Hazardous Hospitals: How the Profit Motive Can Kill You

A front–page article in Yesterday’s New York Times reports “The federal Centers for Disease Control and Prevention projected this year that one of every 22 patients would get an infection while hospitalized — 1.7 million cases a year — and that 99,000 would die, often from what began as a routine procedure.”

A little reported on New England Journal of Medicine study from a few months back concluded that 19,000 people die from preventable infections acquired during the insertion of catheters.

But shock, worry and amazement won’t help answer the question; what makes the hospital environment a major killer? While some medical infections will always occur, through aggressive cleanliness campaigns several European countries have all but eliminated MRSA, one of the most deadly hospital acquired diseases. The New England Journal of Medicine study reports that catheter related blood stream infections dropped 66% with some minor changes (including rigorous hand-washing, thorough cleaning of the skin around catheters, and wearing sterile masks, gowns and gloves as well as removing catheters from patients as soon as possible and avoiding inserting catheters in the groin area). According to a 2004 Canadian survey published in the American Journal of Infection Control, up to half of all hospital-acquired infections were found to be preventable if infection control procedures were adequate. And a similar six-year old American study concluded that up to 75 percent of deadly infections caught in hospitals could be avoided by doctors and nurses using better washing techniques. (Studies show that over half of the time physicians fail to clean their hands before treating patients and that 65 percent of physicians and other medical professionals go more than a week without washing their lab coat.)

Nevertheless, it is wrong to simply blame front-line medical workers for these unnecessary infections. Data shows that successful behavioral change is contingent upon vigilant supervisors who put in place adequate preventive measures and demand proper cleaning practices. As well, understanding management, a culture of respect, proper staffing levels, ongoing education programs and proper shift scheduling have all been shown to improve the health and safety of hospitals — for both patients and workers. (“By nearly doubling cleaning staff hours on one ward,” US News and World Report explains, “a hospital in Dorchester reduced the spread of MRSA by nearly 90 percent.”)

The biggest barrier to improvement, however, is our economic system, which focuses on cures and technology because that’s where the biggest, quickest profits can be found. Pfizer isn’t likely to fund studies that look into the role hand-washing plays in hospital-acquired infections since they don’t see a profit in doing so. Billions of dollars are spent annually on the development of new drugs and medical technologies, but little is spent on basic hospital infection control — even though this would save a greater number of lives — because there has been little economic incentive to do so. Some company makes a profit when a new MRI machine is purchased, but the bottom line that benefits from better hand-washing techniques is only measured in lives.

It has taken a public outcry just to get some states to force hospitals to track and report hospital acquired infections. But, unlike restaurants and cruise ships, the body that inspects and accredits US hospitals, Joint Commission, does not measure cleanliness.An over-reliance on the profit motive outside the hospital door also causes infection-control problems. More than 70 per cent of hospital-acquired infections are resistant to at least one common antibiotic. Infections resistant to antibiotics significantly increase the chance of death.

This increase in deadly multi-resistant viruses is, in large part, attributable to our overuse of antibiotics, which is connected to drug companies’ bottom lines. Doctors, faced with patients demanding quick cures, and encouraged by a pharmaceutical industry that spends tens of billions on advertising, over-prescribe antibiotics. “Prescribing antibiotics has become so common that many doctors literally are just phoning it in,” a recent USA TODAY article explains.

According to an analysis of 1.5 million insurance claims for antibiotic prescriptions in 2004, 40% of people who filled an antibiotic prescription had not seen a doctor in at least a month. Without seeing the patient, how can doctors determine whether their symptoms were the result of a viral infection — which don’t respond to antibiotics — or a bacterial infection that do. This over-prescription of antibiotics increases the growth of multi-resistant organisms.

