Category Archives: Safety

A Perfect Storm in Haiti and Surge Capacity Lessons for the U.S.

Haiti is still reeling from the massive earthquake with over 1 million people living in tent cities. The unfolding cholera outbreak is causing much more misery. Now, Hurricane Tomas is heading that direction. What is the synergy of destruction that is likely to come if Tomas hits Haiti as well?

As of October 27, there were 4,722 cases of cholera and 303 deaths according to the WHO. Realistically though, both the number of cases and deaths is likely much higher due to the difficulties of collecting this data in a country that has had its entire infrastructure so incredibly ravaged.

The health care system there now (at least what there is of it) is  overwhelmed by the number of patients with cholera. There are no beds remaining. Patients have to lie on the floor or outside on the ground. This actually should be a major warning shot across the bow of the US health care infrastructure.

Surge capacity is “The ability to obtain adequate staff, supplies and equipment, structures and systems to provide sufficient care to meet immediate needs of an influx of patients following a large-scale incident or disaster.” Essentially it is describing the ability to care for a large number of people.

Therein lies the problem in the US. There are a decreasing number of bed days available in hospitals. That is essentially a count of the number of available beds each day around the country. That is occurring at the same time that the baby boomer generation will be using MORE of those bed days as they age. (Healthc Financ Manage. 2007 Jun;61(6):114-5.)

Some people might wonder why that is a problem. Won’t the invisible hand of economics resolve the issue? Take a look at where the US stands in comparison to other countries on the number of hospital beds per 1,000 population. It should be noted that this represents the number of licensed, staffed beds. It isn’t looking at usage rates, which paints a far more ominous picture for the future of US health care. The US is far behind other industrialized countries on this measure.

During the winter (pneumonia and influenza season), hospitals can easily reach capacity, without the impact of a disaster. That is the most worrisome part of this problem. The US health care system keeps losing its capacity to care for patients with routine problems. If a major event were to unfold, the system would not likely be able to absorb the impact of mass casualties.

Most people don’t know what hospital care is like until they are older and need it for themselves. Labor and delivery isn’t a good comparison because hospitals fund and market these areas differently than the rest of the facility. Today, staff feel overworked and this can lead to mistakes or at least a less than desirable experience for the patient.

A good analogy of what is happening in health care is the airline industry. Think about what happens when airlines consolidate. Routes are reduced, smaller aircraft are used, and each plane is filled beyond capacity. Travelers now have to deal with minimal leg room, eight peanut meals, baggage fees, and increased chances of getting bumped from a flight. There will be a number of problems in the health care industry as well, although it will be hard to predict exactly what the parallels could be drawn between “riding the friendly skies” and “riding the friendly gurneys.” The equivalent of getting bumped in a hospital though could be tragic.

Is that realistic though? Could hospitals really become that overwhelmed in the US? One only has to look back at the 1918 Spanish Influenza pandemic for a model. Johns Hopkins University Hospital CLOSED to anyone but staff and students. Hospitals routinely turned away patients in Philadelphia. Two military base hospitals at the time paint a grim picture. Camp Devens (near Baltimore) had a hospital that was built to hold 1,200 patients but had OVER 6,000 during the worst of the outbreak. Camp Grant (near Rockford, Ill.) went from 610 to 4,102 patient in only six days. An event on that scale would cripple the health care system today. US hospital capacity is in critical condition.

Back to Haiti

The refugees in Haiti are facing something terrible. Fortunately, it doesn’t look at this time like Tomas will make landfall in the area. However, they have a 50% chance of having to deal with sustained tropical storm (>=39 mph) surface winds and rain. Imagine trying to live that way in a tent or shack. The minimal housing that they have could easily be destroyed. The government has already suggested evacuating these sites, but that will obviously not be possible for a number of people in these areas.

This whole scenario could easily increase the rates of cholera in the area. More of the environment could become tainted and  sanitation and clean water facilities could be compromised. This could give an entirely new meaning to the concept of “a perfect storm.”

How Many Must Die? – Part 2

So how did we get to this point? Is health care delivery really that far behind in quality?

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In April 2000, the Institute of Medicine issued a report titled “To Err Is Human: Building a Safer Health System.” This report detailed the incredible number of mistakes and adverse outcomes that occur in American health care. As one might expect, this sort of exposé had many detractors (JAMA. 2000 Jul 5;284(1):93-5).

Of course, it’s nearly impossible to completely remove errors when humans are a major part of the process. No matter how educated or skilled we are, mistakes are bound to occur. There is something in our nature though that seems to prevent us from admitting to making these mistakes and being transparent about them.

