, one of our highest-scoring teaching hospitals, says it saw a 23 percent reduction in sepsis, a particularly serious infection, and a 34 percent decline in preventable deaths since 2006. “We set goals for medical directors and made them part of their performance appraisals,” says John McWhorter, the hospital’s president.

When bad things happen

When hospitals get low scores, other problems may be at play, as we found when we reviewed inspection and investigation reports conducted by state and federal health departments at three low-scoring hospitals and obtained through Freedom of Information Act requests.

Sacred Heart Hospital in Chicago, our lowest-rated hospital, was cited for a Feb. 25 incident in which an emergency-room doctor declined to provide care to an unresponsive woman in her car in the hospital’s parking lot. She was transported to another hospital, where she was pronounced dead, according to the documents. The inspection reports mentioned rusty surgical tools, a hole in an operating-room wall, nurses who failed to follow precautions to prevent falls and bedsores, and a lab refrigerator so dirty that it “created the potential for contamination of the specimens and infection to the staff.”

Inspection reports at Sacred Heart Hospital in Chicago mentioned rusty surgical tools and a hole in an operating-room wall.

The documents we have for Our Lady of the Resurrection, another low-scoring Chicago hospital, cited failures such as misuse of patient restraints, failure to ensure that nurses could hear patient alarms, and failure to provide timely discharge counseling.

Inspectors at Kimball Medical Center in Lakewood, N.J., which also received low scores, noted substandard cleaning, misuse of restraints, and a failure to properly report adverse events.

When we looked at two top hospitals, we spotted fewer citations. We found only one problem, a medication error, at Alton Memorial Hospital, Illinois’ highest-scoring hospital, since 2009. Similarly, Lancaster General was cited just twice since 2009, according to the records, for not training emergency-room staff on how to comply with a federal law and for transferring patients without full consent.

Hospitals respond

Of the three low-scoring hospitals mentioned above, only Our Lady of the Resurrection responded to a request for comment. It said the hospital tries to correct problems brought to its attention. In addition, the hospital says it “had only one central-line-associated bloodstream infection over the entire past year” and “zero hospital-acquired conditions for more than seven months.”

Harlem Hospital Center, in New York, another low-scoring hospital, acknowledged that it needed to improve in some areas. It said it is “committed to offering high-quality health care to all New Yorkers regardless of their ability to pay.”

Kings County Hospital Center, in Brooklyn, N.Y., said its patients speak more than 100 languages. Both said they had recently seen drops in rates of infections and double CT scans.

If those improvements are maintained and publicly reported, we will include them in future updated Ratings.

8 things that should never happen in a hospital
There’s never an excuse for operating on the wrong patient or body part. But our medical experts say that several less dramatic events should also never or at least very rarely occur in hospitals. Those include the complications listed below, which are part of our Ratings.

1. Bedsores. These painful wounds, usually on the ankles, back, buttocks, hips, or other bony areas, can develop if a patient is left in one position too long. Frequent repositioning and special pads, cushions, and mattresses can prevent them. If you see early signs, including patches of skin that have reddened, let the nursing staff know.

2. Collapsed lungs. If doctors are not careful, they can puncture the lungs when inserting a catheter or needle into the chest. Your doctor should use an ultrasound as guidance, especially if you’re at high risk because of chronic lung disease.

3. Central venous catheter-related bloodstream infections. A doctor or nurse should make sure that these tubes, used to deliver medicine and nutrients, are kept clean and are removed as soon as they’re no longer necessary.

4. Postoperative hip fractures. To prevent a fall that can break your hip, ask for help when you get out of bed. And don’t take more pain medication than you need or walk if you are groggy.

5. Blood clots after surgery. Some surgeries, such as those to replace a hip or knee, can cause blood clots to form in the legs. Those clots can break loose and travel to the lungs, a deadly complication called a pulmonary embolism. Moving about and walking soon after surgery can help prevent the clots, as can blood thinners and special stockings.

6. Postoperative sepsis. This occurs when a serious infection overwhelms the body, leading to failure of the kidneys, liver, lungs, and other organs. Make sure that everyone who touches you washes their hands and that the hospital follows infection-prevention guidelines. Early signs include either high or low body temperature plus rapid breathing and pulse. Treatment includes measures to rein in the infection and control blood pressure.

7. Opening of a wound after surgery. A wound that opens in the days following an operation is an infection waiting to happen. Ask how to care for your surgical wound, how long it should take to heal, and what to do if it doesn’t.

8. Accidental punctures or cuts. Surgeons can accidentally puncture or cut an organ or blood vessel, which can extend your hospital stay. Finding an experienced, skilled surgeon might reduce the risk.