ASSIGNMENT: How should a hospital respond to the New York State initiative to prevent the spread of Candida auris, when there are no evidenced based best practices?
New PART 3 after PARTS 1 & 2
ART 1. April16, 2019. Is it ethical for the public not to be notified about new “super bugs” in hospitals so they can decide whether or not to go to affected hospitals?
PART 2. May 13, 2019. CANDIDA AURIS. “In 30 years, I’ve
never faced so tough a reporting challenge – and one so unexpected. Who
wouldn’t want to talk about a fungus?…
PART 1. April16,
2019. Is it ethical for the public not
be notified about new “super bugs” in hospitals so they can decide
whether or not to go to affected hospitals?
“Last May, an elderly man was admitted to the Brooklyn
branch of Mount Sinai Hospital for abdominal surgery. A blood test revealed
that he was infected with a newly discovered germ as deadly as it was
mysterious. Doctors swiftly isolated him in the intensive care unit.
The germ, a fungus called Candida auris, preys on people
with weakened immune systems, and it is quietly spreading across the globe. Over
the last five years, it has hit a neonatal unit in Venezuela, swept through a
hospital in Spain, forced a prestigious British medical center to shut down its
intensive care unit, and taken root in India, Pakistan and South Africa.
Recently C. auris reached New York, New Jersey and Illinois,
leading the federal Centers for Disease Control and Prevention to add it to a
list of germs deemed “urgent threats.”
The man at Mount Sinai died after 90 days in the hospital,
but C. auris did not. Tests showed it was everywhere in his room, so invasive
that the hospital needed special cleaning equipment and had to rip out some of
the ceiling and floor tiles to eradicate it.
“Everything was positive – the walls, the bed, the
doors, the curtains, the phones, the sink, the whiteboard, the poles, the
pump,” said Dr. Scott Lorin, the hospital’s president. “The mattress,
the bed rails, the canister holes, the window shades, the ceiling, everything
in the room was positive.”” (A)
“Back in 2009, a 70-year-old Japanese woman’s ear
infection puzzled doctors. It turned out to be the first in a series of
hard-to-contain infections around the globe, and the beginning of an ongoing
scientific and medical mystery.
The fungus that infected the Japanese woman, Candida auris,
kills more than 1 in 3 people who get an infection that spreads to their blood
or organs. It hits people who have weakened immune systems, and is most often
found in places like care homes and hospitals. Once it shows up, it’s hard to
get rid of: unlike most species of fungi, Candida auris spreads from person to
person and can live outside the body for long periods of time.
Mount Sinai wasn’t the first hospital to face this task: a
London hospital found itself with an outbreak in 2016, and the only way to stop
it was to rip out fixtures…
Scientists still aren’t sure exactly where this happened or
when. That’s one of the things they’re working on now, says Cuomo, because
figuring out how the fungus evolved could help researchers develop treatments
for it…
Although the “superbug” moniker might sound
alarmist, Candida auris qualifies for two reasons, says Cuomo. First, all
strains of the yeast are resistant to antifungals. There are three major kinds
of antifungals used to treat humans, and some strains of Candida auris are
resistant to all of them, while other strains are resistant to one or two. That
limits the treatment options for someone who has been infected-someone who is
probably already in poor health. The other reason is “this really scary
property of not being able to get rid of it,” Cuomo says.” (B)
“Superbugs are a terrifying prospect because of their
resistance to treatment, and one superbug that is sweeping all over the world
is the Candida auris.
C. auris is a fungus that causes serious infections in
various parts of the body, including the bloodstream and the ear.
While its discovery has been relatively recent in 2009, this
fungus has already wreaked havoc in hospitals in more than 20 different
countries, including the United States, United Kingdom, and Spain, among
others.
In the United States, CDC reports a total of 587 clinical
cases of C. auris infections as of February. Most of it occurred in the areas
of New York City, New Jersey, and Chicago.” (C)
“The CDC issued a public alert in January about a drug-resistant
bacteria that a dozen Americans contracted after undergoing elective surgeries
at Grand View Hospital in Tijuana, Mexico. Yet when similar outbreaks occur at
U.S. hospitals, the agency does not issue a public warning. This is due to an
agreement with states that prohibits the CDC from publicly disclosing hospitals
undergoing outbreaks of drug-resistant infections, according to NYT.
Patient advocates are pushing for more transparency into
hospital-based infection outbreaks, saying the lack of warning could put
patients at risk of harm.
“They might not get up and go to another hospital, but
patients and their families have the right to know when they are at a hospital
where an outbreak is occurring,” Lisa McGiffert, an advocate with the
Patient Safety Action Network, told NYT. “That said, if you’re going to
have hip replacement surgery, you may choose to go elsewhere.”..
The CDC declined NYT’s request for comment. Agency officials
have previously told the publication the confidentiality surrounding outbreaks
is necessary to encourage hospitals to report the drug-resistant
infections.” (D)
“New Jersey is among the states worst affected by an
increasing incidence of the potentially deadly fungus Candida auris, whose
resistance to drugs is causing headaches for hospitals, state and federal
health officials said on Monday.
There were 104 confirmed and 22 probable cases of people
infected by the fungus in New Jersey by the end of February, according to the
federal Centers for Disease Control and Prevention, up sharply from a handful
when the fungus was first identified in the state about two years ago.
The state’s number of cases – now the third-highest after
New York and Illinois – has risen in tandem with an increase, first overseas,
and now in the United States, in a trend that some doctors attribute to the
overuse of drugs to treat infections, prompting the mutation of infection
sources, in this case, a fungus.
The fungus mostly affects people who have existing
illnesses, and may already be hospitalized with compromised immune systems,
health officials said.
Nicole Kirgan, a spokeswoman for the New Jersey Department
of Health, said she didn’t know whether any of the state’s cases have been
fatal, and couldn’t say which hospitals are treating people with the fungus
because they have not, so far, been required to report their cases to state
officials…
But Dr. Ted Louie, an infectious disease specialist at
Robert Wood Johnson University Hospital in New Brunswick, said many hospitals
don’t know how to eradicate the fungus once it has occurred.
Some disinfectants commonly used in hospitals have proved
ineffective in removing the fungus, Dr. Louie said, so hospitals have been
urged to use other disinfecting agents, although it’s not yet clear which of
them work, if any.
“This is a fairly new occurrence and we are still
learning how to deal with it,” he said. “We have to figure out which
disinfectant procedures may be best to try to eradicate the infection, so at
this point, I don’t think we have good enough information to advise.” (E)
“Adding to the difficulty of treating candida auris is
finding it in the first place. The infection is often asymptomatic, showing few
to no immediate symptoms, said Chauhan. The symptoms that do appear, such as
fever, are often confused for bacterial infections, he said.
“Most routine diagnostic tests don’t work very well for
candida auris,” he said. “They’re often misidenfitied as other
species.”
The best way to identify candida auris is by looking under a
microscope, which often takes time because it requires doctors to grow the
fungus, Chauhan said.
As with most infectious diseases, the best course of action
is good hygiene and sterilization protocol. Washing your hands and using hand
sanitizer after helps to prevent transmission and infection, Chauhan said.
Doctors and healthcare workers should use protective gear,
and people visiting loved ones in hospitals and long-term care centers should
take proper precautions, he said.
The Center for Disease Control recommends using a special
disinfectant that is used to treat clostridium difficile spores. The
disinfectant has been effective in wiping out clostridium difficile, known as
c. diff, and disinfects surfaces contaminated with candida auris, as
well.” (F)
“Hospitals and nursing homes in California and Illinois
are testing a surprisingly simple strategy against the dangerous,
antibiotic-resistant superbugs that kill thousands of people each year: washing
patients with a special soap.
The efforts – funded with roughly $8 million from the
federal government’s Centers for Disease Control and Prevention – are taking
place at 50 facilities in those two states.
This novel approach recognizes that superbugs don’t remain
isolated in one hospital or nursing home but move quickly through a community,
said Dr. John Jernigan, who directs the CDC’s office on health care-acquired
infection research.
“No health care facility is an island,” Jernigan
said. “We all are in this complicated network.”
At least 2 million people in the U.S. become infected with
an antibiotic-resistant bacterium each year, and about 23,000 die from those
infections, according to the CDC…
Containing the dangerous bacteria has been a challenge for
hospitals and nursing homes. As part of the CDC effort, doctors and health care
workers in Chicago and Southern California are using the antimicrobial soap
chlorhexidine, which has been shown to reduce infections when patients bathe
with it. Though chlorhexidine is frequently used for bathing in hospital
intensive care units and as a mouthwash for dental infections, it is used less
commonly for bathing in nursing homes…
The infection-control work was new to many nursing homes,
which don’t have the same resources as hospitals, Lin said.
In fact, three-quarters of nursing homes in the U.S.
received citations for infection-control problems over a four-year period,
according to a Kaiser Health News analysis, and the facilities with repeat
citations almost never were fined. Nursing home residents often are sent back
to hospitals because of infections.” (G)
“The C.D.C. declined to comment, but in the past
officials have said their approach to confidentiality is necessary to encourage
the cooperation of hospitals and nursing homes, which might otherwise seek to
conceal infectious outbreaks.
Those pushing for increased transparency say they are up
against powerful medical institutions eager to protect their reputations, as
well as state health officials who also shield hospitals from public scrutiny…
Hospital administrators and public health officials say the
emphasis on greater transparency is misguided. Dr. Tina Tan, the top
epidemiologist at the New Jersey Department of Health, said that alerting the
public about hospitals where cases of Candida auris have been reported would
not be useful because most people were at low risk for exposure and public
disclosure could scare people away from seeking medical care.
“That could pose greater health risks than that of the
organism itself,” she said.
Nancy Foster, the vice president for quality and patient
safety at the American Hospital Association, agreed, saying that publicly
identifying health care facilities as the source of an infectious outbreak was
an imperfect science.
“That’s a lot of information to throw at people,”
she said, “and many hospitals are big places so if an outbreak occurs in a
small unit, a patient coming to an ambulatory surgical center might not be at
risk.”
Still, hospitals and local health officials sometimes hide
outbreaks even when disclosure could save lives. Between 2012 and 2014, more
than three dozen people at a Seattle hospital were infected with a
drug-resistant organism they got from a contaminated medical scope. Eighteen of
them died, but the hospital, Virginia Mason Medical Center, did not disclose
the outbreak, saying at the time that it did not see the need to do so.”
(H)
“Many have heard of the rise of drug-resistant
infections. But few know about an issue that’s making this threat even scarier
in the United States: the shortage of specialists capable of diagnosing and
treating those infections. Infectious diseases is one of just two medicine
subspecialties that routinely do not fill all of their training spots every
year in the National Resident Matching Program (the other is nephrology).
Between 2009 and 2017, the number of programs filling all of their
adult-infectious-disease training positions dropped by more than 40 percent…
Everyone who works in health care agrees that we need more
infectious-disease doctors, yet very few actually want the job. What’s going on?
The problem is that infectious-disease specialists care for
some of the most complicated patients in the health care system, yet they are
among the lowest paid. It is one of the only specialties in medicine that
sometimes pays worse than being a general practitioner. At many medical
centers, a board-certified internist accepts a pay cut of 30 percent to 40
percent to become an infectious-disease specialist.
This has to do with the way our insurance system reimburses
doctors. Medicare assigns relative value units to the thousands of services
that doctors provide, and these units largely determine how much physicians are
paid. The formula prioritizes invasive procedures over intellectual expertise.
The problem is that infectious-disease doctors don’t really
do procedures. It is a cognitive specialty, providing expert consultation, and
insurance doesn’t pay much for that…
Infectious-disease specialists are often the only health
care providers in a hospital – or an entire town – who know when to use all of
the new antibiotics (and when to withhold them). These experts serve as an
indispensable cog in the health care machine, but if trends continue, we won’t
have enough of them to go around. The terrifying part is that most patients
won’t even know about the deficit. Your doctor won’t ask a specialist for help
because in some parts of the country, the service simply won’t be available.
She’ll just have to wing it…
We must hurry. Superbugs are coming for us. We need experts
who know how to treat them.” (I)
People visiting patients at the hospital, and most
hospitalized patients, have little to fear from a novel fungal disease that has
struck more than 150 people in Illinois – all in the Chicago area – a Memorial
Medical Center official said Friday.
“For normal, healthy people, this is not a
concern,” Gina Carnduff, Memorial Health System director of infection
prevention, said in reference to Candida auris infections.
Carnduff, who is based at Memorial Medical Center, said only
the “sickest of the sick” patients are at risk of catching or
spreading the C. auris infection or dying from it.
Those patients, she said, include people who have stayed for
long periods at health care facilities – such as skilled-care nursing homes or
long-term acute-care hospitals – and who are on ventilators or have central
venous catheter lines or feeding tubes…
Officials from both Memorial Medical Center and HSHS St.
John’s Hospital said their institutions already are using the bleach-based
cleaning solutions known to prevent the spread of C. auris and other
infections.
The Illinois Department of Public Health’s website says more
than one in every three people with “invasive C. auris infection”
affecting the blood, heart or brain will die…
The state health department says 154 confirmed cases of C.
auris and four probable cases have been identified, all in the Chicago area.
Ninety-five cases were in Chicago, 56 were in Cook County outside of Chicago,
and seven were spread among the counties of DuPage, Lake and Will.
Eighty-five of the 158 people making up the confirmed and
probable cases have died, but only one death was “directly
attributed” to the infection, Arnold said. It’s not known whether C. auris
played a role in the deaths of the other 84 people, she said. (J)
“There is also the fact that some lab tests will not
identify the superbug as the source of an illness, which means that some
patients will receive the wrong treatment, increasing the duration of the
infection and the chance to transmit the fungus to another person.” (K)
“Hospitals, state health departments and the Centers
for Disease Control and Prevention are putting up a wall of silence to keep the
public from knowing which hospitals harbor Candida auris.
New York health officials publish a yearly report on
infection rates in each hospital. They disclose rates for infections like MRSA
and C. Diff. But for several years, the same officials have been mum about the
far deadlier Candida auris. That’s like posting “Wanted” pictures for
pickpockets but not serial murderers.
Health officials say they’ll disclose the information in
their next yearly report. That could be many months from now. Too late.
Patients need information in real time about where the risks are…
Dr. Eleanor Adams, a state Health Department researcher,
examined all the facilities in New York City affected by Candida auris over a
four-year period. Adams found serious flaws, including “inadequate
disinfection of shared equipment” to take vital signs, hasty cleaning and
careless compliance with rules to keep infected patients isolated…” (L)
“Remedies for curtailing the advance of C. auris are
familiar. Health care facilities must undergo stringent infection controls,
test for new cases and quickly identify any sources passing it along. Visitors
and medical workers must wash their hands after touching patients or surfaces.
The yeast spreads widely throughout patients’ rooms. Some cleanups have
reportedly required removing ceiling and floor tiles.
C. auris isn’t simply an opportunistic infection. Its rise
is additional evidence that becoming too reliant on certain types of drugs may
have unintended consequences. Exhibit A is the overuse of antibiotics in
doctors’ offices and on farms that encourages the development of drug-resistant
bacteria. Researchers suspect a similar situation involving C. auris and
agricultural fungicides used on crops. So far the origins of C. auris are
unclear, with different clusters arising in different areas of the world.
There’s no need to panic. But vigilance is required to track
C. auris and raise awareness in order to combat it. Officials typically are
eager to spread the word about potential health crises, from measles to MRSA.
In this case, the CDC issued alerts about fungus to health care facilities, but
the New York Times encountered an unusual wall of silence while investigating
superbugs such as C. auris. Medical facilities didn’t want to scare off
patients.
Any attempts to hide the spread of a communicable disease
are irresponsible. Knowledge leads to faster prevention and treatment. Patients
and their families have a right to know how hospitals and government agencies
are responding to a new threat. Medical workers also deserve to be informed of
the risks they encounter on the job.
Battling the superbugs requires aggressive responses and,
ultimately, scientific advancements. Downplaying outbreaks won’t stop their
rise.” (M)
“The rise of C. auris, which may have lurked unnoticed
for millennia, owes entirely to human intervention – the massive use of
fungicides in agriculture and on farm animals which winnowed away more
vulnerable species, giving the last bug standing a free run. Sensitised to
clinical fungicides, C. auris has proved to be difficult to extirpate, and
culls infected humans who cannot fight diseases very effectively – infants, the
old, diabetics, people with immune suppression, either because of diseases like
HIV or the use of steroids. The new superfungus has the makings of a future
plague, one of several which may cumulatively surpass cancer as a leading
killer in a few decades.
The origin of C. auris is known because it broke out in the
21st century, but the plagues from antiquity lack origin stories. Even their
spread was understood only retrospectively, in the light of modern science. The
father of all plagues, the Black Death, originated in China in the early 14th
century and ravaged most of the local population before it began its long
journey westwards down the Silk Route, via Samarkand. At the time, the chain of
hosts that carried it would have been incomprehensible – the afflicting
organism Yersinia pestis, the fleas which it infested, the rats which the fleas
in turn infested, which carried it into the homes of humans….” (N)
“WebMD: Most of us know candida from common yeast
infections that you might get on your skin or mucous membranes. What makes this
one different?
Chiller: It’s not acting like your typical candida. We’re
used to seeing those.
Candida – the regular ones – are already a major cause of
bloodstream infection in hospitalized patients. When we get invasive
infections, for example, bloodstream infections, we think that you sort of
auto-infect yourself. You come in with the candida already living in your gut.
You’re in the ICU, you’re on a broad spectrum antibiotic. You’re killing off
bad bacteria, you’re killing off good bacteria, so what are you left with?
Yeast, and it takes over.
What’s new with Candida auris is that it doesn’t act like
the typical candida that comes from our gut. This seems to be more of a skin
organism. It’s very happy on the skin and on surfaces.
It can survive on surfaces for long periods of time, weeks
to months. We know of patients that are colonized [meaning the Candida auris
lives on their skin without making them sick] for over a year now.
It is spreading in health care settings, more like bacteria
would, so it’s yeast that’s acting like bacteria” (O).
PART 2. In 30
years, I’ve never faced so tough a reporting challenge – and one so unexpected.
Who wouldn’t want to talk about a fungus?…
“C. auris is a drug-resistant fungus that has emerged
mysteriously around the world, and it is understood to be a clear and present
danger. But Connecticut state officials wouldn’t tell us the name of the
hospital where they had had a C. auris patient, let alone connect us with her
family. Neither would officials in Texas, where the woman was transferred and
died. A spokeswoman for the City of Chicago, where C. auris has become rampant
in long-term health care facilities, promised to find a family and then stopped
returning my calls without explanation.” (A)
“Candida auris, also referred to as C. auris, is a
potentially deadly fungal infection that appears to be making its way through
hospitals and long-term care facilities across the country. The New York City
area and New Jersey have reported more than 400 cases over the last few years
alone. Federal health authorities have declared this fungus a “serious
global health threat.”” (B)
“The Council of State and Territorial Epidemiologists
(CSTE) says Candida auris infections have been “associated with up to 40%
in-hospital mortality.”
“Most strains of C. auris are resistant to at least one
antifungal drug, one-third are resistant to two antifungal drug classes, and
some strains are resistant to all three major classes of antifungal drugs. C.
auris can spread readily between patients in healthcare facilities. It has
caused numerous healthcare-associated outbreaks that have been difficult to
control,” the CSTE said.
The CDC added, “Patients who have been hospitalized in
a healthcare facility a long time, have a central venous catheter, or other
lines or tubes entering their body, or have previously received antibiotics or
antifungal medications, appear to be at highest risk of infection with this
yeast.”
The CDC is alerting U.S. healthcare facilities to be on the
lookout for C. auris in their patients.” (C)
“”It’s a very serious health threat,” said
Dr. Irwin Redlener, Columbia University professor and an expert on public
health policy. “It’s a superbug, meaning resistant to all-known
antibiotics.”..
“These people would be in danger, so you don’t want
somebody visiting the hospital not knowing that it’s around and somehow
contracting the infection,” Dr. Redlener said. “That would be an
utter disaster.”..
Dr. Redlener says the secrecy is a big mistake.
“If they’re rattled by Candida auris to the point where
we have secrecy pacts among hospitals and public health agencies, then you’re
just hiding something that obviously needs more attention and resources to deal
with,” he said.
The state Department of Health says there is no risk to the
general public and notes that the vast majority of patients have had serious
underlying medical conditions.
Jill Montag, a spokesperson for the New York State
Department of Health, issued a statement to Eyewitness News.
“We are working aggressively with impacted hospitals
and nursing homes to implement infection control strategies for Candida
auris,” it read.
Montag says they plan to include the name of the impacted
facilities in their annual infection report, which will be released later this
year.
Dr. Redlener says they have the information now and should
release the names now…
“To keep that a secret is putting people in
danger,” he said. “And I don’t think that’s reasonable or
ethical.”” (D)
“We don’t know why it emerged,” said Dr. Maurizio
Del Poeta, a professor of molecular genetics and microbiology at Stony Brook
University’s Renaissance School of Medicine. At the very least, he is
recommending hospitals develop stricter rules on foot traffic in and out of
patients’ rooms because the microbe can be carried on the bottom of shoes.
The pathogen clings to surfaces in hospital rooms,
flourishes on floors, and adheres to patients’ skin, phones and food trays. It
is odorless, invisible – and unlikely to vanish from health care institutions
anytime soon.
“It can survive on a hospital floor for up to four
weeks,” Del Poeta said of C. auris. “It attaches to plastic objects
and doorknobs.”..…
“If we don’t want it to become like Staphylococcus
aureus, then we have to act now,” said Del Poeta, referring to the
bacteria that became the poster child of drug resistance when it developed the
ability to defeat the antibiotic methicillin, garnering the name
methicillin-resistant Staphylococcus aureus, or MRSA…
“In order to get Candida auris out of a room, you have
to take away everything – doorknobs, plastic items, everything. It is very
difficult to eradicate it in a hospital,” Del Poeta said. He said his
institution has never had a patient with C. auris…
Scientists such as Del Poeta contend it’s time for new
methods of addressing resistant microbes of all kinds because infectious
pathogens have developed the power to outwit, outpace and outmaneuver
humankind’s most potent agents of chemical warfare, many of them developed in
the 20th century.” (E)
“A case management program piloted by the New York City
health department monitors patients colonized with Candida auris after they are
discharged into the community and notifies health care facilities of their
status, researchers reported at the CDC’s annual Epidemic Intelligence Service
conference….
