Unhealthy care

Print edition : October 08, 2010

INSIDE A HOSPITAL in Srikakulam, Andhra Pradesh, where rainwater has entered.-BASHEER

Hospitals in India are generally lackadaisical in following stringent patient safety and infection-control standards.

AN epidemiological study on the emergence of new antibiotic resistance mechanism in bacteria in India, Pakistan and the United Kingdom was recently published in Lancet, the medical journal. Medical experts in India, supported by the Government of India, quickly rubbished the report. Even before the publication of this study, the World Health Organisation (WHO) had been issuing warnings on the emergence of highly resistant strains of bacteria from South-East Asia. The WHO meeting of Health Ministers from the South-East Asia Region, held in Bangkok recently, focussed on the problem of what is now popularly known as a superbug. Are we justified in downplaying an important issue such as hospital-acquired infections, which could cost lives and money?

I visited a hospital recently as part of an inspection team and was appalled to find that there was no running water in a patient-examination room. It was not possible for medical personnel to wash their hands between patient examinations even if they wanted to. Doctors were not wearing gloves while doing medical examinations. They were using instruments for the examinations, but I could not see how they could sterilise them. This was a teaching hospital and what I saw was possibly an extreme case of poor infection control practices, but hospitals in India have not fallen in line with the stringent patient safety and infection-control standards that hospitals in the West are required to follow.

A few hospitals in India, 16 to be precise, have been accredited by the Joint Commission International (JCI), a United States-based hospitals standards organisation, which has laid down guidelines and standards for hospitals to ensure that errors in health care are minimised. This accreditation was required by these 16 Indian hospitals to treat patients covered by international insurance companies. Medical tourism appears to be the incentive. Another 50 hospitals were accredited by the National Accreditation Board for Hospitals and Healthcare Providers (NABH) of the Quality Council of India (QCI). The guidelines and requirements of this body are, however, less stringent than those of the JCI but cover several aspects of patient safety. There are thousands of hospitals in India without any accreditation.

To err is human

A 1999 report, To Err is Human, of the Institute of Medicine, U.S., aimed at building safe health care systems, attributed 98,000 deaths in the U.S. at that time to medical errors, distinct from medical negligence. This report spurred a movement in the health care industry in the U.S., leading to the development of norms and standards for patient safety over the last decade. The process, which started in 1917 with a one-page note on the minimum requirements for a hospital, was led by the Joint Commission on Accreditation of Hospitals. It has since evolved into a large hospital accreditation and patient safety organisation, with the JCI as its international section. The process triggered in the U.S. by this landmark report also spurred the rest of the world towards patient safety.

The National Patient Safety Agency of the U.K. focusses on safe patient care issues in the National Health Service, which is the largest publicly funded health care agency in the world. Similar organisations are in place all over the Western world, advising hospitals and educating the public on patient safety. The World Alliance on Patient Safety, a WHO initiative, recognises patient safety as a serious global public health issue. According to the WHO, estimates show that in developed countries one in every 10 patients is harmed while receiving hospital care. In the U.S., 2.9 per cent of the people who enter hospitals are actually harmed by the care they receive.

Patient safety goals are defined. Correct patient identification, improved communication, medication safety, reduced risk of health care associated infections, safe environment of care, and safe surgery are some of the major goals for hospitals to achieve to reduce the harm that can be done to patients while intending to do good.

First do no harm is an often quoted term from Hippocrates; the Hippocratic Oath is taken by medical graduates. Errors are adverse events that are preventable. For example, if a patient developed a urinary tract infection after surgery while in hospital, it is an adverse event. If an analysis of the case reveals that the patient was infected because of poor hand-washing or instrument-cleaning techniques used by the staff, the adverse event is considered preventable. But the analysis may conclude that no error occurred; in that case the patient would be presumed to have had a difficult surgical procedure and recovery (not a preventable adverse event).

A study by the Centres for Disease Control and Prevention (CDC) in 2003 reported that 52 per cent of doctors did not clean their hands between patient examinations. A 1997 study found a doctor's lab coat picked up MRSA (Methicillin Resistant Staph Aureus) a hospital acquired bacterium 65 per cent of the time when leaning over an infected patient. In a 2006 study, 77 per cent of blood pressure cuffs on rolling carts were found to be contaminated with MRSA. Since there is no public health Act in India, we have not been able to establish a statutory regulatory or surveillance body for monitoring the outbreak of these dangerous drug-resistant bacteria, and consequently there are no data in the public domain on the occurrence of MRSA infections. Hospital-acquired infections, also called nosocomial infections, are monitored by the National Nosocomial Infections Surveillance Systems (NNISS) in the U.S., and its reports are in the public domain.