And in the case of the Clostridium difficile superbug, which has killed many hospital patients over the past few years, antibiotics perturb the bacterial flora in the intestine. This opens the door to the super-bug. (One study found, according to the Times of London, that “reducing the number of prescriptions for broad–spectrum antibiotics [which kill a wide range of bacteria] from about 53 per 1000 admissions to 17 per 1000 caused the number of cases of C difficile to fall by two thirds.”) Additionally, half of all antibiotics sold each year are used on animals, according to New Scientist. Industrial farmers give their animals constant low doses of these drugs to treat infection but also as a growth hormone. The administration of low doses is especially problematic since it becomes a feeding ground for organisms to mutate. Data shows a strong correlation between increased use of antibiotics on animals and the emergence of resistant strains in the animal population with mirrored increases amongst people.

To end this practice, the European Union recently banned antibiotic growth promoters. Washington and Ottawa, kowtowing to the animal industry, have done little. Hospitals can be much safer and healthier places. Tens of thousands of lives can be saved if real health outcomes can be given priority over profit-making opportunities.

Yves Engler is the author of 12 books. His latest book is Stand on Guard for Whom?: A People's History of the Canadian Military . Read other articles by Yves.

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  1. Terry Greenwood said on July 28th, 2007 at 9:48am #

    Your premise that the profit motive is the problem is wrong. It might be worth checking out the UK’s leading private hospital provider BUPA’s MRSA rate in comparison to the NHS. It is a big round zero for MRSA blood infections in 2006. Here’s a couple of articles from the BMJ which might be of interest.

    Hospital infection rates in England out of control – News – Brief Article – Statistical Data Included
    British Medical Journal, Feb 26, 2000 by Zosia Kmietowicz
    The NHS in England could save an estimated 150m [pounds sterling] ($240m) and many hundreds of lives by tightening hygiene rules in hospitals and investing in infection control, according to the spending watchdog the National Audit Office. The money could then be ploughed back into patient care.

    At least 100 000 cases of hospital acquired infections occur each year in England, with an estimated 5000 deaths, all of which cost the NHS in the region of 1bn [pounds sterling] annually, states the report.

    Better education of staff on the spread of infection, improved surveillance of patients who have had major surgery, and the involvement of senior clinicians and management in the control of infection could reduce this burden by 15%, Sir John Bourn, head of the National Audit Office, told parliament.

    At any one time 9% of patients in hospital are being treated for an infection they acquired there. Yet one in five trusts do not have an infection control programme, 40% are dissatisfied with their isolation facilities, and 60% have no defined budget.

    Despite guidance from the Department of Health that chief executives should take overall responsibility for ensuring effective infection control, there is little evidence of their involvement. More than half were not aware of the resources spent on hospital acquired infection or the number of cases, says the report.

    BMJ. 2002 February 2; 324(7332): 258.

    Winter virus closes Scottish hospitals
    Bryan Christie

    Top A monitoring programme is to be accelerated at Scottish hospitals to check if they are meeting new national standards on infection control. It follows the deaths of three patients at Glasgow’s Victoria Infirmary from salmonella poisoning and an outbreak of a gastric virus at several other hospitals.
    The viral infection, which causes severe vomiting and fever, has affected many parts of Britain, but Scotland has been worst hit. Almost 300 patients and staff at the Victoria Infirmary contracted the virus, and the hospital was forced to close to new admissions for a week. Nine other Scottish hospitals had to impose temporary ward closures.

    The virus involved, a Norwalk-like virus (formerly known as the small round structured virus), can spread through the air and is difficult to control. However, its serious impact in Scotland, coming immediately after the deaths from salmonella, has led to concerns about hospital cleanliness and hygiene standards. The health trade union Unison said that the health service now employs one cleaner for every 360 patients compared with one for every 60 patients in 1985.

    Scotland’s health minister, Malcolm Chisholm, announced that the Clinical Standards Board for Scotland is to accelerate its programme of external checks of hospitals to see how their performance compares with national standards on infection control.

    “There is no shortage of work going on within the NHS to tackle this problem—and no shortage of independent scrutiny of NHS performance. I intend to ensure that we maintain momentum in that work over the coming weeks and months,” said Mr Chisholm.