Patients can remain colonized with C. auris for months in a
health care setting, but it is unclear if they remain colonized after
discharge, noted Genevieve Bergeron, MD, MPH, an Epidemic Intelligence Service
officer with the New York City Department of Health and Mental Hygiene (DOHMH),
and colleagues.
According to Bergeron and colleagues, the state health
department began referring patients colonized with C. auris to the DOHMH on
Oct. 4, 2017. Approximately 12 case managers handled the referrals, conducting
patient interviews and reviewing medical records to obtain relevant clinical
information. They informed the patients’ providers and health care facilities
about their C. auris status and infection control needs.
“We requested that facilities flag the patient in their
electronic medical records to ensure that the patient has the proper
precautions, if the patient were to seek care again at those facilities,”
Bergeron said in a presentation. “Case mangers sent a medical alert card
to the patients for them to use when encountering health care providers unaware
of their infection control needs.”” (F)
“Regions are considering the use of electronic
registries to track patients that carry antibiotic-resistant bacteria including
carbapenem-resistant Enterobacteriaceae (CRE). Implementing such a registry can
be challenging and requires time, effort, and resources; therefore, there is a
need to better understand the potential impact…
When all Illinois facilities participated (n=402), the
registry reduced the number of new carriers by 11.7% and CRE prevalence by 7.6%
over a 3-year period. When 75% of the largest Illinois facilities participated
(n=304), registry use resulted in a 11.6% relative reduction in new carriers
(16.9% and 1.2% in participating and non-participating facilities,
respectively) and 5.0% relative reduction in prevalence. When 50% participated
(n=201), there were 10.7% and 5.6% relative reductions in incident carriers and
prevalence, respectively. When 25% participated (n=101), there was a 9.1%
relative reduction in incident carriers (20.4% and 1.6% in participating and
non-participating facilities, respectively) and 2.8% relative reduction in
prevalence.
Implementing an XDRO registry reduced CRE spread, even when
only 25% of the largest Illinois facilities participated due to patient
sharing. Non-participating facilities garnered benefits, with reductions in new
carriers.” (G)
“Quebec public-health authorities are bracing for the
inevitable arrival of a multi drug-resistant fungus that has been spreading
around the globe and causing infections, some of them fatal…
“We will definitely have cases here and there at one
point,” said Dr. Karl Weiss, chief of infectious diseases at the Jewish
General Hospital. “It’s almost guaranteed. The only thing is when you know
what you’re fighting against, it’s always easier and we will be able to contain
it a lot faster.”
C. auris poses a quadruple threat: it’s tricky to identify;
it can thrive in hospitals for weeks (preying on patients with weakened immune
systems); it’s resistant to two classes of anti-fungal medications; and it can
cause invasive disease, with lingering bloodstream infections that are hard to
treat. The mortality rate can rise as high as 60 per cent.
The pathogen has emerged at a time when hospitals in Quebec
– their budgets stretched more than ever – are already struggling with
antibiotic-resistant superbugs like C. difficile, MRSA and VRE that have caused
outbreaks. The Institut national de santé publique du Québec published a
bulletin last year on steps that hospitals and long-term centres can take to
prevent C. auris outbreaks.
“The problem is if you don’t identify the fungus
properly, then it can slip in between your hands, and you can have an outbreak
in your institution without even knowing it,” Weiss explained.
There was a lot of mis-indentification of this with other
Candida (fungi); and even the automated systems in institutions that identify
bacteria and yeast were mislabelling this Candida for something else. For a
while, people were not aware of this auris. But now we know how to identify it.
“The first thing we did in Quebec – and this was for
all the microbiology labs – is we taught all the microbiologists how to
properly identify Candida auris,” Weiss continued. “All the major
labs in Quebec put in place protocols.”
Weiss, who is president of the Quebec Association of Medical
Microbiologists, noted that under a quality assurance program, samples have
been sent to different labs to test whether the fungus is identified correctly.
The results show that that labs are detecting C. auris to a high degree.
If a patient is discovered to be infected, hospital protocol
dictates that the patient be isolated. During the patient’s hospitalization,
the housekeeping staff must disinfect the room daily with hydrogen peroxide and
other chemicals…” (H)
“Federal officials should declare an emergency over a
deadly, incurable fungus infecting people in New York, New Jersey and across
the country, Sen. Chuck Schumer said Sunday.
Schumer said he’s pushing the federal government to allocate
millions of dollars to fighting Candida auris, which is drug-resistant and
proving very difficult to eradicate…
“When it comes to the superbug, New York could use a little
more help,” said Schumer. “The CDC has the power to declare this an
emergency and automatically give us the resources we need.”..
Schumer said that an emergency declaration by the CDC would
lead to more cases being identified with better testing, and to better tracking
of the disease. It might also reduce the number of unnecessary antibiotic
prescriptions, which Schumer says have helped the disease become
drug-resistant…
Schumer cited other CDC emergency declarations that helped
stop the spread of deadly diseases, including a $25 million award to fight the
Zika virus in 2016 and $165 million given to contain Ebola in 2014.
“Every dollar we can use to better identify, tackle and
treat this deadly fungus is a dollar well spent,” Schumer said.” (I)
“Other medical experts see the overuse of human
antifungal medications in agriculture and floriculture as potential reasons for
resistance in Candida auris, known as C. auris, and possibly other fungi.
Dr. Matt McCarthy, a specialist in infectious diseases at Weill
Cornell Medicine in Manhattan, said tulips, signature flowers of the
Netherlands, are dosed with the same antifungal medications developed to treat
human infections.
“Antifungals are pumped into tulips in Amsterdam to
achieve flawless plants,” he said. “As a fungal expert, I know that
we have very few antifungal medications, and this is a misuse of the
drugs.”
Studies conducted at Trinity College in Ireland support
McCarthy’s argument and have demonstrated that tulip and narcissus bulbs from
the Netherlands may be vehicles that spread drug-resistant fungi.
Trinity scientists, who examined resistance in another
potentially deadly fungus, Aspergillus fumigatus, uncovered why the bugs
repelled the drugs known as triazoles. The fungi became resistant because of
the overuse of triazoles in floriculture. As with C. auris, drug-resistant A.
fumigatus can be deadly in people with poor immunity.
When patients need treatment with triazole-class
medications, the drugs don’t work because the fungi have been overexposed in
the environment, McCarthy said.
He added that the use of antifungal medications in
floriculture is similar to the overuse of antibiotics in the poultry and beef
industries, which have helped drive resistance to those drugs.
The floriculture example is just one way that drug-resistant
fungi can spread around the world. Global trade networks, human travel and the
movement of animals and crops are others.” (J)
“It will take further research to determine if the new
strains of C. auris have their origins in agriculture, but Aspergillus has
already illustrated the perils of modern farming. Antibiotics are applied on a
massive scale in food production, pushing the rise of bacterial drug
resistance. A British government study published in 2016 estimated that, within
30 years, drug-resistant infections will be a bigger killer than cancer, with
some 10 million people dying from infections every year.
We don’t have to end up there. Pesticide use on most farms
can be greatly reduced, or even eliminated, without reducing crop yields or
profitability. Methods of organic farming, even as simple as crop rotation,
tend to promote the growth of mutualistic fungi that crowd out pathogenic
strains such as C. auris. Unfortunately, because conventional agriculture is
heavily subsidized and market prices don’t reflect the costs to the environment
or human health, organic food is more expensive and faces an uphill battle for
greater consumption.
Of course, improved technology could help, with drugs of new
kinds or in breeding and engineering resistant strains of plants. There’s also
plenty of opportunity for lightweight agricultural robots, which can weed
mechanically or spray pesticides more accurately, reducing the quantity of
chemicals used. But tech shouldn’t be the sole focus just because it happens to
be the most profitable route for big industries.” (K)
“The recent outbreak of the so-called superbug – and
other drug-resistant germs – has thrown a spotlight on locally based Xenex
Disinfection Systems. The company makes a robot that uses pulsing, ultraviolet
rays to disinfect surgical suites and other environments that are supposed to
be germ-free.
With the spread of C. auris, Xenex officials say they’ve
seen an uptick in queries about their LightStrike Germ-Zapping Robots, which
are in use at more than 400 health-care facilities around the world since
manufacturing started in 2011.
These devices – often called R2Clean2, Mr. Clean and The
Germinator – disinfect rooms in a matter of minutes. A dome on the top of the
robot rises up, exposing a xenon bulb that emits UV light waves that kill germs
on contaminated surfaces.
Bexar County-owned University Hospital has a fleet of six
Xenex robots. One of the robots is assigned to the Cystic Fibrosis Center to
help protect patients from infection by other patients.
“We are taking every measure possible to reduce the
risk of infections, and this is an additional layer of security that bathes the
room in UV-C light,” said Elizabeth Allen, public relations manager at
University Health System…
Another study, recently published by a doctor at the
Minnesota-based Mayo Clinic, showed that when the hospital used the robots in
rooms that had already been cleaned, infection rates of another superbug –
called Clostridium difficile, or C. diff – fell by 47 percent.” (L)
“It wasn’t publicized locally, but within the past few
years teams of health officials at two Oklahoma health facilities took rapid
actions to contain the spread of a fungal “superbug” that federal
officials have declared a serious global health threat.
Only one patient at each facility was infected, and both
patients recovered. But the incidents reflect the growing alarm among health
officials over the deadly, multidrug-resistant Candida auris, or C. auris,
which can kill 30 percent to 60 percent of those infected…
In April 2017, a team of experts from the federal Centers
for Disease Control and Prevention converged on the University of Oklahoma
Medical Center in Oklahoma City after a patient tested positive for the
drug-resistant fungus.
About a year later, a patient at a southeast Oklahoma health
facility tested positive for the germ during a routine test. In both cases,
health officials isolated the patients, locked down their rooms and ordered
dozens of lab tests to see if the multidrug-resistant fungus had spread…
Unlike with outbreaks in Illinois, New York and New Jersey,
the potentially deadly infection was quickly contained.”..
Public knowledge about the OU Medical Center case makes it
an exception. Typically, health care facilities across the nation don’t release
to the public information when C. auris and other drug-resistant pathogens are
found. No law or policy requires them to do so.
Patient-rights advocates maintain that the public has the
right to know when and where outbreaks or even single cases occur. But health
officials have routinely fought back, suggesting that it could violate patient
rights and discourage patients from seeking hospital care.
But the CDC allows states to make that decision.
Burnsed said the Department of Health tries to walk a tight
line between notifying the public and protecting the patient’s privacy.
He said he would be more likely to identify a facility if
it’s anything more than an isolated case or if officials believed the exposure
wasn’t contained.
“What we consider is if there was a risk to a broader
group of individuals and if there was any evidence that there were a breach in
lab controls,” Burnsed said. “We didn’t put out anything at the time
(on Oklahoma’s two cases) because we didn’t think there was a greater risk to
the public, but it’s a good question to consider.”” (M)
“How many people will needlessly die from a deadly bug
sweeping through New York hospitals and nursing homes before local health
officials acknowledge the danger publicly – and act accordingly?..
Yet public-health officials here have been slow to let
patients know in which hospitals the bug is lurking. Folks are left to take
their chances. That’s outrageous.
Why are officials mum? Partly because they fear that if they
disclose the information, some people who need treatment won’t go for it.
That’s a weak excuse: As McCaughey notes, there are plenty
of local hospitals that aren’t plagued by Candida auris, so patients could get
care and avoid the risk, if they know where it’s safe to go.
More likely, no one wants to damage the reputations (or
incomes) of the affected hospitals. Yet the best way to protect those
reputations is to make sure the facilities are Candida auris-free…
Meanwhile, officials say they will reveal which hospitals
have the germ – in their next yearly report. But that could be months away;
patients need to know now.
If neither the hospitals nor their government regulators are
willing to move sooner, perhaps state lawmaker should step in and require them
to do so… (N)
Infectious disease experts tell Axios they agree with a dire
scenario painted in the UN report posted earlier this week saying that, if
nothing changes, antimicrobial resistance (AMR) could be
“catastrophic” in its economic and death toll.
Threat level, per the report: By 2030, up to 24 million
people could be forced into extreme poverty and annual economic damage could
resemble that from the 2008–2009 global financial crisis, if pathogens continue
becoming resistant to medications. By 2050, AMR could kill 10 million people
per year, in its worst-case scenario.
“There is no time to wait. Unless the world acts
urgently, antimicrobial resistance will have disastrous impact within a
generation.”..
By the numbers: Currently, at least 700,000 people die each
year due to drug-resistant diseases, including 230,000 people from
multidrug-resistant tuberculosis, per the UN. Common diseases – like
respiratory infections, STDs and urinary tract infections – are increasingly
untreatable as the pathogens develop resistance to current medications.
The Centers for Disease Control and Prevention says AMR
causes more than 23,000 deaths and 2 million illnesses in the U.S. annually…
What needs to be done: Jasarevic says the economic and
health systems of all nations must be considered, and targets made to increase
investment in new medicines, diagnostic tools, vaccines and other
interventions.”
The bottom line: Action must be taken to avoid a
catastrophic future.” (O)
“A recent study of patients at 10 academic hospitals in
the United States found that just over half care about what their doctors wear,
most of them preferring the traditional white coat.
Some doctors prefer the white coat, too, viewing it as a
defining symbol of the profession.
What many might not realize, though, is that health care
workers’ attire – including that seemingly “clean” white coat that
many prefer – can harbor dangerous bacteria and pathogens.
A systematic review of studies found that white coats are
frequently contaminated with strains of harmful and sometimes drug-resistant
bacteria associated with hospital-acquired infections. As many as 16 percent of
white coats tested positive for MRSA, and up to 42 percent for the bacterial
class Gram-negative rods.”
It isn’t just white coats that can be problematic. The
review also found that stethoscopes, phones and tablets can be contaminated
with harmful bacteria. One study of orthopedic surgeons showed a 45 percent
match between the species of bacteria found on their ties and in the wounds of patients
they had treated. Nurses’ uniforms have also been found to be contaminated.
Among possible remedies, antimicrobial textiles can help
reduce the presence of certain kinds of bacteria, according to a randomized
study. Daily laundering of health care workers’ attire can help somewhat,
though studies show that bacteria can contaminate them within hours…
It’s a powerful symbol. But maybe tradition doesn’t have to
be abandoned, just modified. Combining bare-below-the-elbows white attire, more
frequently washed, and with more conveniently placed hand sanitizers –
including wearable sanitizer dispensers – could help reduce the spread of
harmful bacteria.
Until these ideas or others are fully rolled out, one thing
we can all do right now is ask our doctors about hand sanitizing before they
make physical contact with us (including handshakes). A little reminder could
go a long way.” (P)
PART 3. May 28,
2019. CADIDA AURIS. “Antibiotic-resistant superbugs are everywhere. If your
hospital claims it doesn’t have them, it isn’t looking hard enough.”
“So far, 12 states from coast to coast have had confirmed
cases of Candida auris, which has spread with particularly speed in New York,
which has had more than half of the nation’s infections.
Some are even calling for the federal government to declare
a national state of emergency and fund better containment of the fungus.
Health officials there are scrambling to contain what the
Centers for Disease Control and Prevention (CDC) have deemed an emerging health
threat, but without stricter guidelines and screening, the fungus will only get
more deadly…
Doctors sometimes struggle to diagnose fungal infections, in
part because their symptoms are little different from those of bacterial
infections…
‘Candida auris has the ability to develop resistance and has
developed mechanisms to survive,’..
‘It’s at least starting to figure that out, and that’s
obviously concerning.’
There are really only three antifungal medications in the
US, so it doesn’t take long for a fungus to become wholly drug resistant.
Dr Chiller says that approximately 90 percent of strains the
CDC has logged are resistant to the first-line drug, another third are
resistant to a second, and between 20 and 30 percent of Candida auris
infections have acquired multi-drug resistance.
‘Some are pan-resistant and those need to be isolated and
stopped and we need to try to prevent them from developing,’ he says.
Neither the CDC, other nation’s health officials or any of
the 12 affected states have been able to work out where the fungus came from,
or how exactly it has spread from state-to-state…
If states don’t require their hospitals to report cases the
fungal infection, the CDC may be severely underestimating the number of cases
across the country.
‘It’s a bit of an uphill battle and it needs to be a really
concerted effort on multiple tiers of the health care system,’ Dr Chiller says…
‘We need to stay on top of it and not let our guard
down.’ (A)
“New York State health officials are considering rigorous
new requirements for hospitals and nursing homes to prevent the spread of a
deadly drug-resistant fungus called Candida auris.
The requirements could include mandatory pre-admission
screening of patients believed to be at-risk and placing in isolation those
patients who are infected, or even those just carrying the fungus on their
skin.
Dr. Howard Zucker, the state health commissioner, and a
fungal expert from the federal Centers for Disease Control and Prevention met
last Friday in Manhattan with nearly 60 hospital officials from across the
state to discuss the proposed guidelines. State health officials said they were
seeking hospital input before issuing the guidelines, which they acknowledged
would likely be a hardship for some institutions.
“One of our guiding objectives is to stop the geographic
spread,” said Brad Hutton, the state’s deputy commissioner of public health. He
said the state’s efforts to contain the spread have required significant
resources — including sending individual infection specialists to investigate
more than 150 cases — and that New York now needs help from individual
institutions.
“We’re at a point where our response strategy needs to
change,” he said. He added that he hoped the guidelines would be finalized by
the end of the year, but said the state is still determining whether to apply
them statewide or just to New York City and surrounding areas. It has yet to be
decided whether the guidelines would be recommendations or regulatory
requirements, he said…
For the moment…. hospitals are pre-screening many patients
who appear to be at risk. But it can take a week to get skin-swab results back
from the state laboratory, posing challenges for housing patients in isolation
during the interim. Further, she said, regular testing is likely to turn up
patients who are carriers but not infected, increasing the number of patients
who require isolation, appropriately or not.”..
For now, much of the burden for surveillance has fallen to
the state. The effort has involved the development of a fast-screening test
that can analyze a skin swab in a matter of hours. But all hospitals, for the
moment, have to send those tests to a state laboratory in Albany and wait
several days before receiving the results, though hospitals say the backlog
means tests can take a week.” (B)
“Unlike cholesterol drugs taken by millions of people for
their entire lives, or $100,000 cancer drugs designed to prolong life,
antibiotics are short-term drugs with limited shelf lives.
“Antibiotics are not valued by society as a high-value
product, so they’re not priced very high,” said Gregory Frank, director of
infectious disease policy at the Biotechnology Innovation Organization, in a
phone interview.
A 2014 paper.. cited a London School of Economics study
showing that while a new arthritis drug’s net present value – a measure of a
drug’s net value over the ensuing decades – would be $1 billion, that of a new
antibiotic would be negative $50 million…
People will buy innovative products in almost any other part
of the economy, but doctors will still keep even the most innovative antibiotic
behind the glass and use it only in the most dire circumstances.
“Antibiotic stewardship is a good thing, but devastating for
the company developing it,” Outterson said…
Jersey City, New Jersey-based Scynexis is one company
developing a treatment for drug-resistant fungal infections, ibrexafungerp, currently
in several clinical trials, including one for C. auris. The company plans to
file its first approval application with the FDA for ibrexafungerp next year.
The drug is expected cost $450-600 per day, in line with the pricing of other
antifungals, said company CEO Marco Taglietti, in a phone interview…
The race against drug-resistant infectious is ultimately a
scientific one. It’s not about finding
better treatments, but newer ones in an endless war that requires always
staying one step ahead of ever-evolving germs, Taglietti said. On the one hand,
it’s important to practice good stewardship in order to delay resistance.
“But that creates a big challenge from an economic point of
view – from the moment you launch your product after spending several hundreds
of millions to develop it, it doesn’t sell,” he said.
The problem appears to be a vicious cycle of science and
economics: Even existing push incentives, however generous, don’t make up for
antibiotics’ lack of the large and chronic patient populations of
cardiovascular disease drugs or the high prices of cancer drugs.” (C)
“Demanding that hospitals release lists of every superbug
they find within their walls, however, as many transparency advocates want, is
not the answer. The irony is that the hospitals that see the most superbugs are
often the best ones we have, for the simple reason that they have the most
sophisticated diagnostic platforms, the most powerful antibiotics and the
experts to administer them.
Compelling a world-class hospital like Massachusetts General
Hospital, where I saw my first superbug as a medical student, to reveal a
microbe list would only freak patients out. It wouldn’t explain where the
microbes came from, whether any patients were infected, and how they were
cured.
In a worst-case scenario, more transparency could lead to
patients avoiding medical care out of a misplaced fear of encountering
drug-resistant bacteria. Hospitals might start refusing patients with certain
infections, especially those coming from nursing facilities where these
microbes are common, out of a concern that the patient’s bacteria could be
added to the list. This would do everyone a disservice: Patients wouldn’t
receive optimal care and superbugs would multiply.
But hospital administrators and government officials do need
to be honest about the microbes in our medical centers and explain what is
really going on. No comment will no longer suffice. People have questions and
this story is not going away. To ensure that patients are well-informed, hospitals
should train spokesmen to address these issues and states should revisit their
reluctance to disclose information. Above all, health care workers and
administrators should speak openly about the measures their hospitals are
already employing to keep people safe.
I’m not particularly interested in the microbes that dwell
inside of a given hospital; what matters is whether its employees follow the
strict protocols that prevent these organisms from going where they shouldn’t…
Silence and evasion gives the perception that this is a
problem spiraling out of control when, in fact, it’s not. An intricate tracking
system exists so that epidemiologists across the country can monitor any
outbreaks to ensure that proper protocols and containment strategies are implemented.