The graph (on page 40) is a depiction of the monitoring of bloodstream infections that are likely to be introduced in intensive care units (ICUs) because of the several intravenous lines that are put in for drug administration. Monitoring helps to reduce the occurrence of these dangerous infections. Modern medicine comes with the responsibility of educating patients of the risks of hospital care and steps taken to reduce these adverse incidents.

The cost of medical errors

Preventable patient injury resulting from medical mistakes costs the U.S. economy $17 billion to $29 billion annually, half of which are health care costs. Effective infection-control measures and surgical and medication safety, therefore, mean reducing costs by this magnitude. In the U.K., the cost of medical errors is estimated at around 4 billion. In India, there are no data on medical errors or studies on the cost of medical errors, but if we go by the evidence that is available from the West, the cost of medical errors here will be huge. The cost of medical errors is social, psychological as well as economic. For instance, a patient who acquires a hospital infection will need an expensive antibiotic treatment, which would extend his stay in the hospital and prolong his recovery time even after discharge from the hospital. This would mean a greater dislocation for the family and time away from work.

One has to only walk into any pharmacy in India to see how drugs of all kinds are dispensed. A prescription for medicines is required only if one cannot remember the names of the drugs. The pharmacist is also helpful in prescribing a drug if you explain your symptoms. Who is responsible for medication safety in this situation? Even if the patient is willing to spend more and seek a medical consultation for a prescription, what is the assurance that the clinician has followed all principles of patient safety? Antibiotic misuse is rampant in this country as it is worldwide. Resistant strains have been identified from clinical establishments and it is well established in medical literature that multi-drug-resistant organisms are the result of poor antibiotic stewardship. Misuse of antibiotics is inevitable when most antibiotics are available over the counter.

Proper Identification

Minimising preventable errors requires an organised effort from the health care industry, the governments and the public. It calls for a culture change in the way health care is delivered.

The public should expect and demand higher standards of safety from hospitals and health care establishments. The protocols for patient safety are not too difficult for a layperson to look out for in a hospital. The first goal of patient safety is proper identification of the patient on admission. Most Western hospitals and a few good ones in India have patient identification bands with patient identification numbers on them fastened to the patient's wrist on admission. Identification of a patient by name alone has resulted in several errors, particularly medication errors. In one particular instance this was a hospital known for quality care two patients by the name of Champa Devi (a common female name in North India) were posted for surgery on the same day. Both needed breast surgery. While one had a biopsy-proven malignant breast disease requiring a radical removal of the breast, the other had a lump in the breast needing a biopsy. The patients were switched and the consequences for the patient who just needed a biopsy (which was, in fact, benign) but had a mutilating breast-removal surgery can well be imagined.

A 19-item surgical safety checklist, developed by the WHO and tested in seven centres in the world, including India, is available for use in hospitals. The rate of death was 1.5 per cent before the checklist was introduced; it declined to 0.8 per cent afterwards. Inpatient complications occurred in 11 per cent of the patients at baseline and in 7 per cent after the introduction of the checklist ( New England Journal of Medicine). However, very few hospitals in India use this checklist.

A Patient Safety culture

Well-displayed stickers and posters reminding doctors, patients and visitors of the importance of hand hygiene, accessible alcohol hand rub dispensers, well-segregated and organised waste disposal systems, and fire escape plans on the walls of the corridors of a hospital should give confidence to patients about the hospital's attempts to reduce harm to its patients.

A regulatory Act concerning clinical establishments is on the anvil. However, mere regulations cannot bring about a patient safety culture that is badly needed in the thousands of clinical establishments in the country. A patient safety culture needs to be introduced in all the hospitals. The initial costs for introducing patient safety measures would be a deterrent to hospitals. But considering the long-term cost savings that can be made from infection control and antibiotic stewardship, along with the cost savings from needless litigation over avoidable errors, the health care industry should be encouraged to move towards benchmarking best practices and standards and seeking accreditation.

The move by the Central Government Health Services (CGHS), mandating NABH accreditation for the empanelment of hospitals, is welcome. Health insurance companies should similarly use their clout to require hospitals to go in for standards accreditation. The most important is awareness on the part of the public of its right to be treated in a safe hospital, whether it is private or public. Consumer protection agencies should be aware of the basic patient safety protocols that a hospital should have, and litigation involving hospitals that do not have quality and safety protocols in place should be dealt with seriously.

The author is the Chancellor of Martin Luther Christian University, Shillong, and a Technical Working Group member of the WHO's World Alliance on Patient Safety.

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