    Hospital acquired infection is a huge problem. A report from the House of Commons public accounts committee in 2000 found that 9% of hospital patients acquire an infection while in hospital. It concluded that 5000 people die a year in England and Wales as a direct result of hospital acquired infection, and it may be a substantial contributory factor in a further 15 000 deaths. The annual death toll in Scotland is estimated at around 450.

    However, 15-30% of cases of hospital acquired infection are preventable, and Professor Hugh Pennington, one of Britain’s leading infection specialists, said that Britain needed to learn lessons from countries such as the United States and Australia, where tackling such infections had been given greater priority. He said that British hospitals needed more infection control staff.

    “We are nearly always reacting to events rather than having any substantial programme of preventative measures. There is a bit of a culture change needed here to get the status of hospital infection control at least as important in managers’ minds as waiting lists,” he said.

    Dr. David Gratzer, a practising physician licensed in Canada and the United States writes “Canadian doctors, once quiet on the issue of private health care, elected Brian Day as president of their national association. Dr. Day is a leading critic of Canadian medicare; he opened a private surgery hospital and then challenged the government to shut it down. “This is a country,” Dr. Day said by way of explanation, “in which dogs can get a hip replacement in under a week and in which humans can wait two to three years.”

    Market reforms are catching on in Britain, too. For six decades, its socialist Labour Party scoffed at the very idea of private medicine, dismissing it as “Americanization.” Today Labour favours privatization, promising to triple the number of private-sector surgical procedures provided within two years. The Labour government aspires to give patients a choice of four providers for surgeries, at least one of them private, and recently considered contracting out some primary-care services — perhaps even to American companies.

    Other European countries follow this same path. In Sweden, after the latest privatizations, the government will contract out some 80% of Stockholm’s primary care and 40% of total health services, including Stockholm’s largest hospital. Beginning before the election of the new conservative chancellor, Germany enhanced insurance competition and turned state enterprises over to the private sector (including the majority of public hospitals). Even in Slovakia, a former Marxist country, privatizations are actively debated.

    Under the weight of demographic shifts and strained by the limits of command-and-control economics, government-run health systems have turned out to be less than utopian. The stories are the same: dirty hospitals, poor standards and difficulty accessing modern drugs and tests.

    Admittedly, the recent market reforms are gradual and controversial. But facts are facts, the reforms are real and they represent a major trend in health care.”

    Finally, I work in the Los Angles County Department of Health Services and I have seen first hand the results of no profit motive at work at Martin Luther King Hospital, which is about to lose it’s license to operate because it is not up to standards.

  2. Eric Patton said on July 28th, 2007 at 1:49pm #

    Market abolishinism: an idea whose time has been here for a while now.

  3. Edward Teague said on July 29th, 2007 at 2:27am #

    It is worth noting that the National Audit Office report by Sir John Bourn was from a body concerned , not with clinical care but costs.

    It galvanised action on a problem well known (Killing patients at roughly the rate of North American hospitals) , but previously ignored .

    Most of the reasons for growth of what were then called Hospital Acquired Infections (HAI) related to ;
    1 Oversubscribing antibiotics
    2 Lack of isolation facilities
    3 Inadequate control of procedures (catheterisation etc.,)
    4 Major growth in invasive surgery for longer periods.
    5 An innate acceptance that age brings death and that is reflected (at least in the UK) by any post operative broncho-pneumonial conditon leading to death as “the old man’s friend”

    Identification and the report’s resulting brou ha ha immediately led to a defensive clinical response;

    1 Renaming and medicalising the condition as “nosocomal” helping to confuse and obfuscate reporting procedures and prevent comparisons over time and between locations – we now have learnt to call it Community RSA – it’s not even a hospital problem it’s everywhere. ***

    2 Early discharge so that patients died at home, reducing the hospital death count as the collection , analysis and public ation of in fection rates became a point of public concern and Hospital Trust’s self flagellation – which was a preliminary to demanding more funds.