We need to hear more from these superbug hunters.” (D)
“A new study published in the Journal of Occupational and
Environmental Health has established protocols for containing the drug
resistant Candida auris (C. auris ) in an animal facility, and by doing so, has
identified four simple rules that can potentially be adopted by healthcare
facilities to limit exposure to staff and patients. The study found that their
double personal protective equipment (PPE), work ‘buddy’ system, disinfection
and biomonitoring protocols were effective at containing high levels of C.
auris infection within their animal facility, even six months after their
experiments…
Before entering the animal holding and procedure rooms,
staff donned a second layer of booties, gloves and gowns, which were later
removed and placed in biohazard bins before exiting the rooms. Handling of
infected cages and equipment was restricted to biosafety cabinets where a buddy
system was implemented so that one person handed clean cages and supplies to a
second person working inside the contaminated biosafety cabinet. This
system-controlled workflow from clearly defined ‘clean’ to ‘dirty’ areas and
allowed workers to monitor each other to ensure proper procedures were
followed. Surfaces and equipment that came in contact with infected mice or
tissues were treated with a strict disinfection protocol of 10% bleach followed
(after five minutes) by 70% ethanol. The effectiveness of the workflow and
protocols were continually monitored using swab testing on surfaces suspected
to be contaminated, and as a second measure, Sabbaroud dextrose plates were
placed inside the biosafety cabinet and on the floor underneath to determine
whether C. auris was aerosolised within the cabinet or whether any debris contaminated
the floor.
The researchers found that possible contamination came from
direct contact with the infected mice or tissues but not from aerosolisation.”
(E)
“A pernicious disease is eating away at Roy Petteway’s
orange trees. The bacterial infection, transmitted by a tiny winged insect from
China, has evaded all efforts to contain it, decimating Florida’s citrus
industry and forcing scores of growers out of business.
In a last-ditch attempt to slow the infection, Mr. Petteway
revved up his industrial sprayer one recent afternoon and doused the trees with
a novel pesticide: antibiotics used to treat syphilis, tuberculosis, urinary
tract infections and a number of other illnesses in humans…
The use of antibiotics on citrus adds a wrinkle to an
intensifying debate about whether the heavy use of antimicrobials in
agriculture endangers human health by neutering the drugs’ germ-slaying
abilities. Much of that debate has focused on livestock farmers, who use 80
percent of antibiotics sold in the United States.
Although the research on antibiotic use in crops is not as
extensive, scientists say the same dynamic is already playing out with the
fungicides that are liberally sprayed on vegetables and flowers across the
world. Researchers believe the surge in a drug-resistant lung infection called
aspergillosis is associated with agricultural fungicides, and many suspect the
drugs are behind the rise of Candida auris, a deadly fungal infection.” (F)
OCTOBER 3, 2018
“A large Candida auris outbreak at a hospital in England
appears to be linked to reusable patient-monitoring equipment, a team of
researchers reports today in the New England Journal of Medicine.
The outbreak in the neurosciences intensive care unit (ICU)
at Oxford University Hospitals involved 70 patients who were infected or
colonized with C auris, a fungus that has become increasingly resistant to
azoles, echinocandins, and polyenes—the three classes of antifungals used to
treat infections caused by Candida and other fungal species.
An epidemiologic investigation and case-control study by
investigators from the University of Oxford, Public Health England, and
elsewhere found that the most compelling explanation for the prolonged outbreak
was the persistence of the organism on reusable skin-surface axillary probes, a
device placed in a patient’s armpit for continuous temperature monitoring.
“Our results indicate that reusable patient equipment
may serve as a source of healthcare-associated outbreaks of infection with C.
auris,” the authors of the study write.” (G)
G. Study links hospital Candida auris outbreak to reusable thermometers, by Chris Dall, http://www.cidrap.umn.edu/news-perspective/2018/10/study-links-hospital-candida-auris-outbreak-reusable-thermometers
In the
doctors’ meeting, the (UNC) chief of pediatric cardiology, Dr. Timothy Hoffman,
was blunt. “It’s a nightmare right now,” he said. “We are in crisis, and
everyone is aware of that.”
North Carolina’s
secretary of health on Friday called for an investigation into a hospital where
doctors had suspected children with complex heart conditions had been dying at
higher than expected rates after undergoing heart surgery.
New PART 2 after PART 1.
PART 1. February 26, 2019. Johns Hopkins All
Children’s Hospital (St Petersburg, Florida) – problems in the hospital’s heart
surgery unit
Assignment:
How would this problem have been avoided if Johns Hopkins quality assurance and
patient safety protocols been followed?
“The Patient
Safety and Healthcare Quality Masters program is a fully online,
interdisciplinary degree offered by Johns Hopkins University. It is a
first-of-its-kind collaboration between the Johns Hopkins Bloomberg School of
Public Health, Johns Hopkins School of Medicine, Johns Hopkins School of
Nursing and the Armstrong Institute for Patient Safety and Quality. It combines
coursework from JHU’s top ranked schools and the Armstrong Institute’s
pioneering advances in patient safety-educating students in the transformative
mechanisms and evidence-based protocols that reduce preventable patient harm
and improve clinical outcomes.
Renowned,
industry-shaping experts lead this exciting new program designed for working
adults. The program focuses on: Measurement of safety and quality; Designing
safer systems; Organizational and cultural change. ” (A)
“Patient
Safety and Quality at Johns Hopkins Medicine.
Each day in
a hospital, staff members undertake complicated tasks caring for patients.
Johns Hopkins Medicine’s patient safety efforts aim to ensure that all of these
steps work together to deliver high-quality, compassionate care to all patients
across our health system.
Johns
Hopkins Health System hospitals and services consistently receive awards and
honors for patient safety and quality, including Top Performer on Key Quality
Measures by the Joint Commission, Magnet designation for nursing, HomeCare
Elite and Delmarva Foundation Excellence Awards. The Johns Hopkins Hospital has
been ranked No. 1 in the nation by U.S. News & World Report for 22 years of
the survey’s 25-year history, most recently in 2013.
Patient
Safety and Quality Measures
This website
shares data for the Johns Hopkins Health System. Here, you will find
information about key safety issues and the patient’s experience of care,
including:
Patient
Experience – Based on survey results from previous patients, you can see how
others rated their experience of care from a Johns Hopkins Medicine hospital or
home health care provider.
Infection
Prevention – These measures include the rate of CLABSIs, a bloodstream
infection caused by a central line (large IV) that are considered preventable
and hand hygiene, the percentage of medical staff members observed washing
their hands or using hand sanitizer before and after caring for a patient.
Core
Measures – These measures are national standards of care and treatment
processes for common conditions. Core measure compliance shows how often a
hospital follows each of these steps.
Surgical
Volumes – Studies have shown a strong relationship exists between the number of
times a hospital performs a specific surgical procedure and the outcomes for
those patients. In 2016, we started sharing our hospitals’ surgical volumes for
many common and high-risk procedures.
Quality of
Care Ratings – The quality of patient care star rating is a summary of how well
the Johns Hopkins Home Care Group and Potomac Home Health Care perform on nine
quality measures such as ambulation.
Pediatrics –
These measures include national standards of treatment for common conditions,
infection prevention, pain management and emergency department wait times for
Johns Hopkins’ pediatric divisions.
Hospital
Readmissions – Patients are most vulnerable for readmission to a hospital
immediately following discharge. This measure tracks how many Medicare patients
with specific conditions were readmitted to the hospital within 30 days for any
reason.
Our
Commitment to Transparency
Patients and
their loved ones deserve to be informed about the quality of their heath care.
At Johns Hopkins Medicine, we are dedicated to sharing our performance and how
we work to provide the best care with past, present and future patients. The
Johns Hopkins Armstrong Institute for Patient Safety and Quality coordinates
safety and quality improvement efforts and training across our health system.
We hope you
will find this website a valuable resource and encourage you to ask your health
care team if you have any questions or concerns. (B)
“Patient
Trust, Confidence Built on Interprofessional Innovation
Medical
errors and preventable patient infections and injuries together make up the
third-leading cause of death in the United States, a startling statistic.
The Johns
Hopkins School of Nursing understands that an increasing focus on patient
safety and quality of care depends upon a healthcare workforce that knows the
risks and the proper responses from patients’ arrival to their safe discharge.
The Helene Fuld
Leadership Program for the Advancement of Patient Safety and Quality (The Fuld
Fellows Program) emphasizes interprofessional education and training,
simulation, and service-learning experiences involving nurses, medical
students, pharmacists, and other health professionals whose collaboration is
critical for reducing preventable harm to patients.
Nurses, as
the primary contact with patients, play a key role in their safety. Hopkins
Nursing, as part of an interprofessional team that includes the Armstrong
Institute for Patient Safety & Quality and the Johns Hopkins Health
Systems, works to prepare nurses ready to communicate, cooperate, innovate, and
lead on issues of patient safety and quality of care.” (C)
“Johns
Hopkins Medicine Armstrong Institute for Patient Safety and Quality
A roadmap
for patient safety and quality improvement
This month
the Agency for Healthcare Research and Quality (AHRQ) published a new report
that identifies the most promising practices for improving patient safety in
U.S. hospitals.
An update to
the 2001 publication Making Health Care Safer: A Critical Analysis of Patient
Safety Practices, the new report reflects just how much the science of safety
has advanced.
A decade ago
the science was immature; researchers posited quick fixes without fully
appreciating the difficulty of challenging and changing accepted behaviors and
beliefs.
Today, based
on years of work by patient safety researchers-including many at Johns
Hopkins-hospitals are able to implement evidence-based solutions to address the
most pernicious causes of preventable patient harm. According to the report,
here is a list of the top 10 patient safety interventions that hospitals should
adopt now.
Top 10
Recommended Patient Safety Strategies
1.
Preoperative checklists and anesthesia checklists to prevent operative and
postoperative events.
2. Bundles
that include checklists to prevent central line-associated bloodstream
infections
3.
Interventions to reduce urinary catheter use, including catheter reminders,
stop orders, or nurse-initiated removal protocols
4. Bundles
that include head-of-bed elevation, sedation vacations, oral care with
chlorhexidine, and subglottic-suctioning endotracheal tubes to prevent
ventilator-associated pneumonia
5. Hand
hygiene
6. The
do-not-use list for hazardous abbreviations
7.
Multicomponent interventions to reduce pressure ulcers
8. Barrier
precautions to prevent healthcare-associated infections
9. Use of
real-time ultrasonography for central line placement
10.
Interventions to improve prophylaxis for venous thromboembolisms…
Even with a
list of sound strategies, creating a plan to implement all or even half of them
may sound like a daunting task. The Armstrong Institute for Patient Safety and
Quality has created a checklist to help you get started.
1. Identify
priorities and assess readiness for change.
2. Establish
engagement and accountability at all levels of the organization.
3.
Communicate constantly (the good and the bad).
4. Measure,
measure, measure… and then measure some more. (D)
“Johns
Hopkins All Children’s Hospital provides expert pediatric care for infants,
children and teens with some of the most challenging medical problems in our
community and around the world.
Named a top
50 children’s hospital by U.S. News & World Report, we provide access to
innovative treatments and therapies. Taking part in pediatric medical education
and clinical research helps us to provide care in more than 50 specialties.
With more
than half of our 259 beds devoted to intensive care level services, we are the
regional pediatric referral center for Florida’s West Coast. Physicians and
community hospitals count on us to care for critically ill patients and perform
complex surgical procedures.
Parents
count on us, too. Our philosophy of family-centered care means family members
are an important part of our health care team. We include parents in making
decisions and plans for their child’s care. We also include patients who are
old enough to take part in these discussions.
To help us
design our hospital that we opened in January 2010, we asked patients, parents
and our staff to share ideas. The result was a spacious and bright hospital
with individual rooms where parents can comfortably spend the night. With the
latest technology and our commitment to family-centered care, our hospital
provides an ideal environment for healing.” (E)
“Quality,
Outcomes and Patient Safety at Johns Hopkins All Children’s
We are
committed to treating you and your child with compassion and respect. We
believe that you deserve honesty in our communication about the plan for your
child’s care and we will demonstrate uncompromising integrity to earn your
trust. We will be responsible for including each family as a part of our care
team that is committed to safe and innovative care practices. Our goal is to
inspire hope for you and your child through our focus on inquiry,
collaboration, and team work.
Johns
Hopkins All Children’s Hospital believes in Creating healthy tomorrows… for one
child, for All Children. Our focus on Quality assures that we are continually
improving our processes in an effort to achieve this vision. Using a team
approach we tap into the know-how of our expert medical staff and employees to
improve the quality and safety of the care we provide.
Our Quality
Model provides the basis for understanding patient needs, measuring and using
data, and achieving real improvement. Improving continuously is our goal. To do
this we encourage each member of our team to find ways to do their work better
and to make patient safety a priority. Together we are focused on pursuing
perfection for All Children.
Quality
Measures
There are
many ways to look at and measure quality. Our data uses information from key
areas to help families, healthcare providers, and others learn about our
progress in pursuing perfection for All Children.” (F)
“Sandra
Vázquez paced the heart unit at Johns Hopkins All Children’s Hospital.
Her
5-month-old son, Sebastián Vixtha, lay unconscious in his hospital crib,
breathing faintly through a tube. Two surgeries to fix his heart had failed,
even the one that was supposed to be straightforward.
Vázquez saw
another mom in the room next door crying. Her baby was also in bad shape.
Down the
hall, 4-month-old Leslie Lugo had developed a serious infection in the surgical
incision that snaked down her chest. Her parents argued with the doctors. They
didn’t believe the hospital room had been kept sterile.
By the end
of the week, all three babies would die…
The
internationally renowned Johns Hopkins had taken over the St. Petersburg
hospital six years earlier and vowed to transform its heart surgery unit into
one of the nation’s best.
Instead, the
program got worse and worse until children were dying at a stunning rate, a
Tampa Bay Times investigation has found.
Nearly one
in 10 patients died last year. The mortality rate, suddenly the highest in
Florida, had tripled since 2015…
Times
reporters spent a year examining the All Children’s Heart Institute – a small,
but important division of the larger hospital devoted to caring for children
born with heart defects…
They
discovered a program beset with problems that were whispered about in heart
surgery circles but hidden from the public.
Among the
findings:
All
Children’s surgeons made serious mistakes, and their procedures went wrong in
unusual ways. They lost needles in at least two infants’ chests. Sutures burst.
Infections mounted. Patches designed to cover holes in tiny hearts failed.
Johns
Hopkins’ handpicked administrators disregarded safety concerns the program’s staff
had raised as early as 2015. It wasn’t until early 2017 that All Children’s
stopped performing the most complex procedures. And it wasn’t until late that
year that it pulled one of its main surgeons from the operating room.
Even after
the hospital stopped the most complex procedures, children continued to suffer.
A doctor told Cash Beni-King’s parents his operation would be easy. His mother
and father imagined him growing up, playing football. Instead multiple
surgeries failed, and he died.
In just a year
and a half, at least 11 patients died after operations by the hospital’s two
principal heart surgeons. The 2017 death rate was the highest any Florida
pediatric heart program had seen in the last decade.
Parents were
kept in the dark about the institute’s troubles, including some that affected
their children’s care. Leslie Lugo’s family didn’t know she caught pneumonia in
the hospital until they read her autopsy report. The parents of another child
didn’t learn a surgical needle was left inside their baby until after she was
sent home.
The Times
presented its findings to hospital leaders in a series of memos early this
month. They declined interview requests and did not make the institute’s
doctors available to comment.
In a
statement, All Children’s did not dispute the Times’ reporting. The hospital
said it halted all pediatric heart surgeries in October and is conducting a
review of the program.
“Johns
Hopkins All Children’s Hospital is defined by our commitment to patient safety
and providing the highest quality care possible to the children and families we
serve,” the hospital wrote. “An important part of that commitment is a
willingness to learn.” (G)
The top
three leaders of Johns Hopkins All Children’s Hospital in Florida resigned
Tuesday following a Tampa Bay Times investigation that revealed increasing
mortality rates among heart surgery patients.
The
resignations from the 259-bed teaching hospital in St. Petersburg included CEO
Jonathan Ellen, M.D., and Vice President Jackie Crain, as well as Jeffrey
Jacobs, M.D., who is the heart institute’s deputy director, the Tampa Bay Times
reported. Paul Colombani, M.D., stepped down as chairman of the department of
surgery but will continue working in a clinical capacity, a statement from the
health system said.
“Losing a
child is something no family should have to endure, and we are committed to
learning everything we can about what happened at the Heart Institute,
including a top-to-bottom evaluation of its leadership and key processes,” a
statement from Johns Hopkins read. “The events described in recent news reports
are unacceptable.”
Johns
Hopkins, which owns and operates the hospital, said it would install Kevin
Sowers, who is president of the Johns Hopkins Health System and executive vice
president of Johns Hopkins Medicine, to lead the hospital in a temporary
capacity while a plan for interim leadership is put into place.
George
Jallo, M.D., who is medical director of the Institute for Brain Protection
Sciences and chief of pediatric neurosurgery, will serve as interim vice dean
and physician-in-chief, and Paul Danielson, M.D., who is chief of the Division
of Pediatric Surgery at Johns Hopkins All Children’s Hospital, will serve as
interim chair of the surgery department.
Johns
Hopkins’ board also said it commissioned an external review to examine the
heart surgery program and said it would share its lessons from the review to
help hospitals around the country avoid the same mistakes.
The moves
come following the Tampa Bay Times investigation that highlighted a growing
number of heart surgery deaths at the hospital amid warnings about safety from
staffers that went unheeded. (H)
“Three
additional senior administrators have left Johns Hopkins All Children’s
Hospital in the wake of a Tampa Bay Times investigation into high mortality
rates at the hospital’s Heart Institute, the hospital announced Wednesday.
A total of
six senior officials have left since the Times report, including the hospital’s
CEO, three vice presidents and two surgeons who held leadership roles at the
Heart Institute. A seventh official stepped down as chairman of the surgery
department but remained employed at the hospital as a doctor.
The
resignations announced Wednesday included vice presidents Dr. Brigitta Mueller,
the hospital’s chief patient safety officer, and Sylvia Ameen, who oversaw
culture and employee engagement and served as the hospital’s chief spokeswoman.
The hospital
also said Dr. Gerhard Ziemer, who started as the Heart Institute’s new director
and chief of cardiovascular surgery in October, would leave the hospital. The
hospital never publicly announced Ziemer had been hired, and he had not yet
obtained his Florida medical license when the Times investigation was published
at the end of November. At that point, the hospital said the Heart Institute
had already stopped performing surgeries.
“While Dr.
Ziemer is not responsible for the current state of the program, we agreed that
a fresh start was needed to ensure success for the program,” Johns Hopkins
Health System President Kevin Sowers said in a letter to the hospital’s staff.”
..
In his
letter to the staff, Sowers said that several hospital executives had been
tasked with leading “critically important work around advancing our culture of
safety.”
“As we work
to rebuild the trust of our community, we must also work to fully embrace and
support a culture where we are each empowered and encouraged to speak up and
speak out if we see or hear something that concerns us,” he wrote. “This
commitment applies to clinical concerns as well as inappropriate workplace
behavior.”
Sowers also
announced that Johns Hopkins had hired external experts to develop a plan to
restart heart surgeries at All Children’s.
That is a
separate effort from an external review of the problems in the Heart Institute,
which Johns Hopkins announced its board had commissioned last month,
spokeswoman Kim Hoppe said…
Johns
Hopkins is one of the most prestigious brands in medicine and is
internationally renowned for developing innovative patient safety protocols
that are used at hospitals across the world. But last weekend, the Times
published a story detailing a series of safety problems at hospitals across its
network. In response, the health system pledged to “do better.” (I)
“The Johns
Hopkins Medicine Board of Trustees has appointed a former federal prosecutor to
lead its investigation into the Johns Hopkins All Children’s Hospital’s heart
surgery unit, the health system announced late Tuesday.
F. Joseph
Warin, of the global law firm Gibson Dunn, and his team will review the high
mortality rates and other problems at the hospital’s Heart Institute and report
back to a special committee of the board of trustees by May, the health system
said.
Once the
review is complete, the health system said it would also name an independent
monitor at All Children’s to “make sure that the hospital is being held
accountable for taking corrective action where necessary.”
The
announcement was accompanied by a video of Johns Hopkins Health System
president Kevin Sowers, who acknowledged for the first time that the hospital
had been warned about problems by frontline workers.
“I know
personally that many of you courageously spoke out when you had concerns but
were ignored or turned away,” he said. “That behavior is unacceptable and will
not be tolerated going forward.”
Sowers, who
is also interim president at All Children’s, said he hoped to meet with the
families of patients affected by problems in the Heart Institute in the coming
days to share his “profound sadness for the failures of care they experienced.”
(J)
“The
external review was prompted by multiple reports by the Tampa Bay Times about
problems at the center which could have contributed to its mortality rate
tripling between 2015 and 2017…
Health News
Florida’s Stephanie Colombini talked about what could come next with Kathleen
McGrory, one of the lead reporters.
One of the
big problems you uncovered in your reporting was the lack of available data
about mortality rates at a lot of these heart surgery programs…
Officials
have either refused to release it or they only release four-year averages,
which could mislead families about the current state of the program they’re
choosing.
How is the
state looking at making these programs more transparent?
There were
some problems at another pediatric heart surgery program in 2015 in Palm Beach
County (St. Mary’s Medical Center), and after those problems surfaced, the
legislature put together a panel (Pediatric Cardiology Technical Advisory
Panel) tasked with looking at transparency and ways we could, as a state, make
these programs better and more accountable.
That panel
is in the middle of doing its work right now and in fact has come close to
finalizing some recommendations.
