Hospitals must boost safety efforts and cut low-value (but high-profit) care, experts say
Doctors and hospitals must redouble their efforts to protect patients in their care, as the coronavirus pandemic reversed years of safety advances, and these must be restored top to bottom — and more.
This powerful, timely argument has been made in a top medical journal by leading federal regulators at the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC). As the quartet of medical doctors (Lee A. Fleisher, Michelle Schreiber, Denise Cardo, and Arjun Srinivasan) reported:
“The public health emergency has put enormous stress on the health care system and disrupted many normal activities in hospitals and other facilities. Unfortunately, these stressors have caused safety problems for both patients and staff …The fact that the pandemic degraded patient safety so quickly and severely suggests that our health care system lacks a sufficiently resilient safety culture and infrastructure. We believe the pandemic and the breakdown it has caused present an opportunity and an obligation to reevaluate health care safety with an eye toward building a more resilient health care delivery system, capable not only of achieving safer routine care but also of maintaining high safety levels in times of crisis.”
The doctors have found the falloff in patient safety is severe, writing in the New England Journal of Medicine:
“We have observed substantial deterioration on multiple patient-safety metrics since the beginning of the pandemic, despite decades of attention to complications of care. Central-line–associated bloodstream infections in U.S. hospitals had decreased by 31% in the 5 years preceding the pandemic; this promising trend was almost totally reversed by a 28% increase in the second quarter of 2020 (as compared with the second quarter of 2019). There were also increases in catheter-associated urinary tract infections, ventilator-associated events, and methicillin-resistant Staphylococcus aureus bacteremia.
“Safety has also worsened for patients receiving post-acute care, according to data submitted to the Centers for Medicare and Medicaid Services (CMS) Quality Reporting Programs: during the second quarter of 2020, skilled nursing facilities saw rates of falls causing major injury increase by 17.4% and rates of pressure ulcers increase by 41.8%. The surges of the Delta and Omicron variants of SARS-CoV-2 in late 2021 and early 2022 do not bode well for a return to pre-pandemic levels for any of these indicators.”
How hospital safety practices have slipped
The doctors, who are experts in oversight of clinical facilities, praise the dedication and valor of health workers to patient care during the worst health care crisis in a century — a calamity that has claimed at least 1 million Americans’ lives. But they also reported that the extreme conditions have caused health workers and hospitals to become unacceptably lax in safeguarding patients:
“The strains on the system have also affected routine safety practices. Overworked clinicians have often had no time for safety rounds, safety audits, or error reporting. Supply-chain disruptions reduced access to personal protective equipment, putting both patients and health care workers at risk. Standard safeguards, such as checklists, quickly became inadequate. Moreover, the pandemic starkly highlighted health disparities, including inequities in the safety of patients and health care personnel.”
For the sake of patients and of themselves, health workers and their employers must work to put in place “a thorough system of safety that reaches from the boardroom to the front lines and that can be maintained during times of crisis,” the doctors have argued, adding:
“[I]t is important to have sufficient resources such as staff and personal protective equipment for times of stress. The United States deserves breakthrough thinking about systems built on foundational principles of safety, akin to those used in other industries in which safety is embedded in every step of a process, with clear metrics that are aggregated, assessed, and acted on. We also need renewed national goals of harm elimination throughout the health care system and a core safety strategy that includes promoting radical transparency, addressing workforce shortages, and continuing to strive for safety while being sensitive to such trade-offs as reporting burden and costs. This effort should extend across the continuum of care, beyond the traditional hospital-based safety indicators, and include attention to diagnostic errors and outpatient care.”
These regulators’ suggestions, however, could be undercut by efforts within CMS to ease the oversight of hospitals and to limit public disclosure of key safety and quality information. This is a proposal infuriating critics.
Still, in case skeptics consider the advocacy of patient safety to be too pie-in-the-sky, experts at Northwestern University and the Johns Hopkins Armstrong Institute for Patient Safety and Quality have taken up the published challenge, responding already with ideas on how better to inform hospitals’ most important users about key metrics of their care.
Better information for patients
They say in an Op-Ed published on Stat, the science and medical news site, that regulators and advocacy groups now present patients with crucial hospital safety and quality of care information that is too complex and difficult to understand. They, instead, argue that the data should be rooted in psychology and displayed to answer three vital patient concerns: “Will I be safe? Will I be heard? And Will I be able to lead my best life?” Data that answer those questions can be further color coded and arrayed, so that patients, as they roll over the queries can see details pop up as to how hospitals rank in each of these areas (see graphic above.)
In my practice, I see not only the harms that patients suffer while seeking medical services, but also the damage that can be inflicted on them and their loved ones by major problems in the U.S. health care system — including medical error, misdiagnoses, as well as over testing and over treatment.
In pre-pandemic times, medical errors claimed the lives of roughly 685 Americans per day — more people than died of respiratory disease, accidents, stroke and Alzheimer’s. That estimate came from a team of researchers led by a professor of surgery at Johns Hopkins. It meant that medical errors ranked as the third leading cause of death in the U.S., behind only heart disease and cancer. (The coronavirus, of course, has risen has a leading killer of Americans.)
Under pandemic duress, wrong determinations about patient conditions, no doubt, occurred, likely with greater frequency. Just to remind of further pre-pandemic research findings in this area: Diagnostic errors affect an estimated 12 million Americans each year and likely cause more harm to patients than all other medical errors combined, studies have found. And misdiagnoses boost health costs through unnecessary tests, malpractice claims, and costs of treating patients who were sicker than diagnosed or didn’t have the diagnosed condition. Experts recently noted in a health care online report that inaccurate diagnoses waste upwards of $100 billion annually in the U.S.
Hospitals and low-value care
The Lown Institute, a health care think tank, has assailed hospitals for putting patients at heightened risk during the pandemic by performing what it terms as 100,000 instances it has found of “overuse, or low-value care …medical services that offer little to no clinical benefit or are more likely to harm patients than help them.” The institute researchers explained, thusly:
“Eight low-value procedures were examined, including hysterectomy for benign disease, coronary stents for stable heart disease, and spinal fusion for low-back pain. The eight procedures were chosen based on validation in previous overuse studies.”
The institute, based on U.S. medical records, has reported in its key takeaways on unnecessary care that:
“From March-December 2020, hospitals delivered more than 100,000 low-value procedures to Medicare beneficiaries; that’s one every four minutes on average. Of the 100,000 procedures, 45,000 were unnecessary coronary stents and 30,000 were unnecessary back surgeries …All of the hospitals on the U.S. News Honor Roll ranking had rates of coronary stent overuse higher than the national average in 2020, and four had rates at least twice that.”
By the way, views may be shifting among those who expressed major concerns about a Tennessee nurse’s criminal case and the effect it might have on getting health workers to fess up to making errors so they could be corrected. That’s because a judge decided that RaDonda Vaught should be sentenced to three years’ probation for injecting Charlene Murphey, 75, with a fatal dose of vecuronium, a paralyzing drug, instead of Versed, a sedative, while at Vanderbilt University Medical Center. Nurses and others expressed outrage that prosecutors criminally charged Vaught. Authorities said she had ignored too many safeguards in committing her lethal error.
We have much work to do to ensure patients that their hospital care is accessible, affordable, safe, and excellent.