Hospital Safety 101: Didn't Mom Teach You to Wash Your Hands?

San Francisco Chronicle Washington Bureau writer Carolyn Lochhead reported today on a new idea somebody had about making hospitals safer: get folks to wash their hands. Hello?

The president of a leading medical standards organization announced a new program Thursday that is designed to improve health care safety practices, starting with a rigorous approach toward hand-washing by hospital staffers.

And this is serious business.

Hand-washing failures contribute to infections linked to health care that kill almost 100,000 Americans a year and cost U.S. hospitals $4 billion to $29 billion a year to combat, said Dr. Mark Chassin, who leads the Joint Commission, which sets standards and accredits hospitals and health care organizations.

Chassin’s announcement came after Hearst Newspapers published the results of an investigation, “Dead by Mistake,” which reported that 247 people die every day in the United States from infections contracted in hospitals.

Anyone who has ever come home from surgery with an infection, or more specifically anyone whose spouse has come home from surgery with an infection (nasty-wound-tending not having been fully explained in those for-better-or-for-worse lines) will applaud the new program, but it’s hard not to wonder what has taken the medical profession so long. Hospitals have found, Lochhead reports, that “caregivers washed their hands less than 50 percent of the time when they should.”

If there’s ever been a good example of potential savings to pay for universal health care, this is one to top the list. Consumers, we who would do well to wash our own hands when visiting or inhabiting hospitals, owe a debt of gratitude to the Joint Commission (and to Hearst Newspapers for the excellent ‘Dead by Mistake’ series.)

Maybe more sinks will be adorned with the sign that gave my husband and me a healthy chuckle during a recent visit to the Kaiser emergency room:

“Hand-wash unto others” it read, “as you would have them hand-wash unto you.”


Hospitals urged to strictly enforce hand-washing.

Obama plays the Medicare card

President Obama, with Vice President Biden and Speaker Pelosi behind him, delivers a joint address to Congress on September 9 (Alex Wong/Getty)
President Obama, with Vice President Biden and Speaker Pelosi behind him, delivers a joint address to Congress on September 9 (Alex Wong/Getty)

For almost anyone over 50, the central issue of health care boils quickly down to Medicare. Will I keep it? Will it be there when I need it? Will it change?

In his address to a joint session of Congress Wednesday night, President Obama looked straight at the camera while saying he wanted “to speak directly to seniors: Medicare has been here for four decades, and is a sacred trust that must be passed down” to future generations. Then he pointed out to those seniors that the legislators opposing his reform plan are the same “folks who voted against Medicare in the beginning” and this year voted for a budget that would privatize it. He said also that much of the plan will be paid for by reducing waste and inefficiency in Medicare and Medicaid. Anybody who’s had (and thank you, I have) Medicare coverage for more than 15 minutes knows about waste and inefficiency. So cut those, and leave the system, and we should all be happy.

We should all be happy, that is, if such care extends to everyone. And if Mr. Obama’s references to the U.S. being the only developed country that lets its citizens suffer daily for want of adequate health care didn’t communicate the moral wrong that reform will attempt to right, you weren’t listening. What we heard was outline, and the president’s throw-away line about a few details yet to be worked out got an expected congregational chuckle. Some of us are more optimistic than others about whether any substantive change for the common good will remain by the time the final bill is drawn.

The details are ahead for the devil to be in, and he/she is surely ready. Whether public support will be forthcoming seems likely to boil down to a whom-to-believe game. Obama repeatedly stressed that “nothing in our plan requires you to change what you have.” But in delivering the Republican response immediately after the speech, Representative Charles Boustany of Louisiana promised listeners that they would be in for “replacing your family’s current plan with government-sponsored healthcare.” Boustany also tossed in references to “rationing care” and to general “fear and anxiety,” giving a distinct impression that battle lines are still drawn.

About those battle lines: Republicans sat on their hands as Obama once again proclaimed the rumors about bureaucrats who would kill off senior citizens — he skipped dignifying Sarah Palin by using the death-panel words — to be “lies, plain and simple.” And although he got the other side of the aisle to stand when he insisted there must be reform of medical malpractice laws, there were no smiles when he pointed out that the cost of health reform will be less than the tax breaks for wealthiest Americans passed during the previous administration.

Somehow, what truths and certainties do exist must be kept alive in the fray: Medicare is not going away. End-of-life conversations won’t kill off grandma. (Sadly, this provision may be already dead anyway.) The plan’s not going to cover illegal immigrants or pay for abortions. Medical malpractice laws must be reformed. Nothing will adequately replace the public option. A health care plan that offers access to all, imperfect or not, is only common decency.

This senior’s trust is still in Barack Obama.

The Public Option Death Panel

Here’s a death panel even Sarah Palin could love — but maybe we’d better not tell her. You, however, will probably understand its value and possibly want to put it to work for your own benefit. It centers around a form called POLST, for Physician Order for Life Sustaining Treatment (in New York it’s MOLST, for Medical Orders) fast catching on across the country. The panel consists, essentially, of your doctor and yourself.

Initially developed in Oregon in 1991, POLST programs are underway in a handfull of states including Washington, California, New York and North Carolina, and are being developed in over a dozen others.