The panel
would like all of these heart surgery programs to be reporting their one-year
data (on mortality rates) rather than their four-year data because that
four-year data can sometimes hide serious problems…
So the state
is looking into making heart surgery programs more accountable, but is anyone
calling for change when it comes to the government’s role in this?
You reported
that multiple times state and federal regulators were alerted to problems at
All Children’s and yet little, to no action was taken.
We saw U.S.
Reps. Kathy Castor and Charlie Crist put some really tough questions to federal
regulators asking what they had investigated and when. We haven’t heard back
yet on that front but we know it’s something they’ll be looking into.
The state
told us that they did the best they could do with the information that they
had, same thing with the federal government.
But ACHA has
a new chief (Mary Mayhew). We haven’t gotten a chance to connect with her yet
and see what her thoughts are on this, but we certainly will do that in the new
year. (K)
“State and federal
inspectors descended on Johns Hopkins All Children’s Hospital this week,
following sharp calls for an investigation into problems in the hospital’s
heart surgery unit, the Tampa Bay Times has learned.
The scope of
the inspection is unclear. But hospital regulators had been criticized in
recent weeks for their lax response to early signs of an increase in mortality
at the hospital’s Heart Institute.
A Florida
Agency for Health Care Administration spokeswoman said her agency had been at
the facility.
A
spokeswoman for the hospital confirmed federal inspectors had been there, too.
“We
appreciate the oversight role that our regulators play and we will, as always,
be fully cooperative and collaborative as they conduct any reviews necessary,”
a statement from the hospital said.
A
spokeswoman for the federal Centers for Medicare and Medicaid Services declined
to comment beyond saying the matter remained “an ongoing review.”
In November,
the Times reported that the mortality rate for heart surgery patients at All
Children’s tripled from 2015 to 2017 to become the highest rate in Florida. The
increase occurred after staff members warned the hospital’s leaders about
problems with two heart surgeons, the Times found.
State and
federal regulators knew the institute was having problems months earlier. In
April, the hospital’s CEO told the Times that the institute had “challenges”
that led to an uptick in mortality, and acknowledged the hospital had left
surgical needles inside two children.
In May,
state regulators cited the hospital for not properly reporting two medical
mistakes, which is required by state law. Days later, a spokeswoman for the
federal agency told the Times that it would perform its own investigation.
But state
regulators didn’t fine the hospital, and overlooked several subsequent warnings
that its surgical results had been poor.
And federal
inspectors later changed course and decided not to undertake a comprehensive
review of the heart surgery program, the Times reported last month. One reason
was that state inspectors hadn’t found any violations of federal rules, a
spokeswoman said. Another was that a nonprofit hospital accreditor was due to
perform a scheduled review.” (L)
Two Omaha
surgeons filed a lawsuit Friday against Children’s Hospital & Medical
Center, alleging that they were wrongfully suspended and forced to resign
privileges there after they raised patient safety concerns.
In the suit,
Dr. Jason Miller and Dr. Mark Puccioni say that the hospital suspended their
privileges to practice at the Omaha facility after they raised concerns about
the death of a 7-month-old during an operation. That operation was performed
this fall by another surgeon, Dr. Adam Conley, the suit says.
In their
communications, according to the suit filed in Douglas County District Court,
the two also questioned Conley’s “skill and ability.”
In addition
to the hospital, the lawsuit names as defendants Conley, as well as Dr. Richard
Azizkhan, who took over as Children’s president and CEO in October 2015.
Children’s
officials said in a statement that the hospital does not comment on pending
litigation “other than to say we strongly disagree with these allegations…
Children’s
has faced other issues in recent months.
In late
November, a former pharmacy director at the hospital was accused of funneling
more than $4.4 million from the organization into her personal account over six
years. She was terminated in June and faces a hearing regarding possible
disciplinary action later this month.
About three
weeks ago, the Nebraska Medical Association sent a letter to the board of
Children’s Hospital expressing concerns about “patient care, safety and
quality” at the Omaha hospital, in addition to the loss of longtime physicians.
In the Dec.
11 letter, the president of the group, Dr. Britt Thedinger, wrote, “We as
physicians are concerned about the summary suspensions, terminations and
resignations of long-time outstanding physician colleagues.” The letter also
expressed concern that children were being transferred to outside institutions
because of “complications” and inadequate staffing at the Omaha hospital.
Thedinger
said the organization did not intend for the letter to become public. The
intent, he said, was to bring issues that had been raised by members to the
hospital board and administration.” (M)
“The New
Jersey Department of Health is investigating four Acinetobacter baumannii cases
in the neonatal intensive care unit (NICU) of University Hospital in Newark,
authorities announced Thursday evening.
DOH
officials stated:
“The
department first became aware of this bacterial infection on Oct. 1 and two
department teams have been closely monitoring the situation. Those department
teams, which have been at the facility last week and this week, have been
ensuring that infection control protocols are followed and are tracking cases
of the infection. The department’s inspection revealed major infection control
deficiencies.”
According to
the DOH, a premature baby with the bacteria who had been cared for at
University Hospital was transferred to another facility and passed away toward
the end of September, prior to the department’s notification of problems in the
NICU.
“Due to the
other compounding medical conditions, the exact cause of death is still being
investigated,” DOH officials said.
The
department has ordered a Directed Plan of Correction that requires University
Hospital to employ a full-time Certified Infection Control Practitioner
consultant, who will report to the DOH on immediate actions taken in the coming
days.
DOH officials
said they are also exploring further actions the agency may need to take in the
coming days to “ensure patient safety.” (N)
“Four New
Jersey pediatric care facilities and one hospital are now under the state’s
microscope after nine children died and 26 people were sickened by a deadly
virus over the past month.
A Department
of Health team of infection control experts and epidemiologists will visit
University Hospital in Newark and four pediatric long-term care facilities in
November to conduct training and assessments of infection control procedures,
Commissioner Dr. Shereef Elnahal has announced.
The team of
experts will visit University Hospital, the Wanaque Center for Nursing &
Rehabilitation in Haskell, Voorhees Pediatric Facility in Voorhees and Children’s
Specialized Hospital in Toms River and Mountainside. The department reached out
to the facilities last week to schedule visits in November.
The decision
comes after nine children at a Wanaque facility have died since an outbreak of
the adenovirus was declared there. Victims became sick between Sept. 26 and
Oct. 22. Authorities confirmed that the virus killed eight of the nine kids.
Twenty-six
kids and a staff member, who has since recovered, have become ill as part of
the outbreak, state health officials said. Laboratory tests confirmed the 26th
case. (O)
“Two decades
ago, the Institute of Medicine shook the medical profession with its “To Err is
Human” report which said nearly 100,000 people a year lost their lives to
preventable medical errors…
During the
7th Annual World Patient Safety, Science & Technology Summit over the
weekend, the Patient Safety Movement Foundation released a new tool on its
website to help with the training.
The patient
safety curriculum is one of 17 Actionable Patient Safety Solutions (APSS) made
available to organizations for free to help train health professionals in
systems science so they can help find ways to reduce preventable patient
deaths, officials said.
“The goal is
to get every health professional to think in a system way,” said Steven
Scheinman, M.D., the president and dean of Geisinger Commonwealth School of
Medicine. He led a Patient Safety Movement working group which included experts
from Geisinger, San Diego State, University of Pittsburgh Medical Center, Johns
Hopkins Health, and MedStar Georgetown to develop the curriculum over an
18-month period.
The Patient
Safety Movement was founded in 2013 to help reduce preventable deaths in
healthcare and in 2015 set a goal of zero preventable deaths by 2020. More than
90,000 patients who might have died as a result of medical errors were saved in
2018 due to efforts made by more than 4,700 hospitals that committed to patient
safety efforts, according to figures released by the foundation. In all, a
total of 273,077 lives have been saved since the first summit, officials said.
The newly
released safety curriculum can be adapted to any healthcare profession
including medicine, nursing, pharmacy, and behavioral health and can be used
for student training, as well as training for experienced professionals.
“We want to
train every health professional to take ownership of the patient’s safety and
experience so they understand safe communication and know when they are telling
another person about the patient or handing them over or referring them over,
how to make sure they get all the critical information there,” Scheinman said…
“The airline
industry solved safety by creating the right systems,” Scheinman said. “Medical
errors are very widespread. But they usually aren’t a doctor making a mistake.
They can be. But they’re more often the system failed to pick something up or
allowed something bad to happen.”
And with
this training, he said, those medical professionals might be that much more
likely to help figure out a new solution to make sure something bad doesn’t
happen again.” (P)
“..
experience showcases the promise of a much-touted but little understood
collaboration in health care: alliances between community hospitals and some of
the nation’s biggest and most respected institutions.
For
prospective patients, it can be hard to assess what these relationships
actually mean – and whether they matter.
Leah Binder,
president and chief executive of the Leapfrog Group, a Washington-based patient
safety organization that grades hospitals based on data involving medical
errors and best practices, cautions that affiliation with a famous name is not
a guarantee of quality.
“Brand names
don’t always signify the highest quality of care,” she said. “And hospitals are
really complicated places.”..
To expand
their reach, flagship hospitals including Mayo, the Cleveland Clinic and
Houston’s MD Anderson Cancer Center have signed affiliation agreements with
smaller hospitals around the country. These agreements, which can involve
different levels of clinical integration, typically grant community hospitals
access to experts and specialized services at the larger hospitals while
allowing them to remain independently owned and operated. For community
hospitals, a primary goal of the brand-name affiliation is stemming the loss of
patients to local competitors…
In some
cases, large hospital systems opt for a different approach, largely involving
acquisition. Johns Hopkins acquired Sibley Memorial and Suburban hospitals in
the Washington, D.C., area, along with All Children’s Hospital in St.
Petersburg, Fla. The latter was re-christened Johns Hopkins All Children’s
Hospital in 2016…
Although
affiliation agreements differ, many involve payment of an annual fee by smaller
hospitals. Officials at Mayo and MD Anderson declined to reveal the amount, as
did executives at several affiliates. Contracts with Mayo must be renewed
annually, while some with MD Anderson exceed five years…
“It is not
the Mayo Clinic,” said Dr. David Hayes, medical director of the Mayo Clinic
Care Network, which was launched in 2011. “It is a Mayo clinic affiliate.”
Of the 250
U.S. hospitals or health systems that have expressed serious interest in
joining Mayo’s network, 34 have become members.
For patients
considering a hospital that has such an affiliation, Binder advises checking
ratings from a variety of sources, among them Leapfrog, Medicare and Consumer
Reports, and not just relying on reputation.
“In theory,
it can be very helpful,” Binder said of such alliances. “The problem is that
theory and reality don’t always come together in health care.”
Case in
point: Hopkins’ All Children’s has been besieged by recent reports of
catastrophic surgical injuries and errors and a spike in deaths among pediatric
heart patients since Hopkins took over. Hopkins’ chief executive has
apologized, more than a half-dozen top executives resigned and Hopkins recently
hired a former federal prosecutor to conduct a review of what went wrong.
“For me and
my family, I always look at the data,” Binder said. “Nothing else matters if
you’re not taken care of in a hospital, or you have the best surgeon in the
world and die from an infection.” ” (Q)
PART 2. June 1, 2019. “The situation that the New York Times described in North Carolina parallels that at Johns Hopkins All Children’s Hospital in St. Petersburg, which stopped performing heart surgeries after the Tampa Bay Times reported on problems in the unit
“Johns Hopkins All Children’s Hospital in St.
Petersburg, Fla., has been given another extension from federal regulators to
correct its problems. The pediatric hospital came under fire in late 2018 after
the Tampa Bay Times uncovered widespread problems at the facility, including a
rising death rate in the pediatric heart unit.
The
reporting from the Times led to the resignation of several high-profile
executives at the hospital and a federal investigation from CMS that led to a
series of corrective actions with the government.
Now, the
hospital still needs more time to meet the demands of inspectors, the Tampa Bay
Times reported. Inspectors found problems with All Children’s infection control
unit, which the hospital must fix by “early May.” The agreement with CMS to
meet corrective actions underscores how the hospital has been at risk of losing
public funding, which covered more than 60% of its patients in 2017, according
to the Times.” (A)
“Care in a
special heart surgery unit at Johns Hopkins All Children’s Hospital in St.
Petersburg, Fla., became so troubled that last year one in 10 patients died and
others suffered devastating complications before procedures were halted, a
year-long investigation by the Tampa Bay Times found.
The
investigation found that staff raised safety concerns as early as 2015 but the
hospital, led by administrators sent by Hopkins, disregarded warnings and
didn’t stop performing the most complex procedures until early last year. All
surgeries were curtailed eventually and a review launched. The status of two
surgeons connected to most of the complications is unclear…
In a
statement to the Tampa Bay Times, All Children’s said it “is defined by our
commitment to patient safety and providing the highest quality care possible to
the children and families we serve. An important part of that commitment is a
willingness to learn. When we became aware of challenges with our heart
institute we took action to address them.”
The hospital
said it initially stopped performing complex cases and brought in a surgeon
from Baltimore. Then it halted all surgeries after that surgeon left. The
hospital said it is currently reviewing the program and recruiting new surgeons
with aid from Hopkins and plans to resume surgeries “when all involved are
confident that the care being delivered meets the high standards set by this
organization.”
A statement
from Johns Hopkins Medicine to The Baltimore Sun said, “We are devastated when
children suffer, and losing a child is something that no parent should have to
endure. We are continuing to take a very close look at the program, and will
not resume open heart surgeries until we are confident this program at Johns
Hopkins All Children’s Hospital delivers care that meets the highest
standards.”” (B)
“Johns
Hopkins All Children’s Hospital posted an operating loss in the three months
ended March 31, as the St. Petersburg pediatric hospital dealt with the fallout
of federal and state probes into its practices.
The hospital
had an $11.5 million quarterly operating loss, according to a May 13 financial
report from The Johns Hopkins Health System Corp. and affiliates. Operating
revenue dropped 7.1 percent to $119.9 million, while operating expenses climbed
10.5 percent to $131.4 million.
The
operating loss was attributed to closing the hospital’s Heart Institute. The
facility closed after an investigation by the Tampa Bay Times found seven
children had died or were permanently injured due to substandard care in the
cardiovascular surgery program…
“The
decrease in income from operations and operating margin percentage was mainly
driven by lower net patient service revenue at [Johns Hopkins All Children’s
Hospital] as a result of the closing of the Heart Institute,” the May 13 report
said.” (C)
“Tasha and
Thomas Jones sat beside their 2-year-old daughter as she lay in intensive care
at North Carolina Children’s Hospital. Skylar had just come out of heart
surgery and should recover well, her parents were told. But that night, she
flatlined. Doctors and nurses swarmed around her, performing chest compressions
for nearly an hour before putting the little girl on life support.
Five days
later, in June 2016, the hospital’s pediatric cardiologists gathered one floor
below for what became a wrenching discussion. Patients with complex conditions
had been dying at higher-than-expected rates in past years, some of the doctors
suspected. Now, even children like Skylar, undergoing less risky surgeries,
seemed to fare poorly.
The
cardiologists pressed their division chief about what was happening at the
hospital, part of the respected University of North Carolina medical center in
Chapel Hill, while struggling to decide if they should continue to send
patients to UNC for heart surgery…
That March,
a newborn had died after muscles supporting a valve in his heart appeared to
have been damaged during surgery. At least two patients undergoing low-risk
surgeries had recently experienced complications. In May, a baby girl with a
complex heart condition died two weeks after her operation. Two days later,
Skylar went in for surgery.
In the
doctors’ meeting, the chief of pediatric cardiology, Dr. Timothy Hoffman, was
blunt. “It’s a nightmare right now,” he said. “We are in crisis, and everyone
is aware of that.”
That comment
and others — captured in secret audio recordings provided to The New York Times
— offer a rare, unfiltered look inside a medical institution as physicians
weighed their ethical obligations to patients while their bosses also worried
about harming the surgical program.
In meetings
in 2016 and 2017, all nine cardiologists expressed concerns about the program’s
performance. The head of the hospital and other leaders there were alarmed as
well, according to the recordings. The cardiologists — who diagnose and treat
heart conditions but don’t perform surgeries — could not pinpoint what might be
going wrong in an intertwined system involving surgeons, anesthesiologists,
intensive care doctors and support staff. But they discussed everything from
inadequate resources to misgivings about the chief pediatric cardiac surgeon to
whether the hospital was taking on patients it wasn’t equipped to handle.
Several doctors began referring more children elsewhere for surgery.
The heart
specialists had been asking to review the institution’s mortality statistics
for cardiac surgery — information that most other hospitals make public — but
said they had not been able to get it for several years. Last month, after
repeated requests from The Times, UNC released limited data showing that for
four years through June 2017, it had a higher death rate than nearly all of the
82 institutions nationwide that do publicly report…
The best
option, Dr. Kelly said, was to combine UNC’s surgery program with Duke’s. For
years, physicians at both children’s hospitals talked informally about joining
forces, but nothing came of it. They were “basically destroying each other’s
capacity to be great,” Dr. Kelly said, by running competing programs less than
15 miles apart. But even combining the programs wasn’t an instant fix: It would
take at least a year and a half, he said…
At a
conference last fall, Dr. Backer, the Chicago heart surgeon, urged fellow
surgeons to consider “rational regionalization,” or joining forces in an effort
to reduce mortalities nationwide for congenital heart defects, potentially
saving hundreds of lives.
Reaching
adequate case volumes to keep up skills is a challenge because so many
hospitals are competing for patients — surgical programs are an important
driver of revenue. The Orlando, Fla., and San Antonio metropolitan areas, for
example, each have three hospitals doing pediatric heart surgeries. Cleveland
has two about a mile apart. A study last year by Dr. Backer and other
physicians found that 66 percent of hospitals doing the surgeries were within
25 miles of another one.” (D)
“The
situation that the New York Times described in North Carolina parallels that at
Johns Hopkins All Children’s Hospital in St. Petersburg, which stopped
performing heart surgeries after the Tampa Bay Times reported on problems in
the unit.
A Tampa Bay
Times analysis found that the death rate among pediatric heart surgery patients
at All Children’s had tripled from 2015 to 2017…
UNC Health
Care only made some of its death rate data public to the New York Times after
numerous requests from the newsroom. The statistics showed that UNC’s
children’s heart surgery program had one of the highest four-year death rates
in the country.
The
newspaper said it is suing the health system for more data.
UNC Health
Care told the New York Times that the physicians’ concerns had been handled
appropriately.
After the
New York Times started reporting, the hospital ramped up efforts to find a
temporary pediatric heart surgeon and reached out to families whose children had
died or had unusual complications to discuss their cases…
The turmoil
at UNC underscores concerns about the quality and consistency of care provided
by dozens of pediatric heart surgery programs across the country. Each year in
the United States about 40,000 babies are born with heart defects; about 10,000
are likely to need surgery or other procedures before their first birthday.
The best
outcomes for patients with complex heart problems correlate with hospitals that
perform a high volume of surgeries — several hundred a year — studies show. But
a proliferation of the surgery programs has made it difficult for many
institutions, including UNC, to reach those numbers: The North Carolina
hospital does about 100 to 150 a year. Lower numbers can leave surgeons and
staff at some hospitals with insufficient experience and resources to achieve
better results, researchers have found.
“We can do
better. And it’s not that hard to do better,” said Dr. Carl Backer, former
president of the Congenital Heart Surgeons’ Society, who practices at Lurie
Children’s Hospital of Chicago. “We don’t have to build new hospitals. We don’t
have to build new ICUs. We just need to move patients to more appropriate
centers.”
North
Carolina Children’s Hospital, part of the University of North Carolina medical
center, performs about 100 to 150 pediatric heart surgeries a year.
Studies show
that the best outcomes for patients with complex heart problems correlate with
hospitals that do a higher volume of surgeries — several hundred a year.
At least
five pediatric heart surgery programs across the country were suspended or shut
down in the last decade after questions were raised about their performance; a
Florida institution run by the prestigious Johns Hopkins medical system stopped
operations after reporting by The Tampa Bay Times in 2018. At least a
half-dozen hospitals have merged their programs with larger ones to achieve
more consistent results. And more institutions are considering such
partnerships.” (E)
“UNC Health
declined a CBS 17 request for an interview. Phil Bridges, UNC Health’s
Integrated Communications Executive Director issued a written statement:
We are proud
of our pediatric congenital heart surgery program, and our current team is
receiving top results that would place us among the best in the nation. We have
been engaged in continuous quality improvement efforts for decades and have
made significant improvements in the past 10+ years.
As the
state’s leading public hospital, the UNC Pediatric Congenital Heart Surgery
program often receives the most complex and serious cases. For many of these
very sick children, we are often parents’ last hope.
As we shared
with the New York Times, there were team culture issues back in 2016. They were
handled appropriately. That, combined with decades of continuous quality
improvement (CQI) efforts, have led us to today in which we have a very strong
program. For our team, and each family, even a single death is too many, and we
will continue our CQI work.
To
characterize today’s program as anything but strong, would not only be
misleading, but not factual. To say we ignored issues would also be false.” (F)
“First and
foremost, we are physicians who have dedicated our lives to caring for and
caring about patients. We celebrate with families the joys of curing illness;
and we are deeply impacted by any death, particularly that of a young child. We
lead our respective areas of surgery and pediatrics with the mindset of always
doing what is right for children and families. Caring for these children is a
privilege. Children and families are always our top priority. Our mission is to
provide the best care for all children across North Carolina. We and our
colleagues live this mission every day.
Regarding
this week’s story from The New York Times (“Doctors Were Alarmed: Would I have
my children have surgery here”): We are proud of the medical care provided to
all patients at UNC Children’s. They become part of our family, and as
providers we wouldn’t hesitate to bring our own loved ones here for treatment.
Any negative outcome or death is taken incredibly seriously and we strive to
constantly look for ways to improve the care provided.” (G)
“North
Carolina’s secretary of health on Friday called for an investigation into a
hospital where doctors had suspected children with complex heart conditions had
been dying at higher than expected rates after undergoing heart surgery.
