Going to hospital:And surviving your stay there

Mounting concern over the MRSA (methicillin-resistant Staphylococcus aureus) crisis in UK hospitals hit a frenzied note recently after news of the superbug’s latest victim hit the headlines. Baby Luke, born a healthy 7lb 7oz with no apparent illness, died just 36 hours after birth. The cause: septicaemia due to MRSA. The incident shook the public’s already wavering faith in the national healthcare system. Indeed, Luke’s father succinctly echoed a nation’s sentiment: If I ever have to go into hospital, I will be afraid.

But as much as you would like to avoid going to hospital, there are times when it is inevitable. And when that time comes, you don’t have to surrender yourself to chance. Many of these hospital-acquired infections (HAIs) are preventable, as are the tens of thousands of medical mistakes due to human error or criminal negligence.

Nevertheless, as WDDTY discovered in our special investigation, inadequate hospital procedures are behind most cases of MRSA as well as most cases of medical mishap. So, before your trip into hospital, forearm yourself with your own preventative medicine. By learning about your pathogenic enemies, discovering how medical blunders can arise and exploring a number of proven alternatives, you can protect yourself and improve your prospects of surviving your stay in hospital.

Killer bugs
Hospitals are, in essence, hothouses for disease-causing organisms. Within hours of admission, patients acquire various hospital bacterial strains on their skin as well as in their respiratory and genitourinary tracts. The majority of these bacteria cause little harm in healthy people, but where there is injury or broken skin, these pathogens can invade the body and trigger a variety of infections. For a hospital patient, such an attack on already compromised immunity could be life-threatening.

To add to the worry, hospital strains of bacteria are known to be particularly virulent. Not only are the majority invulnerable to antibiotics, the first-line treatment for infection, but these hardy bugs are also able to multiply rampantly.

Two factors have fuelled the rise of bacterial antibiotic resistance. First, new strains of bacteria are constantly evolving as mutations enable them to resist the commonly prescribed antibiotics and survive. Second, the overreliance on antibiotics as a solution to every ailment – whether appropriate or otherwise – has dramatically worsened the situation.

Over two million cases of HAIs are recorded in the US alone, incurring additional healthcare expenditure in excess of $2bn. Here in the UK, the number of patients who have died from MRSA-related infection has doubled-up from 487 cases in 1999 to 955 cases in 2003. Yet, as troubling as that is, experts believe that the true figure is even higher, as patients’ original illnesses are often wrongly cited as the cause of death.

While MRSA has received the most media attention, numerous other microbes make up the bacterial soup found in hospital and can cause as much carnage. These include:

* Staphylococcus species: S. epidermidis is a strain of ‘staph’ bacteria capable of clinging to non-living surfaces such as intravenous tubes and prosthetic devices. It is responsible for most of the blood infections seen in hospital; cancer patients and newborns receiving intravenous supplements are especially at risk. This species also accounts for 40 per cent of prosthetic-valve endocarditis, infection of the inner heart membranes brought on by an implanted artificial valve.

S. saprophyticus lives inside of and around the urethra in 5 per cent of healthy individuals. It is responsible for 10-20 per cent of urinary tract infections (UTIs) in hospital patients.

* Enterococcus species: These are part of the normal gut flora of healthy humans and animals. While there are more than 15 different strains, the two that are most commonly associated with HAIs – more specifically, UTIs – are E. faecalis and E. faecium. Enterococcal infections are commonly seen in the elderly, as this patient group is more frequently subjected to urinary-tract catheterisation.

This hardy species has been noted for their seeming invincibility against most antibiotic treatments. An equivalent to MRSA are the VRE – vancomycin-resistant enterococci.

* Pseudomonas aeruginosa. This organism can be found in soil, water, plants and animals. Unlike the other bacteria species already mentioned, P. aeruginosa is an opportunistic pathogen that only affects those who are already sick or immunocompromised. It rarely causes disease in healthy persons. This bacterial species is the second most common cause of hospital-acquired pneumonia among intensive-care patients.

All-too-easy access
What increases a patient’s risk of getting an HAI? Basically, the more tubes you have stuck into your body, the more opportunities there are for bacteria to gain unhampered access. Urinary catheters, intravenous lines, ventilating tubes – all of these invasive devices increase the patient’s risk of acquiring HAIs sevenfold (BMJ, 1997; 314: 1503).