As an example, assume you are the parent of a child and your pediatrician makes a mistake. Don’t you think you should have a right to know? Most parents want this kind of disclosure (Arch Dis Child. 2010 Apr;95(4):286-90). Unfortunately, mistakes are often buried and not disclosed. This is even more likely when the pediatrician thinks the parent is less likely to find out about the error. (Arch Pediatr Adolesc Med. 2008 Oct;162(10):922-7).

Obviously, one of the things that works against disclosure is our litigious society. That seems like a rather pat answer though. Lawsuits may actually be more of a symptom of a deeper problem and not the primary cause of what is happening.

There are probably a couple of factors that are playing roles in the health care quality problem.

First, health care has become incredibly complicated. It isn’t just due to the types of care provided using advanced technology but also the business of health care is a massive tangle. If you don’t think so, just try to contact a few hospitals and see if you can find out the cost of something as simple as an appendectomy. It’s unlikely that you will be able to get a straight answer. Some of this is legitimate because of other medical conditions that may come into play because of the cost of care. The crazier part of it though is that the cost isn’t set – it’s completely influenced by the prices negotiated by your health insurance provider. Even if you need to go into an emergency room to obtain care, it’s unlikely that anyone you come in contact with would have any clue as to how much your visit is going to cost you.

This complicated system drives health care organizations into the second problem, structures that are very resistant to change. This is even more evident as organizations become larger and larger. Not only is there a systemic problem, but the large scale of organizations and the multiple approvals needed for projects turns health care systems into institutions with all of the speed and nimble handling of a glacier.

This problem is even more apparent when you look at how long it takes for a new pharmaceutical agent or medical device to gain wide acceptance in the marketplace. Granted, there is some reluctance for providers to become early adopters of new technology until it has stood the test of time. Guess how long though it takes for widespread adoption of new medicine or technology. Do you think it might be five or ten years? Try again. The average is 19 years.

Personally, I use the “loved ones test” when I look at new technology. Essentially, if there is enough convincing medical literature suggesting benefit, I ask myself “would I want this for one of my loved ones?” If the answer is yes, it’s probably a pretty good technology to at least trial if not outright adopt.

This resistance to change might be one of the biggest barriers to improving quality in health care. It’s both a problem of organization size and inertia along with something that is much more sinister and not discussed –  the problems of power, ego, and self-interest. On the surface nobody will admit to this, but I have seen these themes crop up over and over again. For example, I worked at a large metropolitan hospital and wanted to empower patients to ask their caregivers if they had washed their hands. Seems like a simple thing, doesn’t it? Obviously it wasn’t. I had to bring the idea before the nursing union which adamantly blocked the process. I had never dealt with the union before and I wasn’t sure why the senior administration wouldn’t tackle this issue with them since they were responsible for union negotiation issues.

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This whole problem reminds me of a book I read that was recommended to me by a friend years ago (thanks Jennifer). The book is People of the Lie: The Hope of Healing Human Evil by M. Scott Peck. In it, Peck gives a number of case studies of individuals who appeared normal on the outside but clearly had problems of evil within their cores. Maybe that’s something that our superficial culture has spawned. Later in the book though, he discusses corporate evil, which is one of the most fascinating topics and arguments I’ve ever read. He conducts an organizational case study of the Mỹ Lai Massacre by a unit of the US Army during the Vietnam War. He poses the question “How is it that approximately five hundred men, the majority of whom were not evil as individuals, could all have participated in an act as monstrously evil as that at MyLai?” The answer to that question has fascinated me since I read the book years ago. The entire discussion on the topic of organizational evil is really a must-read for anyone interested in organizational culture.

So are health care organizations evil? Usually not. Do they have evil characteristics? Sometimes. You don’t have to look far to find ones who blatantly put profit over safety. For example, in 2008 it was discovered that an endoscopy clinic in Nevada was reusing syringes and medication vials in attempt to cut costs. The incident led to the largest public health investigation (40,000 people) in US history. I’m board-certified in infection prevention and was dumbfounded to hear that something like this occurred with so many patients at risk and so many providers at fault. This is exactly the kind of group think that Peck was referring to in his book.

There are other problems that occur in the health care system as well. For example, I’ve seen instances where physicians are allowed to make decisions around preventative measures in a hospital that would potentially impact the volume of work they would see in their private practice. In other industries, that would be considered a major conflict of interest but that problem didn’t even seem to make anyone’s radar because it was the normal way of doing things. That thinking and process must change if we are to see improvements in health care quality.

So here is the real question. Why is it that health care is following the lead around manufacturing processes (the Toyota Production System in order to learn to be lean, Six Sigma from Motorola to reduce variability and improve quality) or simple things like preflight checklists in the airline industry to ensure safety? Health care is making progress in these areas but shouldn’t health care be the leader instead of the manufacturing and transportation industries? Where did we go wrong?