Dr. Mandy
Cohen, the secretary, said in a statement that a team from the state’s division
of health service regulation would work with federal regulators to conduct a
“thorough investigation” into events that occurred in 2016 and 2017 at North
Carolina Children’s Hospital, part of the University of North Carolina medical
center in Chapel Hill.
“As a mother
and a doctor my heart goes out to any family that loses a child,” Dr. Cohen
said in the statement. “Patient safety, particularly for the most vulnerable
children, is paramount.”
The
investigation is in response to an article published by The New York Times on
Thursday, which gave a detailed look inside the medical institution as
cardiologists grappled with whether to keep sending their young patients there
for surgery.
The article
included discussions among doctors that were captured on secret audio
recordings provided to The Times, in which the physicians talked openly about
their concerns, including that some might not feel comfortable allowing their
own children to have surgery at the hospital. The physicians also discussed
unexpected complications with lower-risk patients.
While the
doctors could not pinpoint what might be going wrong, they considered
everything from inadequate resources to misgivings about the chief pediatric
cardiac surgeon to whether the hospital was taking on patients it was not
equipped to handle.” (H)
The 2018-19
Best Children’s Hospitals Honor Roll (I)
1. Boston
Children’s Hospital
2.
Cincinnati Children’s Hospital Medical Center
3.
Children’s Hospital of Philadelphia
4. Texas
Children’s Hospital
5.
Children’s National Medical Center
6.
Children’s Hospital Los Angeles
7.
Nationwide Children’s Hospital
8. Johns Hopkins Children’s Center
(BALTIMORE)
9.
Children’s Hospital Colorado
10. Ann and
Robert H. Lurie Children’s Hospital of Chicago
North
Carolina Children’s Hospital at UNC. Pediatric Cardiology & Heart Surgery Scorecard.
ASSIGNMENT: Profile medical advances made during World War I, World WAR II, the Korean War, Vietnam, Afghanistan and Iraq.
Memorial Day 2019
From 1967 to 1970, during the Vietnam War, I served first as
a 2nd Lieutenant and Administrative
Officer of the 4th Casualty Staging Flight attached to Wilford Hall USAF
Medical Center, Lackland AFB in San Antonio, Texas. We received combat
casualties still in battlefield bandages, often within 24 hours of injury, and
either admitted them to Wilford Hall or further transported them to hospitals
near home.
New PART 2 after
PART 1
Part 1. July 3,
2018. “BATTLEFIELD MEDICINE: THE REVOLUTIONARY WAR
“When the Revolutionary War began its actual skirmishes
in 1776, early attempts to prepare for the medical needs related to War were
made in the City of New York. During the spring and summer of 1776, Samuel
Loudon was publishing his newspaper the New York Packet, in which he included
numerous articles and announcements regarding the Continental Army. On July 29,
for example, came the following announcement written by Thomas Carnes, Stewart
and Quartermaster to the General Hospital of King’s College, New York.
Anticipating an increase demand for medically trained staff, he filed the
following request for volunteers:
“GENERAL HOSPITAL New-York, July 29, 1776 Wanted
immediately in the General Hospital, a number of women who can be recommended
for their honesty, to act in the capacity of nurses: and a number of faithful
men for the same purpose…King’s College, New York” (A)
“One of the most famous surgeons, and the first, was
Cornelius Osborn. He was recruited in the Spring of 1776 and had little
training even as a physician. The Continental Congress was even concerned about
the well-being of the troops and the militia. They passed several ordinances
and helped establish the order for the several field Hospitals during the War.
The hospitals served about 20,000 men in the fight. Each hospital was required
for each surgery to have at least one physician or surgeon, and one assistant,
which was usually and apprentice of some sort. Each hospitals staff numbers
varied on how many wounded it served and the severity of the wounds….
Most of the deaths in the Revolutionary War were from
infection and illness rather than actual combat. The common practice if a limb
was badly infected of fractured was amputate it. Where most amputees died of
gangrene a result of not properly cleaning instruments after surgeries. Only
35% of amputees actually survived surgery. There was no pain killers quite
developed back then. So at most the patient were given alcohol and a stick to
bite down on while the surgeon worked. Two assistant would hold him down, a
good surgeon could perform the entire process in a mere 45 seconds, after which
the patient usually went into shock and fainted. This allowed the surgeon to
stich up the wound, and prepare for the next amputation. Another way they
decided to clean wounds, disease, or infection was by applying mercury directly
to the cut of injured space, and letting it run through the blood stream which
usually resulted in death.” (B)
“To seek treatment for any serious ailment, a soldier
would have had to go to a hospital of sorts. Military regiments had a surgeon
on staff to care for the men, so the soldier’s first stop would be with the
surgeon. During battles, the surgeon could be found in a makeshift or
“flying” hospital that consisted of a tent, an operating table, and
some medical equipment. If the surgeon could not treat the soldier, he might be
sent to a hospital. Many regimental hospitals were in nearby houses, while
general hospitals for more in-depth treatment were sometimes set up in barns,
churches, or other public buildings. The conditions were often cramped, which
resulted in the rapid spread of contagious illnesses and infections….
Woe to the soldier who required surgery after being wounded
on the battlefield! The conditions in “flying” hospitals were
deplorable. Not only was the operating room simply a table in a tent, but there
was little thought given to keeping the table and tools clean. In fact, wounds
were sometimes cleaned using plain water from a bucket, and the used water
would be saved to clean out the next soldier’s wounds as well. (C)
Hospitalization was a serious problem during the American
Revolutionary War. Plans were made quite early to care for the wounded and
sick, but at the best they were meager and inadequate. However on April 11,
1777 Dr. William Shippen Jr., of Philadelphia was chosen Director General of
all the military hospitals for the army. Consequently the reorganization of
hospital conditions took place.
Four hospital districts were created: Easter, Northern,
Southern and Middle. The wage scale was as follows: Director General’s pay
$6.00 a day and 9 rations; District Deputy Director $5.00 a day and 6 rations;
Senior Surgeon $4.00 a day and 6 rations; Junior Surgeon $2.00 and 4 rations;
Surgeon mate $1.00 and 2 rations.
After the battle of Brandywine, September 11, 1777, hospitals
were established at Bethlehem, Allentown, Easton and Ephrata. After the battle
of Germantown, October 4, 1777, emergency hospitals were organized at
Evansburg, Trappe, Falkner Swamp and Skippack. Hospitals at Litiz and Reading
were also continued. By December 1777, new hospitals were opened at Rheimstown,
Warwick and Shaeferstown. Yellow Springs (now Chester Springs) an important
hospital was organized under the direction of Dr. Samuel Kennedy. At Lionville,
Uwchlan Quaker Meeting House was also made a hospital for a time. Apothecary
General Craigie’s shop, Carlisle, was the source of hospital drugs….
It seems there was carelessness in making necessary health
reports, consequently Washington ordered on January 2, 1778: “Every Monday
morning regimental surgeons are to make returns to the Surgeon Gen’l. or in his
absence to one of the senior surgeions, present in camp or otherwise under the
immediate care of the regimental surgeons specifying the mens names Comps.
Regts. and diseases.” [Weedon’s Valley Forge Orderly Book, p. 175]
January 13, 1778. “The Flying Hospitals are to be 15
feet wide and 25 feet long in the clear and the story at least 9 feet high to
be covered with boards or shingles only without any dirt, windows made on each
side and a chimney at one end. Two such hospitals are to be made for each
brigade at or near the center and if the ground permits of it not more than 100
yards distance from the brigade.” [Weedon’s Valley Forge Orderly Book, p.
191] The Commander-in-Chief always solicitous about the comfort of his soldiers
issued the following order January 15, 1778: “The Qr. Mr. Genl. is
positively ordered to provide straw for the use of the troops and the surgeons
to see that the sick when they are removed to huts assigned for the hospital are
plentifully supplied with this article.” [Weedon’s Valley Forge Orderly
Book, pp. 192-199-204-216] ” (D)
PART 2. May 28,
2019. “BATTLEFIELD” MEDICINE: THE CIVIL WAR. “Many of America’s modern medical
accomplishments have their roots in the legacy of America’s defining war.”
“During the 1860s,
doctors had yet to develop bacteriology and were generally ignorant of the
causes of disease. Generally, Civil War doctors underwent two years of medical
school, though some pursued more education. Medicine in the United States was
woefully behind Europe. Harvard Medical School did not even own a single
stethoscope or microscope until after the war. Most Civil War surgeons had
never treated a gunshot wound and many had never performed surgery. Medical
boards admitted many “quacks,” with little to no qualification. Yet,
for the most part, the Civil War doctor (as understaffed, underqualified, and
under-supplied as he was) did the best he could, muddling through the so-called
“medical middle ages.” Some 10,000 surgeons served in the Union army
and about 4,000 served in the Confederate. Medicine made significant gains
during the course of the war. However, it was the tragedy of the era that
medical knowledge of the 1860s had not yet encompassed the use of sterile
dressings, antiseptic surgery, and the recognition of the importance of
sanitation and hygiene. As a result, thousands died from diseases such as
typhoid or dysentery.
The deadliest thing that faced the Civil War soldier was
disease. For every soldier who died in battle, two died of disease. In
particular, intestinal complaints such as dysentery and diarrhea claimed many
lives. In fact, diarrhea and dysentery alone claimed more men than did battle
wounds. The Civil War soldier also faced outbreaks of measles, small pox,
malaria, pneumonia, or camp itch. Soldiers were exposed to malaria when camping
in damp areas which were conductive to breeding mosquitos, while camp itch was
caused by insects or a skin disease. In brief, the high incidence of disease
was caused by a) inadequate physical examination of recruits; b) ignorance; c)
the rural origin of my soldiers; d) neglect of camp hygiene; e) insects and
vermin; f) exposure; g) lack of clothing and shoes; h) poor food and water…
Battlefield surgery…was also at best archaic. Doctors often
took over houses, churches, schools, even barns for hospitals. The field
hospital was located near the front lines — sometimes only a mile behind the
lines — and was marked with (in the Federal Army from 1862 on) with a yellow
flag with a green “H”. Anesthesia’s first recorded use was in 1846
and was commonly in use during the Civil War. In fact, there are 800,000
recorded cases of its use. Chloroform was the most common anesthetic, used in
75% of operations. ..A capable surgeon could amputate a limb in 10 minutes.
Surgeons worked all night, with piles of limbs reaching four or five feet. Lack
of water and time meant they did not wash off hands or instruments
Bloody fingers often were used as probes. Bloody knives were
used as scalpels. Doctors operated in pus stained coats. Everything about Civil
War surgery was septic. The antiseptic era and Lister’s pioneering works in
medicine were in the future. Blood poisoning, sepsis or Pyemia (Pyemia meaning
literally pus in the blood) was common and often very deadly…” (A)
“Early on, stretcher bearers were members of the regimental
band, and many fled when the battle started. Soldiers acting as stretcher
bearers rarely returned to the front lines. As the war evolved, stretcher
bearers became part of the medical corps. At the battle of Antietam, there were
71 Union field hospitals. As the war went on, these were consolidated. There
were ambulances here that were used to bring the wounded to temporary
battlefield hospitals, which were larger, often under tents, and out of
artillery range. Later in the war, patients were transported to large general
hospitals by train or ship in urban centers. These did not exist when the war
began. There was no military ambulance corps in the Union Army until August of
1862. Until that time, civilians drove the ambulances. Initially the ambulance
corps was under the Quartermaster corps, which meant that ambulances were often
commandeered to deliver supplies and ammunition to the front…
Large general hospitals were established by September of
1862 (11). These were in large cities, and soldiers were transported there by
train or ship. At the end of the war, there were about 400 hospitals with about
400,000 beds. There were 2 million admissions to these hospitals with an
overall mortality of 8%. In the South, the largest general hospital,
Chimborazo, was in Richmond, Virginia. It was built out of tobacco crates on 40
acres. It contained five separate hospitals, each made up of 30 buildings.
There were 150 wards with 40 to 60 patients per ward. The census was as high as
4000. They treated about 76,000 patients with a 9% mortality (12)…
Three of every four surgical procedures performed during the
war were amputations. Each amputation took about 2 to 10 minutes to complete.
There were 175,000 extremity wounds to Union soldiers, and about 30,000 of
these underwent amputation with a 26.3% mortality… Only about 1 in 15 Union
physicians was allowed to amputate. Only the most senior and experienced
surgeons performed amputations. These changes were put into effect because of
the public perception that too many amputations were being performed.
Amputations were not carried out using sterile technique, given that Lister’s
classic paper on antisepsis did not appear until after the war in 1867…
Physicians at the time had an extraordinary workload. The
following was excerpted from a letter Dr. Daniel Holt wrote to his wife,
Euphrasia:
You cannot imagine the amount of labor I have to perform. As
an instance of what almost daily occurs, I will give you an account of
day-before-yesterday’s duty. At early dawn, while you, I hope, were quietly
sleeping, I was up at Surgeon’s call and before breakfast prescribed for 86
patients at the door of my tent. After meal I visited the hospitals and a barn
where our sick are lying, and dealt medicines and write prescriptions for one
hundred more; in all visited and prescribed for, one hundred and eighty-six
men. I had no dinner. At 4 o’clock this labor was completed and a cold bite was
eaten. After this, in the rain, I started for Sharpsburg, four miles distant,
for medical supplies (17). (B)
Most of the major medical advances of the Civil War were in
organization and technique, rather than medical breakthroughs. In August of 1862, Jonathan Letterman, the
Medical Director of the Army of the Potomac, created a highly-organized system
of ambulances and trained stretcher bearers designed to evacuate the wounded as
quickly as possible. A similar plan was
adopted by the Confederate Army. This
system was a great improvement on previous methods. He established a trained ambulance corps,
consolidated all of the ambulances of a Brigade, and created a system of
layered levels of care for the wounded on the battlefield. The levels of care were small field dressing
stations (usually directly on the battlefield), field hospitals (located in a
safer place just beyond the battlefield), and a system of general hospitals in
most large cities. Transporting the
wounded men from one hospital to another was also coordinated. The Letterman plan remains the basis for present
military evacuation systems.
A system of triage was established that is still used
today. The sheer number of wounded at
some of the battles made triage necessary.
In general, the wounded soldiers were divided into three groups: the
slightly wounded, those “beyond hope”, and surgical cases. The surgical cases were dealt with first
since they would be the most likely to benefit from immediate care. These included many of the men wounded in the
extremities and some with head wounds that were considered treatable. The slightly wounded would be tended to next,
their wounds were not considered life-threatening so they could wait until the
first group was treated. Those beyond
hope included most wounds to the trunk of the body and serious head wounds. The men would have been given morphine for
pain and made as comfortable as possible…
Hospitals became places of healing rather than places to go
to die, as they were widely considered before the war. The large-scale hospitals set up by the
medical departments had an astounding average death rate of only 9%… Women nurses were first truly accepted during
the war, mainly out of necessity.
Although there was a great deal of prejudice against them, especially
early on, surgeons came to see that their contributions went a long way in
aiding the patients. Once they had an
established place in medical care they would not give it up. Nursing as a profession was born.
Due to the sheer number of wounded patients the surgeons had
to care for, surgical techniques and the management of traumatic wounds
improved dramatically. Specialization
became more commonplace during the war, and great strides were made in
orthopedic medicine, plastic surgery, neurosurgery and prosthetics. Specialized hospitals were established, the
most famous of which was set up in Atlanta, Georgia, by Dr. James Baxter Bean
for treating maxillofacial injuries.
General anesthesia was widely used in the war, helping it become
acceptable to the public. Embalming the
dead also became commonplace.
Medical technology and scientific knowledge have changed
dramatically since the Civil War, but the basic principles of military health
care remain the same. Location of
medical personnel near the action, rapid evacuation of the wounded, and providing
adequate supplies of medicines and equipment continue to be crucial in the goal
of saving soldiers’ lives.” (C)
“Many misconceptions exist regarding medicine during the
Civil War era, and this period is commonly referred to as the Middle Ages of
American medicine. Medical care was heavily criticized in the press throughout
the war. It was stated that surgery was often done without anesthesia, many
unnecessary amputations were done, and that care was not state of the art for
the times. None of these assertions is true. Actually, during the Civil War,
there were many medical advances and discoveries..
Medical Use
of quinine for the prevention of malaria
Use of quarantine, which virtually eliminated yellow fever
Successful treatment of hospital gangrene with bromine and
isolation
Development of an ambulance system for evacuation of the
wounded
Use of trains and boats to transport patients
Establishment of large general hospitals
Creation of specialty hospitals
Surgical Safe use of
anesthetics
Performance of rudimentary neurosurgery
Development of techniques for arterial ligation
Performance of the first plastic surgery..” (B)
“However, while “advanced” or “hygienic” may not be terms
attributed to medicine in the nineteenth century, modern hospital practices and
treatment methods owe much to the legacy of Civil War medicine. Of the
approximately 620,000 soldiers who died in the war, two-thirds of these deaths
were not the result of enemy fire, but of a force stronger than any army of
men: disease. Combating disease as well treating the legions of wounded
soldiers pushed Americans to rethink their theories on health and develop
efficient practices to care for the sick and wounded.
At the beginning of the Civil War, medical equipment and
knowledge was hardly up to the challenges posed by the wounds, infections and
diseases which plagued millions on both sides. Illnesses like dysentery,
typhoid fever, pneumonia, mumps, measles and tuberculosis spread among the
poorly sanitized camps, felling men already weakened by fierce fighting and
meager diet. Additionally, armies initially struggled to efficiently tend to
and transport their wounded, inadvertently sacrificing more lives to mere
disorganization…
The wounded and sick suffered from the haphazard
hospitalization systems that existed at the start of the Civil War. As battles
ended, the wounded were rushed down railroad lines to nearby cities and towns,
where doctors and nurses coped with the onslaught of dying men in makeshift
hospitals. These hospitals saw a great influx of wounded from both sides and
the wounded and dying filled the available facilities to the brim. The Fairfax
Seminary, for example, opened its doors twenty years prior to the war with only
fourteen students, but it housed an overwhelming 1,700 sick and wounded
soldiers during the course of the war…
However, the heavy and constant demands of the sick and
wounded sped up the technological progression of medicine, wrenching American
medical practices into the light of modernity.
Field and pavilion hospitals replaced makeshift ones and efficient
hospitalization systems encouraged the accumulation of medical records and
reports, which slowed bad practices as accessible knowledge spread the use of
beneficial treatments…
The sheer quantity of those who suffered from disease and
severe wounds during the Civil War forced the army and medical practitioners to
develop new therapies, technologies and practices to combat death. Thanks to
Hammond’s design of clean, well ventilated and large pavilion-style hospitals,
suffering soldiers received care that was efficient and sanitary. In the later
years of the war, these hospitals had a previously unheard of 8% mortality rate
for their patients…
In field hospitals and pavilion-style hospitals, thousands
of physicians received experience and training.
As doctors and nurses became widely familiar with prevention and
treatment of infectious diseases, anesthetics, and best surgical practices,
medicine was catapulted into the modern era of quality care. Organized relief
agencies like the 1861 United States Sanitary Commission dovetailed doctors’
efforts to save wounded and ill soldiers and set the pattern for future
organizations like the American Red Cross, founded in 1881.
Death from wounds and disease was an additional burden of
the war that took a toll on the hearts, minds, and bodies of all Americans, but
it also sped up the progression of medicine and influenced practices the army
and medical practitioners still use today. While the Union certainly had the
advantage of better medical supplies and manpower, both Rebels and Federals
attempted to combat illness and improve medical care for their soldiers during
the war. Many of America’s modern medical accomplishments have their roots in
the legacy of America’s defining war.” (D)
ASSIGNMENT: Draft the principles for federal “surprise bill” legislation
I thought I was a good OUT-OF-NETWORK detective and could avoid SURPRISE MEDICAL BILLS. Not so! Recently I switched physicians within a sub-specialty practice group. The first MD took my Medicare “GAP” insurance but the second did not. This lesson already cost me $1,000 versus an in network cost of probably $200. One can never be too vigilant!
New PART 2 after
PART 1.
PART 1. July 29,
2018. SURPRISE MEDICAL BILLS. Write in
AS LONG AS THE PROVIDERS ARE IN MY NETWORK…before you sign any hospital
admission documents accepting financial responsibility for your care.
“No Surprise Charges” is one of the key Lessons
Learned in Elisabeth Rosenthal’s fabulous new book AN AMERICAN SICKNESS
(Penguin Press, 2017). “Hospitals in your network should also be required
to guarantee that all doctors who treat you are in your insurance
network.”
We have all harshly experienced or heard about under-the counter
out-of-network hospital charges:
“A Kaiser Family Foundation survey finds that among
insured, non-elderly adults struggling with medical bill problems, charges from
out-of-network providers were a contributing factor about one-third of the
time. Further, nearly 7 in 10 of individuals with unaffordable out-of-network
medical bills did not know the health care provider was not in their plan’s
network at the time they received care.”(A)
A study that looked at more than 2 million emergency
department visits found that more than 1 in 5 patients who went to ERs within
their health-insurance networks ended up being treated by an
“out-of-network” doctor – and thus exposed to additional charges not
covered by their insurance plan.” (B)
Here is a brief case study:
“When Janet Wolfe was admitted to the hospital near
Macon, Georgia, a few years ago, her lungs were functioning at just one-fifth
their normal capacity. The problem: graft-versus-host disease, a complication
from a stem cell transplant she received to treat lymphoma. Over the course of
three days she saw three different doctors. Unbeknownst to Janet and her
husband, Andrew, however, none of them was in her health plan’s network of
providers. That led the insurer to pay a smaller fraction of those doctors’
bills, leaving the couple with some hefty charges.” (C)
So what can you do to avoid out-of-network charges?
– Speak with a practice representative before being seen to
understand the costs of seeing your doctor on an out-of-network or a cash
basis. (DOCTOR note: maybe you need to leave and go to an in-network physician
instead)
– If you need additional services, such as surgery, imaging
or physical therapy, ask your doctor to refer you to an in-network facility to
keep your costs down. (D)
A New York law is a great start toward transparency to
reduce out-of-network surprises.