The most common HAIs are the bladder-related infections. The majority of hospital-acquired UTIs occur after a patient has undergone bladder catheterisation. The procedure is used for a variety of reasons, such as to completely drain urine from the patient or to relieve bladder pressure, to measure urine volume or to run medication into the bladder. How long the urinary catheter is kept in place depends on its purpose, but the longer it stays in your body without being replaced, the more likely you are to develop a UTI.

Pneumonia is the second most common type of HAI. A particular hotspot for pneumonia in hospital is the intensive care unit (ICU), a place where multiresistant hospital pathogens thrive. This is also where patients tend to be particularly vulnerable as they often have a ventilator tube forced down their throat to help them breathe.

However, these airway tubes also give bacteria easy passage directly into the lungs. In addition, these respiratory procedures prevent the patient from coughing or gagging, the body’s reflex action for stopping microbes from entering the lungs. Up to half of all ICU patients contract ventilator-assisted pneumonia – one of the more common HAIs – and of these, 37-50 per cent even die of the condition (Infect Dis Clin North Am, 1998; 12: 761-79).

Surgery is another obvious gateway for bacteria to enter parts of the body that would normally remain sterile. An infection can be acquired from either contaminated surgical equipment or direct contact with the hospital staff. After surgery, the surgical wound – as with any breaks in the skin – becomes a ready target for infection.

Localised infection can also occur in the skin near the entry site of intravenous (iv) catheters, used for supplying medications or nutrients directly into a patient’s vein. These iv lines also afford pathogens direct passage into the bloodstream, thereby leading to a generalised infection that may, in serious cases, lead to septicaemia – also known as ‘blood poisoning’.

As already mentioned, most HAIs can be prevented. All it takes is a good standard of hygiene. Sadly, as WDDTY has discovered, it’s not possible to rely on the healthcare system to maintain infection-control measures.

Indeed, in Canada, it has been reported that the country’s hospitals have fewer regulations for infection control than do their restaurants. While the food and beverage industry are subject to continuous health inspections, there aren’t any health watchdogs to monitor the infection-control measures used in hospitals.

Moreover, many Canadian hospitals don’t even have the minimum number of staff they’re supposed to employ to combat infections (CBC News, 23 March 2005). Budget cutbacks have been blamed for this but, considering that the cost of not cracking down on infections is estimated to be as high as Ca$100 million, this appears to be a prime example of a false economy.

A survey carried out by UK’s Patients Association, a voice-box for patients’ rights and better standards of care, also provides a worrying insight into the appalling level of infection control in today’s hospitals. For example, when asked whether endoscopes are sterilised after each use, an astonishing 95 per cent reported that they only disinfect, rather than sterilise, the devices. By simply disinfecting, they are only reducing the number of microbes clinging onto the device rather than removing them completely – which is achieved by sterilising. Patients who are next in line to receive the endoscope may be less likely to contract an infection, but there’s no guarantee.

While you may not be able to control how clean the hospital is, you can help yourself by being scrupulous about your own cleanliness, and the hygiene of those who come into contact with you as well as of your immediate area. Such steps may be simple, but they can determine who wins in the battle between germs and humans. These steps include:

* Making sure that the level of cleanliness around your bed is impeccable. If there is dust or dirt around or under your bed, ask for the area to be cleaned
* Don’t get too close to other patients
* Always wash with antibacterial soap after touching other patients or anything that may have been in constant close contact with them, such as an oxygen mask
* Watch that your visitors and the staff also do the above
* Ensure that the toilets and bath are clean before using them
* Always wear shoes or slippers. Bare feet pick up dirt from the floor and bring it into your bed
* Do not use tissues more than once
* Make sure that you keep yourself as well-nourished as possible to keep your immune function going strong
* Arm yourself with a number of essential oils which can act as effective antibacterial/antifungal agents (see box, page 4).

Medicine mix-up
Aside from being fertile ground for pathogens to breed, hospitals house staff who, like any other people, can make mistakes. Many have to work tortuously long hours and, in the current climate of constant cutbacks, often have to ‘make do’ with inadequate tools. Added to the fact that many patients still believe in the infallibility of the white coat and don’t dare to question their doctors, it’s hardly surprising that medical blunders not only happen, but do so at a worryingly high frequency (see box, page 2).