Erin Henke, POLST Program Manager for the California Coalition for Compassionate Care, outlined the program for a group of healthcare professionals this week in San Francisco, part of CCCC’s efforts to get it efficiently established across the state. The key, she emphasized, is the conversation between individual patient and medical professionals. You don’t get the form signed, in other words, unless and until patient and physician have discussed what the former wants: CPR if you’re not breathing? Feeding tube? Comfort care only, if you’re in bad shape, but you’ve got a pulse and are breathing? Or perhaps every intervention possible — tubes, wires, ventilators, the works, including transfer to a hospital intensive care unit. But the point is, you make your own decisions. Once the form is completed and signed, it follows you as part of your medical record. In California it’s printed on Pulsar Pink card stock, and not easy to overlook.

Rollout of the program, Henke explained, is an ongoing process; it will only work when it is widely known and understood not only by individual patients and physicians but also by the many other members of the profession — nurses, caregivers, ER personnel and others. CCCC’s focus right now is on skilled nursing facilities and hospitals, though Henke and the teams of POLST program advocates around the state are working toward a broad educational spectrum.

The basic POLST approach, as explained in a Journal of Palliative Medicine article by Diane E. Meier, M.D. and health care journalist Larry Beresford published earlier this year, is to provide “actionable information on how to honor the wishes of a patient with a life-threatening condition” on a variety of issues. It goes farther than an Advance Directive (though if there’s a discrepancy, the Advance Directive takes precedence) and it differs from an out-of-hospital DNR (Do Not Resusitate) form because it lets you choose treatment.

I asked Henke if the patient/doctor conversation which is necessary in order for this extraordinarily useful document to be completed is covered by most insurance companies. She says that to her knowledge there is no specific code for such a conversation, although she understands there are other codes under which physicians can bill. Let’s hope Betsy McCaughey and Sarah Palin don’t find out. Or Chuck Grassley.

Though I am only terminal just now in the same sense that all of us mortals are, I talked about the POLST form with my Kaiser primary care physician just to be sure we remain on the same page. Wouldn’t it be nice if everyone had that same opportunity.

What to do about Mom?

My friend Joan is distressed about her mother.   Joan – that’s an alias, we both value her privacy – lives quite near her parents, visits regularly, helps out with finances, health issues and everyday needs. They are in their late eighties. Other siblings live in other states. Until recently everything was fine; now the parents are in separate areas of their assisted living residence, Joan’s mother is in frequent despair and need. What’s a daughter to do?

This story is being repeated thousands of times every day across the country. Only this story has a peculiar twist: Joan’s parents did everything right. They lived frugally, planned ahead, raised their children to be successful and independent, moved early into a retirement community which offers care through illnesses minor and terminal. With Joan’s help they kept their affairs in order, including updated advance directives. (You don’t have your advance directives done? Horrors. Let me know and I will be at your door, cyberspacially speaking, to walk you through them immediately.) Joan’s parents were among early advocates for advance planning and end-of-life choice.

Joan comments: “Frankly, Mother is tired of being alive.  She’s not depressed, just ‘finished’, especially as she sees these slow declines in her quality of life as a steady and inevitable progression.  Her greatest desire would be to have a massive stroke and not survive.  But then her greatest nightmare would be to have a stroke and live . . . Even with the best advanced directives reflecting her choices, that’s a fine line to navigate.”

The moral of this story is that no amount of planning and preparation can guarantee the kinds of last months and years we might want. My own mother died peacefully at home, followed 20 years later by my father, same story. But that was in 1967 and 1987, in the small town of Ashland, Virginia where they had lived since 1939. The town looked after them; their out-of-state daughters merely visited and counted their blessings. Towns and neighborhoods like Ashland are in diminishing supply.

But all is not gloom and doom; this writer is constitutionally unable to write doom and gloom. Joan is at least clear about her parents’ wishes, and her parents have good care plus all allowable precautions: DNR orders, POLST forms, understandings with their medical professionals. Most of these are possible for today’s Boomers and their Beyonder parents; if you can’t find them I’ll happily tell you how. Joan’s parents are also in housing of their choice. And those choices are many: co-housing, retirement communities, assisted living facilities, many of them available to middle and low income Americans. Anyone over 50 who thinks he or she should postpone considering all of these issues, documents and choices until next year is delusional. Essays re housing choices have appeared in earlier Boomers and Beyond posts; others will follow. The secondary moral of this story is that without planning, late years can quickly turn into hell for elderly parents and adult children alike.

What we don’t have, of course, is health care such as Joan’s parents still enjoy for others who need it. The thing is, we can.

More on Health Care: Where the Costs Are

A few interesting factoids were dropped into the health reform debate by New York Times writer Amanda Cox Tuesday:

In 2006, health care expenses among half the United States population totaled less than $800 per individual, according to the federal Agency for Healthcare Research and Quality.

For openers, that seems entirely reasonable. Would that we could actually care for the citizenry at $800 a pop. Keep reading.