Under a recent New York law, Hold Harmless Protections for
Insured Patients, “… patients are generally protected from owing more than
their in-network copayment, coinsurance or deductible on bills they receive for
out-of-network emergency services or on surprise bills.
A bill is considered a surprise if consumers receive
services without their knowledge from an out-of-network doctor at an in-network
hospital or ambulatory surgical center, among other things. In addition, if
consumers are referred to out-of-network providers but don’t sign a written
consent form saying they understand the services will be out of network and may
result in higher out-of-pocket costs, it’s considered a surprise bill.”
(E)
“Advocates for patients, senior citizens, labor unions,
and businesses hailed Gov. Phil Murphy’s signing of a complex and controversial
measure designed to curb the impact of costly “surprise” medical
bills in New Jersey. Supporters said the law, nearly 10 years in the making, is
the strongest of its kind nationwide…
The Democratic governor, who pledged his support for the
bill in March, said the law closed a loophole to protect patients and make
healthcare more affordable; sponsors called it the right thing to do to protect
vulnerable residents. “We have put patients first. We have made clear that
New Jersey stands for transparency when it comes to health care,” …
The reform is designed to protect patients, businesses, and
others who pay for medical care from the high-cost bills associated with
emergency or unintentional care from doctors or other providers who are not
part of their insurance network. The law requires greater disclosure from both
insurance companies and providers – so patients are clear on what their plan
covers – ensures patients aren’t responsible for excess costs, and establishes
an arbitration process to resolve payment disputes between providers and
insurers, a mechanism intended to better control costs…
“It’s a solution that is fair to healthcare providers
and consumers alike because it strikes a balance between providing reasonable
compensation to facility-based providers, while protecting consumers from
unexpected, nonnegotiable bills that drive health insurance premiums
higher,” said NJBIA president and CEO Michele Siekerka. “This was an
extremely difficult and complicated issue, and NJBIA commends the governor and
the bill sponsors who worked hard to address the concerns of all stakeholders.””
(F)
A price transparency RFI released by the agency this week
asks for input on how CMS might develop consumer-friendly policy. In a request
for information announced Thursday, the Centers for Medicare & Medicaid
Services asked whether providers and suppliers should be required to tell
patients, in advance, how much a given healthcare service will cost
out-of-pocket. If the agency were to move forward with a price transparency
requirement on physician practices, it could prove controversial. Many doctors
say they themselves lack the training they would need to have effective
conversations about how much the healthcare services they provide will
ultimately cost patients.
But CMS has repeatedly indicated that it aims to get more
pricing information to consumers one way or another. “We are concerned
that challenges continue to exist for patients due to insufficient price
transparency,” the agency wrote in its RFI, which is included in proposed
revisions to the Physician Fee Schedule, Quality Payment Program, and other policies
for 2019…
In order to determine what additional actions may be
appropriate to connect consumers with accessible price information, the CMS
price transparency RFI includes a variety of questions, including the
following:How should the phrase “standard charges” be defined in
various provider and supplier settings?
Which information types would be most useful to
beneficiaries, and how can providers and suppliers empower consumers to engage
in price-conscious decision-making?
Should providers and suppliers have to tell patients how
high their out-of-pocket costs are expected to be before providing a
service?” (G)
“Patients are at a higher risk of receiving surprise
medical bills on Affordable Care Act exchanges, according to a new report.
In 2018, more than 73% of plans available in the exchange
marketplace offered restrictive networks, compared with 48% in 2014, according
to the report (PDF) commissioned by Physicians for Fair Coverage. PFC is a
nonprofit alliance of physician groups which advocates for ending surprise
insurance gaps and improving patient protections…
“This research confirms what patients and physicians
across the country have known for some time,” said PFC President and CEO
Michele Kimball in a statement. “Insurers have been systematically
narrowing their networks and increasing premiums, creating surprise insurance
gaps that patients don’t realize exist until it’s too late. While insurers are
making record profits, patients are paying more for less.”
The coalition, which includes tens of thousands of emergency
physicians, anesthesiologists and radiologists from across the country, is
pressing for more states to adopt legislation to solve the problem of surprise
medical bills. The problem often occurs when a patient seeks care at an in-network
hospital but is then surprised the doctor treating them is out of their
insurance company’s network-a fact they usually find out when they get the
doctor’s bill.
“When it comes to health care, nobody likes a surprise.
This study confirms what we’ve been hearing from patients for years: there is
no real way for patients to avoid a ‘surprise’ medical bill, even when they’re
insured and try to stay in-network. We need a transparent healthcare system
designed for patients, not profits,” Rebecca Kirch, executive vice
president of healthcare quality and value at the National Patient Advocate
Foundation, said in a statement…
The best estimates indicate that 1 out of 7 times someone
goes to the emergency department, they are going to be stuck with a surprise bill.”
(H)
A patient came to see me with lower abdominal pain. Was she
interested in my medical opinion? Not really. She was told to see me by her
gynecologist who had advised that the patient undergo a hysterectomy. Was this
physician seeking my medical advice? Not really. Was this patient coming to see
me as her day was boring and she needed an activity? Not really. After the
visit with me, was the patient planning to return for further discussion of her
medical status? Not really.
So, what was going on here. What had occurred that day was
the result of an insurance company practice that I had thought had been
properly interred years ago.
The woman had pelvic pain and consulted with her
gynecologist. An ultrasound found a lesion within her uterus. A hysterectomy
was advised. The insurance company directed that a second opinion be solicited.
A second gynecologist concurred with the first specialist. The patient advised
me that the insurance company wanted an opinion from a gastroenterologist that
there was no gastrointestinal explanation for her pain. In other words, they
did not want to pay for a hysterectomy that they deemed to be unnecessary.
How should we respond? (I)
“In the absence of laws barring balance bills and
surprise bills, there are steps hospitals and health plans can take to protect
consumers from medical debt. The Healthcare Financial Management Association
urges hospitals to inform patients that they may be eligible for financial
assistance provided directly by the hospital and make clear to patients what
services are and are not included in their price estimates. Hospitals also need
to communicate better with uninsured patients about medical costs and options
for sharing costs..
Health plan best practices include helping members estimate
expected out-of-pocket costs and sharing price information for providers in a
given region.
Beyond that, hospitals need to double down to ensure they
have contracts with as many in-network providers as possible. “It requires
the physicians, hospitals, health plans all working together to make sure that
everybody’s in-network or, if they’re not, the patient knows that clearly up
front,” says Rick Gundling, HFMA’s senior vice president for healthcare
financial practices. “It’s kind of a three-legged stool.”
Consumers also need to become savvier when it comes to costs
of medical care. Most people do see providers in their network, says Gupta.
However, “because of their high-deductible health plan, they often don’t
recognize until they get hit with a bill that the same MRI might be $3,000
after the deductible at a local hospital that is convenient for them versus
$1,000 a mile down the street at an imaging center,” he adds.” (J)
“Cooper works as a physician assistant and hears about
medical billing problems all the time.
So when she initially found out she was pregnant, this
health care provider did everything she could to make sure anyone associated
with her pregnancy would be considered what’s referred to as
“in-network.”
She contacted her insurance company, Aetna, and she also
contacted Banner Gateway Hospital, the hospital where she planned to give
birth. The hospital then sent her written confirmation that she had nothing to
worry about.
“She said, ‘Send me a picture of your insurance card
front and back and I’ll double check that you’re covered.’ And, she sent me
back an hour later saying, ‘Yes, you are in network,'” Cooper said.
Cooper eventually delivered her little girl at Banner
Gateway Hospital. But, not long after, Cooper started getting a number of large
“out-of-network” medical bills.
“Aetna then sent me back something that said, ‘No you
are out-of-network’ and that’s how everything started to trickle through,”
she said.
“Out-of-network.” How could that happen? Remember,
she got written confirmation from Banner Gateway Hospital indicating she was
“in-network.”…
When she added them all up, her medical bills came to around
$18,000, money she shouldn’t have been responsible for. Still, she says she
wasn’t getting any resolution…
We asked them to review Cooper’s case and after they did,
they acknowledged there was a mistake.
As a result, Aetna reprocessed all of Heather’s bills as
“in-network.”..
That means Cooper will now only have to pay just $750 out of
pocket, the cost of her deductible rather than $18,000. Cooper said she
couldn’t be happier and says it all happened with the help of 3 On Your
Side.” (K)
“On the first morning of Jang Yeo-im’s vacation to San
Francisco in 2016, her eight-month-old son Park Jeong-whan fell off the bed in
the family’s hotel room and hit his head.
There was no blood, but the baby was inconsolable. Jang and
her husband worried he might have an injury they couldn’t see, so they called
911, and an ambulance took the family – tourists from South Korea – to
Zuckerberg San Francisco General Hospital.
The doctors at the hospital quickly determined that baby
Jeong-whan was fine – just a little bruising on his nose and forehead. He took
a short nap in his mother’s arms, drank some infant formula, and was discharged
a few hours later with a clean bill of health. The family continued their
vacation, and the incident was quickly forgotten.
Two years later, the bill finally arrived at their home:
They owed the hospital $18,836 for the 3 hour and 22 minute visit, the bulk of
which was for a mysterious fee for $15,666 labeled “trauma
activation,” which sometimes is known as “a trauma response
fee.”
Update: After this story was published on June 28,
Zuckerberg San Francisco General Hospital agreed to waive the $15,666 trauma
response fee charged for Park Jeong-whan’s visit to the hospital. In a letter,
the hospital’s patient experience manager said the hospital did a clinical
review and offered “a sincere apology for any distress the family
experienced over this bill.” Further, the hospital manager wrote that the
case “offered us an opportunity to review our system and consider
changes.” (L)
“The health insurer Anthem is coming under intense
criticism for denying claims for emergency room visits it has deemed
unwarranted…
The insurer initially rolled out the policy in three states,
sending letters to its members warning them that, if their emergency room
visits were for minor ailments, they might not be covered. Last year, Anthem
denied more than 12,000 claims on the grounds that the visits were “avoidable,”
according to data the insurer provided to Senator Claire McCaskill, a Democrat
from Missouri, one of the affected states.
But when patients challenged their denials, Anthem reversed
itself most of the time, according to data the company gave Ms. McCaskill. The
report concludes that the high rate of reversals suggests that Anthem did not
do a good initial job of identifying improper claims, meaning some patients who
did not challenge their denials may have been stuck paying big bills they
should not have been responsible for.” (M)
PART 2. Private
Equity is a Driving Force Behind Devious Surprise Billings,
“The expectant mother
was in labor at South Shore Hospital when she requested a common pain medicine,
which was administered by an anesthesiologist. Home with a newborn days later,
she was surprised when a bill arrived from the doctor’s group for $2,143.44.
Another patient who went to Emerson Hospital’s emergency
department for what turned out to be a broken rib also received a surprise
bill: $300.91, for the services of the doctor who read the X-ray…
Patients should not have to “contact their health plan and
complain,’’ said David Seltz, executive director of the Massachusetts Health
Policy Commission, which monitors health care spending in the state. “Through
no fault of their own they are being put in this situation.’’
An analysis by the policy commission found that 10,000
Massachusetts patients in just one year may have received surprise bills for
so-called out-of-network care, and policy experts believe that figure underestimates
the extent of the problem…
More than 35 percent of complaints filed with Healey were
over out-of-network charges, which can be up to 200 percent higher than what
insurers pay in-network doctors. Among the physicians that were outside the
patients’ insurance networks were anesthesiologists assisting in colonoscopies
and emergency medicine doctors repairing broken bones and treating heart
attacks, something that frustrated patients told Healey’s office they had no
way of knowing in advance. Radiologists and pathologists also directly billed
patients out-of-network charges.
It’s not unusual for a hospital to have practitioners
working in their facilities who are not covered by all their agreements with
insurers, a technicality that is often not apparent to patients.” (A)
“ (Trump)” In my State of the Union address, I asked
Congress to pass legislation to protect American patients. For too long, surprise billings — which has
been a tremendous problem in this country — has left some patients with thousands
of dollars of unexpected and unjustified charges for services they did not know
anything about and, sometimes, services they did not have any information
on. They weren’t told by the doctor. They weren’t told by the hospitals in the
areas they were going to. And they get,
what we call, a “surprise bill.” Not a
pleasant surprise; a very unpleasant surprise.
So this must end.
We’re going to hold insurance companies and hospitals totally
accountable.” (B)
“But physician advocacy groups, including the American
Medical Association (AMA) while applauding the effort to eliminate surprise
bills, expressed some concern that a simplified approach to a complex problem
could have unintended consequences for healthcare delivery…
“We agree with the president that patients should not be
responsible for coverage gaps and for any costs beyond their in-network cost
sharing when they do not have an opportunity to choose an in-network
physician,” said Barbara L. McAneny, MD, AMA’s president in a statement. “We
also agree that physicians and hospitals should be transparent about their
costs, and payers should offer transparency about their networks, scope of
coverage, and out-of-pocket costs. In addition, insurers should be held
accountable for their contributions to the problem and ensure network adequacy,
adherence to the prudent layperson standard for emergency care in current law,
and reasonable cost-sharing requirements.”” (C)
“Reps. Frank Pallone (D-NJ) and Greg Walden (R-OR), the top
Democrat and Republican on the House Energy and Commerce Committee, have
jointly released a draft bill that would prevent patients from facing
unexpected charges after they go to the emergency room or receive other
non-emergency medical care…
The Pallone and Walden bill takes a multi-pronged approach
to ending surprise medical bills:
Health insurers would be required to treat out-of-network
emergency care as in network for their enrollee’s cost-sharing and
out-of-pocket obligations. So patients wouldn’t have to pay any more for receiving
emergency treatment at an out-of-network hospital than they would at an
in-network one.
Balance billing — when a health care provider sends a
patient a bill charging them whatever the difference is between the price set
for a service by the provider and the price the health insurer is willing to
pay — would be prohibited.
Insurers would have to make a minimum payment to
out-of-network providers for their enrollee’s care, based on the price the
insurer pays to nearby in-network providers… (D)
“These protections would apply to all out-of-network
emergency services and to all out-of-network nonemergency services received at
an in-network facility from “facility-based providers,” which the bill defines
to include anesthesiologists, radiologists, pathologists, neonatologists,
assistant surgeons, hospitalists, intensivists, and any additional provider
types specified by the Secretary of Health and Human Services (HHS). Other
provider types would still be allowed to treat patients on an out-of-network
basis in nonemergency situations if they met the strong notice and consent
requirements detailed in the discussion draft. Limiting notice and consent
exceptions to physician specialties that patients typically actively choose
strikes a sensible balance. It preserves patients’ ability to seek
out-of-network care in circumstances where it is appropriate, while mitigating
the risk that the flood of paperwork involved in seeking medical care will
result in some patients consenting to out-of-network billing without understanding
what they are consenting to or whether they have a reasonable alternative.” (E)
“A new draft bill released this morning sets up a so-called
“baseball-style” arbitration process for providers and plans as an option to
settle payment disputes, POLITICO’s Rachel Roubein writes. Today’s draft comes
after Sens. Bill Cassidy (R-La.), Michael Bennet (D-Colo.) and four others
spent eight months refining legislation first introduced in September. More for
Pros.
— Today’s legislation prohibits balance billing in three
instances, Rachel writes. (1) For emergency care, (2) during elective care at
an in-network facility but when a service is performed by an out-of-network
provider and (3) when a patient needs additional medical care after an
emergency at an out-of-network facility but can’t travel elsewhere.
— The most contentious part of addressing surprise medical
bills: the payment. Under the new bill, providers would automatically be paid
the median in-network rate. But they can dispute that, initiating a so-called
“baseball-style” arbitration process, where mediators will base decisions on
“commercially reasonable rates” (the in-network rates for that area and not
actual charges).” (F)
“The House of Representatives and the Senate have unveiled
dueling legislation aimed at surprise billing, and the two are split on one key
element: arbitration.
The House bill (PDF), which was introduced earlier this week
by Reps. Frank Pallone, D-New Jersey and Greg Walden, R-Oregon, would require
insurers to cover out-of-network emergency care at in-network rates and would
ban balance billing.
Balance billing most often occurs in emergency departments
or during elective surgery, when a patient goes to an in-network facility but
is treated by an out-of-network clinician, typically an anesthesiologist or
radiologist.
The Senate’s bill, however—which is backed by Sens. Bill
Cassidy, R-Louisiana, and Maggie Hassan, D-New Hampshire—would include a
“baseball-style” arbitration program to mitigate disputes, alongside similar
elements to the House iteration.” (G)
“The administration said its top priority is to make sure
patients no longer receive separate bills from out-of-network doctors, an
approach known as a “bundled payment.”..
Vidor Friedman, president of the American College of
Emergency Physicians, said a bundled payment puts too much pressure on
hospitals to contract with physicians, essentially making hospitals take on the
role of insurer.
“It would create another layer between the patient and
providers of care,” Friedman said, noting that doctors would need to negotiate
directly with hospitals for payment, rather than with insurance companies…
Instead, doctors and hospitals want an independent
arbitrator to examine the amount the doctor is charging and what the insurer is
agreeing to pay — and then determine which one is fairer…
But insurers are opposed to arbitration, and they’re pushing
for Congress to set reimbursement rates.
In a letter to House and Senate leaders in March, America’s
Health Insurance Plans urged lawmakers to “avoid the use of complex, costly and
opaque arbitration processes that can keep consumers in the middle and lead to
higher premiums.”
The White House also threw cold water on arbitration. During
a briefing with reporters on Thursday, administration officials called
arbitration an “unnecessary distraction.”..
“Providers point
fingers at payers, payers point fingers at providers, and the American people
are left really getting the shaft,” a senior administration official said.
The White House and lawmakers have been warning all the
players to solve the problem on their own. But now with pressure from the White
House, Congress is likely to act.
“There will come a point in time when they want to move a
solution forward,” AHA’s Smith said. “It’s unlikely you’ll come to a solution
where every one of the stakeholders is happy.”” (H)
“One of the major drivers of surprise bills is the
deliberate decision by health insurance plans to narrow the networks of
providers available to their insureds—core network adequacy requirements should
be an essential component of any solution,” AMA Executive Vice President and
CEO James L. Madara, MD, wrote in the letters to committee leaders. “Shrinking
networks increase the likelihood that patients may receive care from an out-of-network
provider, particularly in emergency situations.”
..Patients are shouldering more of the costs through larger
deductibles and higher copays. The median out-of-network deductible for
individual marketplace is $12,000 and almost a third of individual market plans
have deductibles of more than $20,000 according to research by the Robert Wood
Johnson Foundation cited in the letter.
“Limited networks of providers and unaffordable deductibles
for care outside those networks can expose patients to high out-of-pocket
costs,” Dr. Madara wrote.
..Often insurance companies will use tactics such as prior
authorization or “fail-first” step therapy protocols to make patients pay out
of pocket for medically necessary treatment they refuse to cover.
.. Despite federal mental health-parity requirements,
patients can feel squeezed by their health plans when it comes to mental health
and substance-use disorder treatments—and that leads to a greater reliance on
out-of-network care…
..Some insurance companies have enacted policies of not
paying for emergency care after it was determined that patients did not require
it—even though the severity of their symptoms at the time made it prudent to go
to the nearest emergency department.
..Insurance companies often change their drug formularies
after patients are locked into their plan. This can lead to restricting access
to treatment that has proven to work for them and has stabilized their
condition. Patients may seek to pay out of pocket to continue their treatment
rather than jump through their insurance company’s prior-authorization hoops.”
(I)
“Surprise medical bills exist for a number of reasons, each
of which are specifically rooted in problems inherent to a privatized,
profit-driven health-care system. For one thing, there wouldn’t be
out-of-network bills without networks themselves—a health insurance innovation
put forward in the 1980s. Unlike more regulated health-care systems in peer
nations, the American health-care system lacks a robust mechanism to control prices.
This leaves each insurance plan to negotiate with providers on its own, and
gives the latter more power to set prices.
Once health-care prices began to skyrocket in the 1970s,
insurance companies began to try several cost-cutting measures that are now all
too familiar to modern policyholders…The theory behind networks was simple
enough: By contracting only with certain providers, insurers could deliver a
higher volume of patients to each one and thereby gain more leverage over
pricing negotiations. They could then translate the savings into lower
premiums, attract more customers, and increase market share…
..and it’s the same problem underlying the proliferation of
varied “insurance products” that cater to different types of
patients. The degree of “choice” a given person has is overwhelmingly
determined by their income and health status, which is a shamefully unjust way
to allocate the costs of running a health-care system. The healthiest people
are able to take their chances on a narrow network, while those with greater
health-care needs are financially penalized for needing a wider breadth of
providers. Meanwhile, the less money someone has available, the more they’re
coerced into “choosing” a plan based on price rather than benefits…
Discussing and tackling the inequities—and potential for
financial ruin—in our health-care financing system demands an acknowledgment
that the sheer diversity of insurance plans in this country, each with their
own pricing and benefit structures, is an inherently bad thing. When it comes
to insurance policies, a multitude of consumer choices translates into genuine
differences in the ability to access care. “Surprise out-of-network
bills” are one highly visible example of how that hurts people. Others are
never hard to find.” (J)
“While President Donald Trump prods Congress to limit
surprise billing, at least three states are debating legislation to ban the
practice…
Current state laws vary in scale and effectiveness. Federal
legislation would be more effective, as it would protect the millions who
receive self-funded coverage through their employer. But the political climate
in Washington, where even historically bipartisan efforts move slowly at best,
has left states to step in and do what they can…
The Colorado General Assembly passed a bill earlier this
month that prohibits surprise billing and sets a reimbursement rate based on
either commercial claims data or the insurers’ median in-network rate for the
service. Gov. Jared Polis, a Democratic, is expected to sign the bill Tuesday,
a spokesman told Healthcare Dive.