Among the possible medical accidents that can occur, the most frequent are errors in giving out drugs. Around 18 per cent of UK patients have reported being the victim of a medication error at some time in the previous two years – and some 7000 people in the US die from such mistakes.

According to a US Food and Drug Administration (FDA) consumer report, one of the more common causes of these errors is confusion over drug names (see http://www.fda.gov/fdac/features/2000/500_err.html). This is no surprise considering that the number of drugs has grown by 500 per cent over the last decade. There are over 17,000 trade and generic drug names currently listed on the North American market alone.

One example of how drugs with similar names can be easily mixed up is the antiepileptic drug Lamictal and the antifungal drug Lamisil. The possible consequences of giving patients the wrong drug are not to be belittled. Epileptic patients receiving Lamisil can have their epileptic seizures worsened, whereas non-epileptic patients wrongly given Lamictal could develop a serious rash, blood pressure changes or other side-effects. So frequent were the reports of dispensing errors involving these two drugs that Lamictal’s manufacturer, Glaxo Wellcome, was forced to launch a campaign warning pharmacists of the possible confusion.

Another common mix-up is between the arthritis drug Celebrex, the anticonvulsant Cerebyx and the antidepressant Celexa. There have been more than 100 accounts of mix-ups among the three drugs although, so far, none has resulted in serious harm to the patient.

Another cause of medication errors is miscommunication of drug orders, which may involve illegible handwriting on the prescription form, misreading of the dosage and/or inappropriate abbreviations.

Errors can also arise through incomplete patient information – not knowing about patients’ allergies or other medicines they are taking, leading to possible dangerous drug interactions – and inappropriate labelling of the drugs themselves.

In a bid to cut down on medication mistakes, computerised tracking systems are now increasingly being integrated into hospitals and healthcare centres. These systems are designed to improve the overall drug-administration process by reducing lost orders, transcription time and cost. They also reduce ambiguity due to bad handwriting and incompleteness of written orders.

As computers are also likely maintain electronic medical records of the patients, it should be possible to screen for potentially dangerous drug interactions between a newly prescribed drug and one that the patient is already taking.

So, what’s the catch? Technology comes at a price, and few hospitals-and even fewer independent doctors-can afford it. And, as we all know from experience, computers are not perfect. Just one of those so-called ‘computer glitches’ could set off a time-consuming false alarm.

Also, don’t forget that human input is required to make the system work, and any carelessness on the part of the person entering the data will render useless the very ‘super’ system you’ve paid for to avoid mistakes.

Instead of putting yourself at the mercy of doctors and computers, you can take positive action to ensure that you don’t fall victim to a preventable medical blunder.

* Keep in the loop. Ask plenty of questions and make sure you are satisfied with the answer, and don’t let the doctor wave away your concerns. Is the proposed drug prescription necessary? Are there any alternatives that could achieve the same effect as the drug? What drugs or foods should be avoided while taking the drug? Ask about the possible drug side-effects-from the common to the rare occurrences.

* Double-check the prescription. As mentioned earlier, similar sounding names of different drugs can easily give rise to prescription errors. Confirm for yourself that the drug is the right one for your condition. And don’t simply accept your doctor’s word for the safety of the drug. Many of them rely on the marketing talk-ups and pharmaceutical sales reps, and what they read in the adverts.

* Make it a point to know what you’re supposed to be taking. Try and learn the names of the drugs that will be administered to you at hospital, and find out the dosage schedule. Always ask the doctor or nurse to confirm both the drug and dosage every time you’re given it. While this may make you seem somewhat paranoid, such a nudge could jolt tired hospital staff into realising they’ve made a possibly fatal error.

* Keep an eye on the intravenous drip. Apply the same precautions to the drip. Know what you’re supposed to be getting in your iv preparation, and always check that the label on the bottle is consistent.

* Recruit another pair of watchful eyes. As you may not always be fit enough to maintain a vigil over your medication and dosage schedules, enlist a family member or friend to check the drugs/dosages you’re supposed to be taking.

Tina Tan
For more information on ways to protecting yourself during a hospital stay, read WDDTY’s The Hospital Survival Guide-£6.95 (UK)/£8.45 (overseas).

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Written by What Doctors Don't Tell You

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