But the expenditures were not uniformly distributed throughout the overall population. Spending was far higher among the elderly, the obese and people who identified themselves as unhealthy. Median spending in those groups totaled $2,300 per individual. Although these patients represent just one-third of the population, they accounted for almost 60 percent of health care spending.

I hate to stomp this nearly dead — oops, bad metaphor — horse even further into its grave, but a lot of us, given the chance to talk to our doctors about aggressive, invasive, often futile end-of-life treatments that are going to make our ends horrific might choose to go home and spend our remaining time with palliative care, at peace. A nifty way to cut that $2,300 back down to $800. But Senator Grassley and others think we should now allow those conversations.

The truth may be too obscured by the cleverly promoted lies, but the issue is about choice. Compassion. Comfort. Peace. Sanity. If anyone could get this truth across to seniors, that one critical segment of reform might still survive. And personally, I’d like to have the option of saving the rest of you taxpayers my $1,500.

via Making Sense of the Health Care Debate – Prescriptions Blog – NYTimes.com.

Pelosi Sticks With Public Option

Speaker Nancy Pelosi at a gathering of interfaith leaders in San Francisco today (Justin Sullivan/Getty)
Speaker Nancy Pelosi at a gathering of interfaith leaders in San Francisco today (Justin Sullivan/Getty)

House Speaker Nancy Pelosi held a press conference in San Francisco this morning at which she reiterated her commitment to a public option in the health reform bill and expressed hope, though with somewhat  lowered optimism, for coverage of end-of-life conversations. She did get in a dig at opponents of the latter: In response to a question about whether voluntary reimbursement for discussion of end-of-life care would stay in the bill, Pelosi said, “You know, the language is almost exactly the same as what the Republicans put into the prescription drug bill.”

The press conference, hosted by the San Francisco Interfaith Council, was an apparent reinforcement of the Democrats’ strategy of  broadening health reform support among members of religious communities. With leaders from the San Francisco Bay Area Christian, Muslim and Jewish communities arrayed behind her, the Speaker made repeated references to health care for all being a moral issue. Responding to the above question, she said, “People of faith, people in healthcare” and others know that “it makes life better if a person has expressed his or her own wishes. The key to this is that it is voluntary; it serves the purpose of saying what is your wish, rather than someone else having to make a decision you might not want. I don’t know what will happen (to the provision); I surely hope it will stay in.”

Pelosi was unequivocal, however, in her response to questions about the public option and to one reporter’s comment that “some Democrats and liberals are frustrated because it seems you are caving in to the far right.” “Is that you?” she repeated, pointing to herself. “The public option is the best way to go. If anybody can come up with a better alternative we’ll consider it. But the President is not backing off. The co-op might work in some states and that’s fine.  There is no way I can pass a bill on health reform without the public option.”

Pelosi was equally emphatic about her intention to retain the 400% of poverty measurement. Hesitantly using the term “seniors,” she said that many people between the ages of 50 and 65 have lost jobs, or may be making just $30,000 to $40,000 per year, and cannot afford needed medical care or prescription drugs. “I believe we have to have the 400% of poverty for them.”

Would the Democrats accept a scaled-down version of health reform? Pelosi repeated her litany of what is needed: reduced costs, improved quality, expanded coverage, affordable care for all; “What are you going to give up? At the end of the day, this is what we must have. And we must have reform of the insurance industry.”

In the small, carefully selected audience assembled at St. James Episcopal Church where her children attended preschool, Pelosi was on her own turf and among friends.  And she was characteristically upbeat. “Have we lost control of the debate? I disagree. I have 218 votes, and expect to have more. I am optimistic, and the President is committed to change.”

Counseling Improves Life's End. Surprise!

Knowledge, care and compassion really do bring peace. Why should this be a surprise? And why should a few strident opponents prevent those approaching life’s end from having this benefit?

A study appearing in today’s Journal of the American Medical Association points out the benefits of end-of-life counseling, although the widespread misinformation loose in the land may have doomed what should be a significant piece of health reform.

As a political uproar rages over end-of-life counseling, a new study finds offering such care to dying cancer patients improves their mood and quality of life.

The study of 322 patients in rural New Hampshire and Vermont also suggests the counseling didn’t discourage people from going to the hospital.

The Senate bill provision axed by Finance Committee chair Charles Grassley would have allowed coverage for conversations with physicians about things like hospice care, advance directives and treatment options.  But to opponents of reform, it was a handy attack mechanism. They enlisted a few standard bearers like former Alaska Gov. Sarah Palin and media darling Rush Limbaugh to twist the issue into menacing “death panels,” and in no time at all Sen. Grassley had his excuse to excise.

Losers in this are all of us. Eventually, 100% of us will die. Aggressive treatment and expensive, futile procedures are common today to that experience; compassion and peace are harder to come by.

In the new study, trained nurses did the counseling with patients and family caregivers using a model based on national guidelines. All the patients in the study had been diagnosed with terminal cancer. Half were assigned to receive usual care. The other half received usual care plus counseling about managing symptoms, communicating with health care providers and finding hospice care.

Patients who got the counseling scored higher on quality of life and mood measures than patients who did not.

Could someone please get this information to Sarah Palin?

Study: End-of-life advice aids terminally ill.