A surprise billing law is also on the governor’s desk In
Washington. It calls for a “commercial reasonable amount” to be paid
to out-of-network providers and establishes arbitration if the parties cannot
agree on a rate through negotiation.
In Texas, a bill has passed the Senate and is currently
making its way through the House. It requires an arbitration process for
payments that do not include patient involvement. Previous legislation in the
state required people receiving surprise bills to request remediation…
The Employee Retirement Income Security Act of 1974 limits
the effectiveness of state surprise billing legislation because state laws
can’t apply to employer self-funded plans, which cover the majority of
Americans. Still, the laws can serve a few key purposes.
Several of the bills proposed in Congress defer to state
laws on issues like rate setting or arbitration. So even if Washington passes a
ban on surprise billing, states that want to set their own plans can count on
using their own laws going forward…
“States have a lot of authority over providers … just
making sure the providers have posted information and are being as informative
as possible when consumers are coming into their facilities,” she said.” (K)
Arizona’s new law on surprise medical bills went into effect
January 1. It sets up a procedure where patients can request dispute resolution
through the state’s Department of Insurance. Unresolved disputes will enter
arbitration. If an enrollee participates in an informal settlement
teleconference (IST) beforehand, the law spells out what an enrollee’s
liability: “By virtue of having participated in the IST, the enrollee can only
be held responsible for paying the amount of the enrollee’s cost-sharing
requirements (copay, coinsurance and deductible) plus any amount the health
insurer paid the enrollee for the services provided by the out-of-network
health care provider.” (L)
“Consumer complaints about surprise medical bills have
fallen substantially in New York in the wake of a 2014 law that established a
“baseball-style” arbitration protocol to address these situations, according to
a new report.
Researchers at the Georgetown University Center on Health
Insurance Reforms (CHIR) conducted a case study (PDF) on the state’s Emergency
Services and Balance Billing Law and found that state officials report a
“dramatic” decline in consumer reports about balance bills since the law took
effect in 2015.
Based on an analysis of calls to the Consumer Service
Society’s helpline for surprise billing, 57% of complaints were handled using
the systems established under the law.
“It’s downgraded the
issue from one of the biggest [consumer complaints our call center receives] to
barely an issue,” a state regulator told the CHIR researchers.
In addition to surveying state officials, the Georgetown
researchers also interviewed physicians, insurers and patients, and they found
that overall the participants view the arbitration process as fair. However,
providers were more enthusiastic than insurers, according to the study.
As of October, the number of resolutions in favor of
insurers and in favor of physicians is about even, according to the study—618
were decided in favor of payers and 561 in favor of providers.
Insurers were more likely to win disputes over
out-of-network emergency care billing, while providers were more likely to win
in situations where a patient is treated by an out-of-network physician without
his or her knowledge during an elective procedure.” (M)
“The American Hospital Association was among six national
hospital groups that sent a letter to Congress on Wednesday to suggest
parameters and ideas that legislators should keep in mind as they pursue a
solution to surprise medical bills…
The letter to Congress, a copy of which was obtained by
ROI-NJ, asks federal representatives to consider:
Defining what is considered a surprise bill;
Ensuring patients are protected and not balance billed;
Ensuring patients are not denied emergency coverage if a
visit is considered non-emergent in retrospect;
Avoiding setting a fixed payment rate;
Ensuring patients are educated about their rights and
coverage;
Supporting state laws (like those in New Jersey) that are
protecting consumers.” (N)
“Assemblyman Nick Chiaravalloti is planning to introduce
legislation in May that would plug a loophole in the (New Jersey)
out-of-network law that has been affecting patients transferred out of state…
Health care professionals would be required to document in
the patient records and notify patients of
The patient’s right to receive care at a facility of choice;
Clinical rationale for the out-of-state transfer;
Location of the out-of-state facility;
Availability of clinically appropriate services at nearby
New Jersey facilities;
The nature of the relationship if the patient is being
transferred or referred to an affiliated facility; and
In instances of trauma, stroke or cardiovascular diagnoses,
an explanation as to why the patient is not being transferred to a facility in
New Jersey.
The bill also requires patients be provided information from
their insurance providers as to their potential out-of-pocket costs for an
out-of-state facility, and requires health facilities to disclose to patients
their relationships with out-of-state providers the patients are being referred
to.
This is particularly important with the recent merger
activity in South Jersey with some hospitals tied to health systems in
Pennsylvania…
“To ensure that
health care consumers are able to make well-informed health care decisions,
patients should be informed of their right to select the facility in which they
receive their care before being transferred to another state,” he said.
“Patients should have all the information about why they are being transferred,
and their financial responsibilities associated with the transfer — only then
can a patient make an informed choice.” (O)
“One of the many wonderful advantages we have as residents
of New Jersey is access to high quality, advanced health care. In fact, more
than half of New Jersey’s 67 acute-care hospitals received an “A”
rating in the Leapfrog Hospital Safety Report, the highest percentage of
“A” ratings in any state across the nation. New Jersey is also home
to tremendously skilled physicians and nurses, as well as 13 academic health
systems training the next generation of health care professionals and
researchers. Clearly, New Jersey residents have access to some of the nation’s
greatest health care resources.
Despite these facts, a significant number of patients are
referred or transferred to health care providers and hospitals located out of
state. Some estimates indicate that New Jersey residents spend more than $2
billion annually on health care services out of state. Often these patients are
paying considerably more for their out-of-state health care and receiving care
that is equal to or less effective than they could have received at hospitals
in New Jersey. With health care consumers paying a larger percentage of their
health care costs through higher deductibles, copayments, and coinsurance,
paying more for the same quality of care further from home makes little sense.
New Jersey residents should have the right to obtain health
care wherever they believe it is best, but often patients do not have critical
information necessary to make an informed decision. Moreover, many New Jersey
residents do not understand the strong consumer protections they are forfeiting
by seeking care outside of the state.” (P)
“Bob Ensor didn’t see the boom swinging violently toward him
as he cleaned a sailboat in dry dock on a spring day two years ago. But he
heard the crack as it hit him in the face.
He was transported by ambulance to an in-network hospital
near his home in Middletown, N.J., where initial X-rays showed his nose was
broken as were several bones of his left eye socket. The emergency physician
summoned the on-call plastic surgeon, who admitted him to the hospital and
scheduled him for surgery the next day.
Shortly before surgery, the doctor introduced Ensor to a
second plastic surgeon who would assist in the 90-minute procedure. Entering
through Ensor’s nose, the physicians realigned his facial bones, temporarily
sewing Ensor’s left eye shut so that the lids would stay in place as the bones
knitted back together.
Six weeks later, as Ensor, then 65, continued to make an
uneventful recovery, a collection agency called to inquire how he and his wife
planned to pay the $71,729 bill for the assistant surgeon. Ensor’s company
health plan had denied payment because the surgeon wasn’t part of its
contracted physician network.
There was more bad news. Ensor received notice that the
health plan wouldn’t cover the $95,885 charged by the first plastic surgeon
either because he also was out-of-network.
“The hospital knew these doctors were out-of-network and
didn’t bother to tell us,” said his wife, Linda Ensor, noting they faced more
than $167,000 in charges. “We were panicked.”
Riverview Medical Center in Red Bank, N.J., where Ensor was
treated, said that it “empathizes with patients who are trying to navigate the
complexity of the health care billing system” and that transparency in billing
has not always been optimal for emergency department patients…
Many plastic surgeons don’t participate in health plans because
they have flexibility other physicians may not have — their practices often
focus on elective cosmetic procedures like nose reshaping and breast
augmentation that patients pay for on their own…
Luckily for the Ensors, the sailing club stepped in to take
up his case with the out-of-network plastic surgeons. Since sailing club
members were required to volunteer on work projects to keep membership costs in
check, the club’s insurer agreed to cover the accident as a workers’
compensation case. It paid 100% of the outstanding bill.” (Q)
“In an email to a complaining patient, the CEO of Spectrum
Health acknowledged there needs to be more transparency regarding how patients
are billed for doctor visits.
“We agree with you that a more transparent process is
necessary,” Spectrum Health CEO Tina Freese Decker wrote (PDF) in response to a
complaint. “I have shared your suggestion (for additional transparency) with
our Spectrum Health Medical Group leadership so that we can apply this
suggestion into our workflow.”..
The patient who sent the email to the CEO — and shared the
response with Target 8 — had been charged $142 for a second appointment because
she briefly discussed two minor issues with her doctor during her annual exam…
A month later, the patient received her bill. The annual
wellness visit was covered by insurance, but there was a second charge for the
same day that was not covered…
Additionally, a single mother from a small town in Kent
County, who Target 8 is identifying only as Lindsey, previously reached out to
Target 8 regarding a bill she got after a wellness visit with a physician at
Spectrum medical building in Grand Rapids. While she waited for the
appointment, Lindsey filled out the standard questionnaire, checking a box to
indicate she had periodic leg cramps.
“(The doctor) looked at the form and she said, ‘Oh, I see
you checked yes to leg cramps. Tell me more about it,’” Lindsey recalled.
Lindsey said the doctor showed her some stretches, told her
to drink more water and checked her magnesium and iron levels in addition to
the routine blood tests that were already scheduled for her annual physical.
“I get the bill… and I was charged for two office visits,”
Lindsey said in an interview with Target 8 Thursday. “I called the doctor’s
office right away and I said, ‘This can’t be right. Is this a mistake?’”
But it wasn’t a mistake…
If you’re going in for preventive services, know that there
is a scope of services that’s considered preventive with zero cost, but if you
go in and have a complaint or a scenario diagnosed, then it changes… to another
category of care,” ”.. (R)
“Yale researchers Zack Cooper and Fiona Scott Morton looked
at emergency department visits that occurred at hospitals that were in
insurers’ networks, in a paper for the New England Journal of Medicine. “On
average,” they found, “in-network emergency-physician claims were paid at 297%
of Medicare rates,” while “out-of-network emergency physicians [within
in-network hospitals] charged an average of 798% of Medicare rates.”
A study from UnitedHealthGroup, looking at its own claims
nationwide, recently estimated that out-of-network emergency physicians
increased health care charges by $6 billion per year.” (S)
What’s behind this explosion of outrageous charges and
surprise medical bills? Physicians’ groups, it turns out, can opt out of a
contract with insurers even if the hospital has such a contract. The doctors
are then free to charge patients, who desperately need care, however much they
want.
This has made physicians’ practices in specialties such as
emergency care, neonatal intensive care and anesthesiology attractive takeover
targets for private equity firms…
A 2018 study by Yale health economists looked at what
happened when the two largest emergency room outsourcing companies — EmCare and
TeamHealth — took over hospital ERs. They found:
“…that after EmCare took over the management of emergency
services at hospitals with previously low out-of-network rates, they raised
out-of-network rates by over 81 percentage points. In addition, the firm raised
its charges by 96 percent relative to the charges billed by the physician
groups they succeeded.”
TeamHealth used the threat of sending high out-of-network
bills to the insurance company’s covered patients to gain high fees as
in-network doctors. The researchers found:
“…in most instances, several months after going
out-of-network, TeamHealth physicians rejoined the network and received
in-network payment rates that were 68 percent higher than previous in-network
rates.”
What the Yale study failed to note, however, is that EmCare
has been in and out of PE hands since 2005 and is currently owned by KKR.
Blackstone is the once and current owner of TeamHealth, having held it from
2005 to 2009 before buying it again in 2016.
Private equity has shaped how these companies do business.
In the health-care settings where they operate, market forces do not constrain
the raw pursuit of profit. People desperate for care are in no position to
reject over-priced medical services or shop for in-network doctors.
Private equity firms are attracted by this opportunity to
reap above-market returns for themselves and their investors.
Patients hate surprise medical bills, but they are very
profitable for the private equity owners of companies like EmCare (now called
Envision) and TeamHealth. Fixing this problem may be more difficult than the
White House imagines. (T)
PART 1. April16,
2019. Assignment: it ethical for the public not be notified about new
“super bugs” in hospitals so they can decide whether or not to go to
affected hospitals?
“Last May, an elderly man was admitted to the Brooklyn
branch of Mount Sinai Hospital for abdominal surgery. A blood test revealed
that he was infected with a newly discovered germ as deadly as it was
mysterious. Doctors swiftly isolated him in the intensive care unit.
The germ, a fungus called Candida auris, preys on people
with weakened immune systems, and it is quietly spreading across the globe.
Over the last five years, it has hit a neonatal unit in Venezuela, swept
through a hospital in Spain, forced a prestigious British medical center to
shut down its intensive care unit, and taken root in India, Pakistan and South
Africa.
Recently C. auris reached New York, New Jersey and Illinois,
leading the federal Centers for Disease Control and Prevention to add it to a
list of germs deemed “urgent threats.”
The man at Mount Sinai died after 90 days in the hospital,
but C. auris did not. Tests showed it was everywhere in his room, so invasive
that the hospital needed special cleaning equipment and had to rip out some of
the ceiling and floor tiles to eradicate it.
“Everything was positive – the walls, the bed, the
doors, the curtains, the phones, the sink, the whiteboard, the poles, the
pump,” said Dr. Scott Lorin, the hospital’s president. “The mattress,
the bed rails, the canister holes, the window shades, the ceiling, everything
in the room was positive.”” (A)
“Back in 2009, a 70-year-old Japanese woman’s ear
infection puzzled doctors. It turned out to be the first in a series of
hard-to-contain infections around the globe, and the beginning of an ongoing
scientific and medical mystery.
The fungus that infected the Japanese woman, Candida auris,
kills more than 1 in 3 people who get an infection that spreads to their blood
or organs. It hits people who have weakened immune systems, and is most often
found in places like care homes and hospitals. Once it shows up, it’s hard to
get rid of: unlike most species of fungi, Candida auris spreads from person to
person and can live outside the body for long periods of time.
Mount Sinai wasn’t the first hospital to face this task: a
London hospital found itself with an outbreak in 2016, and the only way to stop
it was to rip out fixtures…
Scientists still aren’t sure exactly where this happened or
when. That’s one of the things they’re working on now, says Cuomo, because
figuring out how the fungus evolved could help researchers develop treatments
for it…
Although the “superbug” moniker might sound
alarmist, Candida auris qualifies for two reasons, says Cuomo. First, all
strains of the yeast are resistant to antifungals. There are three major kinds
of antifungals used to treat humans, and some strains of Candida auris are
resistant to all of them, while other strains are resistant to one or two. That
limits the treatment options for someone who has been infected-someone who is
probably already in poor health. The other reason is “this really scary
property of not being able to get rid of it,” Cuomo says.” (B)
“Superbugs are a terrifying prospect because of their
resistance to treatment, and one superbug that is sweeping all over the world
is the Candida auris.
C. auris is a fungus that causes serious infections in
various parts of the body, including the bloodstream and the ear.
While its discovery has been relatively recent in 2009, this
fungus has already wreaked havoc in hospitals in more than 20 different
countries, including the United States, United Kingdom, and Spain, among
others.
In the United States, CDC reports a total of 587 clinical
cases of C. auris infections as of February. Most of it occurred in the areas
of New York City, New Jersey, and Chicago.” (C)
“The CDC issued a public alert in January about a
drug-resistant bacteria that a dozen Americans contracted after undergoing
elective surgeries at Grand View Hospital in Tijuana, Mexico. Yet when similar
outbreaks occur at U.S. hospitals, the agency does not issue a public warning.
This is due to an agreement with states that prohibits the CDC from publicly
disclosing hospitals undergoing outbreaks of drug-resistant infections,
according to NYT.
Patient advocates are pushing for more transparency into
hospital-based infection outbreaks, saying the lack of warning could put
patients at risk of harm.
“They might not get up and go to another hospital, but
patients and their families have the right to know when they are at a hospital
where an outbreak is occurring,” Lisa McGiffert, an advocate with the
Patient Safety Action Network, told NYT. “That said, if you’re going to
have hip replacement surgery, you may choose to go elsewhere.”..
The CDC declined NYT’s request for comment. Agency officials
have previously told the publication the confidentiality surrounding outbreaks
is necessary to encourage hospitals to report the drug-resistant
infections.” (D)
“New Jersey is among the states worst affected by an
increasing incidence of the potentially deadly fungus Candida auris, whose
resistance to drugs is causing headaches for hospitals, state and federal
health officials said on Monday.
There were 104 confirmed and 22 probable cases of people
infected by the fungus in New Jersey by the end of February, according to the
federal Centers for Disease Control and Prevention, up sharply from a handful
when the fungus was first identified in the state about two years ago.
The state’s number of cases – now the third-highest after
New York and Illinois – has risen in tandem with an increase, first overseas,
and now in the United States, in a trend that some doctors attribute to the
overuse of drugs to treat infections, prompting the mutation of infection
sources, in this case, a fungus.
The fungus mostly affects people who have existing illnesses,
and may already be hospitalized with compromised immune systems, health
officials said.
Nicole Kirgan, a spokeswoman for the New Jersey Department
of Health, said she didn’t know whether any of the state’s cases have been
fatal, and couldn’t say which hospitals are treating people with the fungus
because they have not, so far, been required to report their cases to state
officials…
But Dr. Ted Louie, an infectious disease specialist at
Robert Wood Johnson University Hospital in New Brunswick, said many hospitals
don’t know how to eradicate the fungus once it has occurred.
Some disinfectants commonly used in hospitals have proved
ineffective in removing the fungus, Dr. Louie said, so hospitals have been
urged to use other disinfecting agents, although it’s not yet clear which of
them work, if any.
“This is a fairly new occurrence and we are still
learning how to deal with it,” he said. “We have to figure out which
disinfectant procedures may be best to try to eradicate the infection, so at
this point, I don’t think we have good enough information to advise.” (E)
“Adding to the difficulty of treating candida auris is
finding it in the first place. The infection is often asymptomatic, showing few
to no immediate symptoms, said Chauhan. The symptoms that do appear, such as
fever, are often confused for bacterial infections, he said.
“Most routine diagnostic tests don’t work very well for
candida auris,” he said. “They’re often misidenfitied as other
species.”
The best way to identify candida auris is by looking under a
microscope, which often takes time because it requires doctors to grow the
fungus, Chauhan said.
As with most infectious diseases, the best course of action
is good hygiene and sterilization protocol. Washing your hands and using hand
sanitizer after helps to prevent transmission and infection, Chauhan said.
Doctors and healthcare workers should use protective gear,
and people visiting loved ones in hospitals and long-term care centers should
take proper precautions, he said.
The Center for Disease Control recommends using a special
disinfectant that is used to treat clostridium difficile spores. The
disinfectant has been effective in wiping out clostridium difficile, known as
c. diff, and disinfects surfaces contaminated with candida auris, as well.”
(F)
“Hospitals and nursing homes in California and Illinois
are testing a surprisingly simple strategy against the dangerous,
antibiotic-resistant superbugs that kill thousands of people each year: washing
patients with a special soap.
The efforts – funded with roughly $8 million from the
federal government’s Centers for Disease Control and Prevention – are taking
place at 50 facilities in those two states.
This novel approach recognizes that superbugs don’t remain
isolated in one hospital or nursing home but move quickly through a community,
said Dr. John Jernigan, who directs the CDC’s office on health care-acquired
infection research.
“No health care facility is an island,” Jernigan
said. “We all are in this complicated network.”
At least 2 million people in the U.S. become infected with
an antibiotic-resistant bacterium each year, and about 23,000 die from those
infections, according to the CDC…
Containing the dangerous bacteria has been a challenge for
hospitals and nursing homes. As part of the CDC effort, doctors and health care
workers in Chicago and Southern California are using the antimicrobial soap
chlorhexidine, which has been shown to reduce infections when patients bathe
with it. Though chlorhexidine is frequently used for bathing in hospital
intensive care units and as a mouthwash for dental infections, it is used less
commonly for bathing in nursing homes…
The infection-control work was new to many nursing homes,
which don’t have the same resources as hospitals, Lin said.
In fact, three-quarters of nursing homes in the U.S.
received citations for infection-control problems over a four-year period,
according to a Kaiser Health News analysis, and the facilities with repeat
citations almost never were fined. Nursing home residents often are sent back
to hospitals because of infections.” (G)
“The C.D.C. declined to comment, but in the past
officials have said their approach to confidentiality is necessary to encourage
the cooperation of hospitals and nursing homes, which might otherwise seek to
conceal infectious outbreaks.
Those pushing for increased transparency say they are up
against powerful medical institutions eager to protect their reputations, as
well as state health officials who also shield hospitals from public scrutiny…
Hospital administrators and public health officials say the
emphasis on greater transparency is misguided. Dr. Tina Tan, the top
epidemiologist at the New Jersey Department of Health, said that alerting the
public about hospitals where cases of Candida auris have been reported would
not be useful because most people were at low risk for exposure and public
disclosure could scare people away from seeking medical care.
“That could pose greater health risks than that of the
organism itself,” she said.
Nancy Foster, the vice president for quality and patient
safety at the American Hospital Association, agreed, saying that publicly
identifying health care facilities as the source of an infectious outbreak was
an imperfect science.
“That’s a lot of information to throw at people,”
she said, “and many hospitals are big places so if an outbreak occurs in a
small unit, a patient coming to an ambulatory surgical center might not be at
risk.”
Still, hospitals and local health officials sometimes hide
outbreaks even when disclosure could save lives. Between 2012 and 2014, more
than three dozen people at a Seattle hospital were infected with a
drug-resistant organism they got from a contaminated medical scope. Eighteen of
them died, but the hospital, Virginia Mason Medical Center, did not disclose
the outbreak, saying at the time that it did not see the need to do so.” (H)
“Many have heard of the rise of drug-resistant
infections. But few know about an issue that’s making this threat even scarier
in the United States: the shortage of specialists capable of diagnosing and
treating those infections. Infectious diseases is one of just two medicine
subspecialties that routinely do not fill all of their training spots every
year in the National Resident Matching Program (the other is nephrology).
Between 2009 and 2017, the number of programs filling all of their
adult-infectious-disease training positions dropped by more than 40 percent…
Everyone who works in health care agrees that we need more
infectious-disease doctors, yet very few actually want the job. What’s going
on?