    3 Whilst MRSA finds it’s happy home in the nasal mucosae and be distributed by that route. Clinical staff identified an area of practice – hospital cleaning which was without their area of responsibility – hence an orgy of concern about , floor swabbing, hand washing, laun dry procedures etc., I have maintained for many years that if there was a Royal College of Hospital Cleaners you would never have heard of dirty hospitals – underpaid, menial cleaners are an easy . transient and readily identified demon – xenophobia playing no small part as many were / are recent immigrants.

    4. Profit incentivised suppliers soon found a ready market for alcohol wipes, swabs, copper door handles, UV light air filters and other technical wizardry as expenditure on these items was readily equated with effort and attention to the problem.

    In the modern NHS Medical treatment is mistaken for health care and and their improvement is made to depend on allocating more resources to their management.

    5. Due to the immutable Law of Unexpected Consequences, more intensive antibiotic therapy of MRSA suferers in hospital led to massive doses of agressive (and expensive) antibiotics , resulting in gastric flora being damaged and the adventitious and opportune invasion of other common and sub fatal organism, Klebbsiella, Clostridium which again weakened the host hastening death is a slightly more roundabout (and unpleasant fashion for both patient and family).

    The use of expensive therapies bolstered of course the belief and all embracing management paradigm that expense is equivalent to effort and effort will be result in success.

    Meanwhile in Holland with vanishingly low rates of HAI’s they screen patients before admission for communicable disease, they have isolation wards, they use small rooms with sliding doors (preventing contominated internal airflows), and simple effective procedures for dealing with wounds / catheters and other skin punctures with barriers, disposables and rigorous disposal.

    Meanwhile in my local NW England surgery they have instituted a touch screen procedure for booking in at an appointment requiring at least seven screen touches. When I pointed out to the doctor that it was probably not possible to design and implement a better method of distributing communicable disease amongst patients she looked blank and said she hadn’t seen it in use.

    The threat of MDRTB , multiple drug Resistant TB (especially for the UK with a huge growth in immigrants from areas where it is endemic (especially in prisons) – Estonia in the EU, parts of Africa, Russia / Ukraine ) was, when John Bourn reported in 2002 a mere speck on the horizon.

    The prospects of this on a large scale are truly frightening in health and in cost, 2 outbreaks in London hispital have cost Millions to sterilise premises.

  4. Joshua said on July 31st, 2007 at 8:48am #

    Germs and MRSAs might be small, but they pose a big problem in healthcare environments. Man & Machine has spent years developing products to fight the spread of MRSAs and other harmful microbes. MMI has created keyboards with no cracks, crevices or seams, which means that germs do not have a place to hide and grow. So disinfecting our really cool keyboards is quick and easy

    Our non-porous, latex-free, silicone rubber keyboards and mice are waterproof, dust proof and highly mess-resistant. Most importantly, their rugged construction allows them to be cleaned with alcohol, 10% bleach solutions and other chemical disinfectants.

    In environments such as hospitals, where MRSAs can cause serious infections, Man & Machine keyboards definitely puts the power of infection control at the users’ fingertips.

    You can check out the products at http://www.man-machine.com

  5. Lloyd said on August 5th, 2007 at 5:45am #

    Re Terry Greenwood’s “counter” to Engler’s article, saying that “Your premise that the profit motive is the problem is wrong. It might be worth checking out the UK’s leading private hospital provider BUPA’s MRSA rate in comparison to the NHS. It is a big round zero for MRSA blood infections in 2006.”:

    Although I question the validity of that “big round zero,” of course in a mixed private-public system, the enormously more expensive private side will have relatively more effective (and costly) medicine. Only the richest patients are funding it (and only the richest physicians, many of whom are among the most competent, are working in it).

    Greenwood is just arguing from fantasy. Or does he have an example of a private medical system providing the same level of care to all a country’s citizens?

    Historically, socialist institutions are like islands thrust up in an ocean of capitalism. And you have to ask yourself: How much is learned about continents from islands?