The problem is that infectious-disease specialists care for
some of the most complicated patients in the health care system, yet they are
among the lowest paid. It is one of the only specialties in medicine that
sometimes pays worse than being a general practitioner. At many medical
centers, a board-certified internist accepts a pay cut of 30 percent to 40
percent to become an infectious-disease specialist.
This has to do with the way our insurance system reimburses
doctors. Medicare assigns relative value units to the thousands of services
that doctors provide, and these units largely determine how much physicians are
paid. The formula prioritizes invasive procedures over intellectual expertise.
The problem is that infectious-disease doctors don’t really
do procedures. It is a cognitive specialty, providing expert consultation, and
insurance doesn’t pay much for that…
Infectious-disease specialists are often the only health
care providers in a hospital – or an entire town – who know when to use all of
the new antibiotics (and when to withhold them). These experts serve as an
indispensable cog in the health care machine, but if trends continue, we won’t
have enough of them to go around. The terrifying part is that most patients
won’t even know about the deficit. Your doctor won’t ask a specialist for help
because in some parts of the country, the service simply won’t be available.
She’ll just have to wing it…
We must hurry. Superbugs are coming for us. We need experts
who know how to treat them.” (I)
People visiting patients at the hospital, and most
hospitalized patients, have little to fear from a novel fungal disease that has
struck more than 150 people in Illinois – all in the Chicago area – a Memorial
Medical Center official said Friday.
“For normal, healthy people, this is not a
concern,” Gina Carnduff, Memorial Health System director of infection
prevention, said in reference to Candida auris infections.
Carnduff, who is based at Memorial Medical Center, said only
the “sickest of the sick” patients are at risk of catching or
spreading the C. auris infection or dying from it.
Those patients, she said, include people who have stayed for
long periods at health care facilities – such as skilled-care nursing homes or
long-term acute-care hospitals – and who are on ventilators or have central
venous catheter lines or feeding tubes…
Officials from both Memorial Medical Center and HSHS St.
John’s Hospital said their institutions already are using the bleach-based
cleaning solutions known to prevent the spread of C. auris and other
infections.
The Illinois Department of Public Health’s website says more
than one in every three people with “invasive C. auris infection”
affecting the blood, heart or brain will die…
The state health department says 154 confirmed cases of C.
auris and four probable cases have been identified, all in the Chicago area.
Ninety-five cases were in Chicago, 56 were in Cook County outside of Chicago,
and seven were spread among the counties of DuPage, Lake and Will.
Eighty-five of the 158 people making up the confirmed and
probable cases have died, but only one death was “directly
attributed” to the infection, Arnold said. It’s not known whether C. auris
played a role in the deaths of the other 84 people, she said. (J)
“There is also the fact that some lab tests will not
identify the superbug as the source of an illness, which means that some
patients will receive the wrong treatment, increasing the duration of the
infection and the chance to transmit the fungus to another person.” (K)
“Hospitals, state health departments and the Centers
for Disease Control and Prevention are putting up a wall of silence to keep the
public from knowing which hospitals harbor Candida auris.
New York health officials publish a yearly report on
infection rates in each hospital. They disclose rates for infections like MRSA
and C. Diff. But for several years, the same officials have been mum about the
far deadlier Candida auris. That’s like posting “Wanted” pictures for
pickpockets but not serial murderers.
Health officials say they’ll disclose the information in
their next yearly report. That could be many months from now. Too late.
Patients need information in real time about where the risks are…
Dr. Eleanor Adams, a state Health Department researcher,
examined all the facilities in New York City affected by Candida auris over a
four-year period. Adams found serious flaws, including “inadequate
disinfection of shared equipment” to take vital signs, hasty cleaning and
careless compliance with rules to keep infected patients isolated…” (L)
“Remedies for curtailing the advance of C. auris are
familiar. Health care facilities must undergo stringent infection controls,
test for new cases and quickly identify any sources passing it along. Visitors
and medical workers must wash their hands after touching patients or surfaces.
The yeast spreads widely throughout patients’ rooms. Some cleanups have
reportedly required removing ceiling and floor tiles.
C. auris isn’t simply an opportunistic infection. Its rise
is additional evidence that becoming too reliant on certain types of drugs may
have unintended consequences. Exhibit A is the overuse of antibiotics in
doctors’ offices and on farms that encourages the development of drug-resistant
bacteria. Researchers suspect a similar situation involving C. auris and
agricultural fungicides used on crops. So far the origins of C. auris are
unclear, with different clusters arising in different areas of the world.
There’s no need to panic. But vigilance is required to track
C. auris and raise awareness in order to combat it. Officials typically are
eager to spread the word about potential health crises, from measles to MRSA.
In this case, the CDC issued alerts about fungus to health care facilities, but
the New York Times encountered an unusual wall of silence while investigating
superbugs such as C. auris. Medical facilities didn’t want to scare off
patients.
Any attempts to hide the spread of a communicable disease
are irresponsible. Knowledge leads to faster prevention and treatment. Patients
and their families have a right to know how hospitals and government agencies
are responding to a new threat. Medical workers also deserve to be informed of
the risks they encounter on the job.
Battling the superbugs requires aggressive responses and,
ultimately, scientific advancements. Downplaying outbreaks won’t stop their
rise.” (M)
“The rise of C. auris, which may have lurked unnoticed
for millennia, owes entirely to human intervention – the massive use of
fungicides in agriculture and on farm animals which winnowed away more
vulnerable species, giving the last bug standing a free run. Sensitised to
clinical fungicides, C. auris has proved to be difficult to extirpate, and
culls infected humans who cannot fight diseases very effectively – infants, the
old, diabetics, people with immune suppression, either because of diseases like
HIV or the use of steroids. The new superfungus has the makings of a future
plague, one of several which may cumulatively surpass cancer as a leading
killer in a few decades.
The origin of C. auris is known because it broke out in the
21st century, but the plagues from antiquity lack origin stories. Even their
spread was understood only retrospectively, in the light of modern science. The
father of all plagues, the Black Death, originated in China in the early 14th
century and ravaged most of the local population before it began its long
journey westwards down the Silk Route, via Samarkand. At the time, the chain of
hosts that carried it would have been incomprehensible – the afflicting
organism Yersinia pestis, the fleas which it infested, the rats which the fleas
in turn infested, which carried it into the homes of humans….” (N)
“WebMD: Most of us know candida from common yeast
infections that you might get on your skin or mucous membranes. What makes this
one different?
Chiller: It’s not acting like your typical candida. We’re
used to seeing those.
Candida – the regular ones – are already a major cause of bloodstream
infection in hospitalized patients. When we get invasive infections, for
example, bloodstream infections, we think that you sort of auto-infect
yourself. You come in with the candida already living in your gut. You’re in
the ICU, you’re on a broad spectrum antibiotic. You’re killing off bad
bacteria, you’re killing off good bacteria, so what are you left with? Yeast,
and it takes over.
What’s new with Candida auris is that it doesn’t act like
the typical candida that comes from our gut. This seems to be more of a skin
organism. It’s very happy on the skin and on surfaces.
It can survive on surfaces for long periods of time, weeks
to months. We know of patients that are colonized [meaning the Candida auris
lives on their skin without making them sick] for over a year now.
It is spreading in health care settings, more like bacteria
would, so it’s yeast that’s acting like bacteria” (O).
PART 2. In 30
years, I’ve never faced so tough a reporting challenge — and one so unexpected.
Who wouldn’t want to talk about a fungus?…
“C. auris is a drug-resistant fungus that has emerged
mysteriously around the world, and it is understood to be a clear and present
danger. But Connecticut state officials wouldn’t tell us the name of the
hospital where they had had a C. auris patient, let alone connect us with her
family. Neither would officials in Texas, where the woman was transferred and
died. A spokeswoman for the City of Chicago, where C. auris has become rampant
in long-term health care facilities, promised to find a family and then stopped
returning my calls without explanation.” (A)
“Candida auris, also referred to as C. auris, is a
potentially deadly fungal infection that appears to be making its way through
hospitals and long-term care facilities across the country. The New York City
area and New Jersey have reported more than 400 cases over the last few years
alone. Federal health authorities have declared this fungus a “serious global
health threat.”” (B)
“The Council of State and Territorial Epidemiologists (CSTE)
says Candida auris infections have been “associated with up to 40%
in-hospital mortality.”
“Most strains of C. auris are resistant to at least one
antifungal drug, one-third are resistant to two antifungal drug classes, and
some strains are resistant to all three major classes of antifungal drugs. C.
auris can spread readily between patients in healthcare facilities. It has
caused numerous healthcare-associated outbreaks that have been difficult to
control,” the CSTE said.
The CDC added, “Patients who have been hospitalized in
a healthcare facility a long time, have a central venous catheter, or other
lines or tubes entering their body, or have previously received antibiotics or
antifungal medications, appear to be at highest risk of infection with this
yeast.”
The CDC is alerting U.S. healthcare facilities to be on the
lookout for C. auris in their patients.” (C)
“”It’s a very serious health threat,” said Dr.
Irwin Redlener, Columbia University professor and an expert on public health
policy. “It’s a superbug, meaning resistant to all-known
antibiotics.”..
“These people would be in danger, so you don’t want
somebody visiting the hospital not knowing that it’s around and somehow
contracting the infection,” Dr. Redlener said. “That would be an
utter disaster.”..
Dr. Redlener says the secrecy is a big mistake.
“If they’re rattled by Candida auris to the point where
we have secrecy pacts among hospitals and public health agencies, then you’re
just hiding something that obviously needs more attention and resources to deal
with,” he said.
The state Department of Health says there is no risk to the
general public and notes that the vast majority of patients have had serious
underlying medical conditions.
Jill Montag, a spokesperson for the New York State
Department of Health, issued a statement to Eyewitness News.
“We are working aggressively with impacted hospitals
and nursing homes to implement infection control strategies for Candida
auris,” it read.
Montag says they plan to include the name of the impacted
facilities in their annual infection report, which will be released later this
year.
Dr. Redlener says they have the information now and should
release the names now…
“To keep that a secret is putting people in
danger,” he said. “And I don’t think that’s reasonable or
ethical.”” (D)
“We don’t know why it
emerged,” said Dr. Maurizio Del Poeta, a professor of molecular genetics and
microbiology at Stony Brook University’s Renaissance School of Medicine. At the
very least, he is recommending hospitals develop stricter rules on foot traffic
in and out of patients’ rooms because the microbe can be carried on the bottom
of shoes.
The pathogen clings to surfaces in hospital rooms,
flourishes on floors, and adheres to patients’ skin, phones and food trays. It
is odorless, invisible — and unlikely to vanish from health care institutions
anytime soon.
“It can survive on a hospital floor for up to four
weeks,” Del Poeta said of C. auris. “It attaches to plastic objects
and doorknobs.”..…
“If we don’t want it
to become like Staphylococcus aureus, then we have to act now,” said Del Poeta,
referring to the bacteria that became the poster child of drug resistance when
it developed the ability to defeat the antibiotic methicillin, garnering the
name methicillin-resistant Staphylococcus aureus, or MRSA…
“In order to get
Candida auris out of a room, you have to take away everything — doorknobs,
plastic items, everything. It is very difficult to eradicate it in a
hospital,” Del Poeta said. He said his institution has never had a patient
with C. auris…
Scientists such as Del Poeta contend it’s time for new
methods of addressing resistant microbes of all kinds because infectious
pathogens have developed the power to outwit, outpace and outmaneuver
humankind’s most potent agents of chemical warfare, many of them developed in
the 20th century.” (E)
“A case management program piloted by the New York City
health department monitors patients colonized with Candida auris after they are
discharged into the community and notifies health care facilities of their
status, researchers reported at the CDC’s annual Epidemic Intelligence Service
conference….
Patients can remain colonized with C. auris for months in a
health care setting, but it is unclear if they remain colonized after
discharge, noted Genevieve Bergeron, MD, MPH, an Epidemic Intelligence Service
officer with the New York City Department of Health and Mental Hygiene (DOHMH),
and colleagues.
According to Bergeron and colleagues, the state health department
began referring patients colonized with C. auris to the DOHMH on Oct. 4, 2017.
Approximately 12 case managers handled the referrals, conducting patient
interviews and reviewing medical records to obtain relevant clinical
information. They informed the patients’ providers and health care facilities
about their C. auris status and infection control needs.
“We requested that facilities flag the patient in their
electronic medical records to ensure that the patient has the proper
precautions, if the patient were to seek care again at those facilities,”
Bergeron said in a presentation. “Case mangers sent a medical alert card to the
patients for them to use when encountering health care providers unaware of
their infection control needs.”” (F)
“Regions are considering the use of electronic registries to
track patients that carry antibiotic-resistant bacteria including
carbapenem-resistant Enterobacteriaceae (CRE). Implementing such a registry can
be challenging and requires time, effort, and resources; therefore, there is a
need to better understand the potential impact…
When all Illinois facilities participated (n=402), the
registry reduced the number of new carriers by 11.7% and CRE prevalence by 7.6%
over a 3-year period. When 75% of the largest Illinois facilities participated
(n=304), registry use resulted in a 11.6% relative reduction in new carriers
(16.9% and 1.2% in participating and non-participating facilities,
respectively) and 5.0% relative reduction in prevalence. When 50% participated
(n=201), there were 10.7% and 5.6% relative reductions in incident carriers and
prevalence, respectively. When 25% participated (n=101), there was a 9.1%
relative reduction in incident carriers (20.4% and 1.6% in participating and
non-participating facilities, respectively) and 2.8% relative reduction in
prevalence.
Implementing an XDRO registry reduced CRE spread, even when
only 25% of the largest Illinois facilities participated due to patient
sharing. Non-participating facilities garnered benefits, with reductions in new
carriers.” (G)
“Quebec public-health authorities are bracing for the
inevitable arrival of a multi drug-resistant fungus that has been spreading
around the globe and causing infections, some of them fatal…
“We will definitely
have cases here and there at one point,” said Dr. Karl Weiss, chief of
infectious diseases at the Jewish General Hospital. “It’s almost guaranteed.
The only thing is when you know what you’re fighting against, it’s always
easier and we will be able to contain it a lot faster.”
C. auris poses a quadruple threat: it’s tricky to identify;
it can thrive in hospitals for weeks (preying on patients with weakened immune
systems); it’s resistant to two classes of anti-fungal medications; and it can
cause invasive disease, with lingering bloodstream infections that are hard to
treat. The mortality rate can rise as high as 60 per cent.
The pathogen has emerged at a time when hospitals in Quebec
— their budgets stretched more than ever — are already struggling with
antibiotic-resistant superbugs like C. difficile, MRSA and VRE that have caused
outbreaks. The Institut national de santé publique du Québec published a
bulletin last year on steps that hospitals and long-term centres can take to
prevent C. auris outbreaks.
“The problem is if you don’t identify the fungus properly,
then it can slip in between your hands, and you can have an outbreak in your
institution without even knowing it,” Weiss explained.
There was a lot of mis-indentification of this with other
Candida (fungi); and even the automated systems in institutions that identify
bacteria and yeast were mislabelling this Candida for something else. For a
while, people were not aware of this auris. But now we know how to identify it.
“The first thing we did in Quebec — and this was for all the
microbiology labs — is we taught all the microbiologists how to properly
identify Candida auris,” Weiss continued.
“All the major labs in Quebec put in place protocols.”
Weiss, who is president of the Quebec Association of Medical
Microbiologists, noted that under a quality assurance program, samples have
been sent to different labs to test whether the fungus is identified correctly.
The results show that that labs are detecting C. auris to a high degree.
If a patient is discovered to be infected, hospital protocol
dictates that the patient be isolated. During the patient’s hospitalization,
the housekeeping staff must disinfect the room daily with hydrogen peroxide and
other chemicals…” (H)
“Federal officials should declare an emergency over a
deadly, incurable fungus infecting people in New York, New Jersey and across
the country, Sen. Chuck Schumer said Sunday.
Schumer said he’s pushing the federal government to allocate
millions of dollars to fighting Candida auris, which is drug-resistant and
proving very difficult to eradicate…
“When it comes to the superbug, New York could use a little
more help,” said Schumer. “The CDC has the power to declare this an emergency
and automatically give us the resources we need.”..
Schumer said that an emergency declaration by the CDC would
lead to more cases being identified with better testing, and to better tracking
of the disease. It might also reduce the number of unnecessary antibiotic
prescriptions, which Schumer says have helped the disease become drug-resistant…
Schumer cited other CDC emergency declarations that helped
stop the spread of deadly diseases, including a $25 million award to fight the
Zika virus in 2016 and $165 million given to contain Ebola in 2014.
“Every dollar we can use to better identify, tackle and
treat this deadly fungus is a dollar well spent,” Schumer said.” (I)
“Other medical experts see the overuse of human antifungal
medications in agriculture and floriculture as potential reasons for resistance
in Candida auris, known as C. auris, and possibly other fungi.
Dr. Matt McCarthy, a specialist in infectious diseases at
Weill Cornell Medicine in Manhattan, said tulips, signature flowers of the
Netherlands, are dosed with the same antifungal medications developed to treat
human infections.
“Antifungals are pumped into tulips in Amsterdam to
achieve flawless plants,” he said. “As a fungal expert, I know that
we have very few antifungal medications, and this is a misuse of the
drugs.”
Studies conducted at Trinity College in Ireland support
McCarthy’s argument and have demonstrated that tulip and narcissus bulbs from
the Netherlands may be vehicles that spread drug-resistant fungi.
Trinity scientists, who examined resistance in another
potentially deadly fungus, Aspergillus fumigatus, uncovered why the bugs
repelled the drugs known as triazoles. The fungi became resistant because of
the overuse of triazoles in floriculture. As with C. auris, drug-resistant A.
fumigatus can be deadly in people with poor immunity.
When patients need treatment with triazole-class
medications, the drugs don’t work because the fungi have been overexposed in
the environment, McCarthy said.
He added that the use of antifungal medications in
floriculture is similar to the overuse of antibiotics in the poultry and beef
industries, which have helped drive resistance to those drugs.
The floriculture example is just one way that drug-resistant
fungi can spread around the world. Global trade networks, human travel and the
movement of animals and crops are others.” (J)
“It will take further research to determine if the new
strains of C. auris have their origins in agriculture, but Aspergillus has
already illustrated the perils of modern farming. Antibiotics are applied on a
massive scale in food production, pushing the rise of bacterial drug
resistance. A British government study published in 2016 estimated that, within
30 years, drug-resistant infections will be a bigger killer than cancer, with
some 10 million people dying from infections every year.
We don’t have to end up there. Pesticide use on most farms
can be greatly reduced, or even eliminated, without reducing crop yields or
profitability. Methods of organic farming, even as simple as crop rotation,
tend to promote the growth of mutualistic fungi that crowd out pathogenic
strains such as C. auris. Unfortunately, because conventional agriculture is
heavily subsidized and market prices don’t reflect the costs to the environment
or human health, organic food is more expensive and faces an uphill battle for
greater consumption.
Of course, improved technology could help, with drugs of new
kinds or in breeding and engineering resistant strains of plants. There’s also
plenty of opportunity for lightweight agricultural robots, which can weed
mechanically or spray pesticides more accurately, reducing the quantity of
chemicals used. But tech shouldn’t be the sole focus just because it happens to
be the most profitable route for big industries.” (K)
“The recent outbreak of the so-called superbug — and other
drug-resistant germs — has thrown a spotlight on locally based Xenex
Disinfection Systems. The company makes a robot that uses pulsing, ultraviolet
rays to disinfect surgical suites and other environments that are supposed to
be germ-free.
With the spread of C. auris, Xenex officials say they’ve
seen an uptick in queries about their LightStrike Germ-Zapping Robots, which
are in use at more than 400 health-care facilities around the world since
manufacturing started in 2011.
These devices — often called R2Clean2, Mr. Clean and The
Germinator — disinfect rooms in a matter of minutes. A dome on the top of the
robot rises up, exposing a xenon bulb that emits UV light waves that kill germs
on contaminated surfaces.
Bexar County-owned University Hospital has a fleet of six
Xenex robots. One of the robots is assigned to the Cystic Fibrosis Center to
help protect patients from infection by other patients.
“We are taking every measure possible to reduce the risk of
infections, and this is an additional layer of security that bathes the room in
UV-C light,” said Elizabeth Allen, public relations manager at University
Health System…
Another study, recently published by a doctor at the
Minnesota-based Mayo Clinic, showed that when the hospital used the robots in
rooms that had already been cleaned, infection rates of another superbug —
called Clostridium difficile, or C. diff — fell by 47 percent.” (L)
“It wasn’t publicized locally, but within the past few years
teams of health officials at two Oklahoma health facilities took rapid actions
to contain the spread of a fungal “superbug” that federal officials have
declared a serious global health threat.
Only one patient at each facility was infected, and both
patients recovered. But the incidents reflect the growing alarm among health
officials over the deadly, multidrug-resistant Candida auris, or C. auris,
which can kill 30 percent to 60 percent of those infected…
In April 2017, a team of experts from the federal Centers
for Disease Control and Prevention converged on the University of Oklahoma
Medical Center in Oklahoma City after a patient tested positive for the
drug-resistant fungus.
About a year later, a patient at a southeast Oklahoma health
facility tested positive for the germ during a routine test. In both cases,
health officials isolated the patients, locked down their rooms and ordered
dozens of lab tests to see if the multidrug-resistant fungus had spread…
Unlike with outbreaks in Illinois, New York and New Jersey,
the potentially deadly infection was quickly contained.”..
Public knowledge about the OU Medical Center case makes it
an exception. Typically, health care facilities across the nation don’t release
to the public information when C. auris and other drug-resistant pathogens are
found. No law or policy requires them to do so.
Patient-rights advocates maintain that the public has the
right to know when and where outbreaks or even single cases occur. But health
officials have routinely fought back, suggesting that it could violate patient
rights and discourage patients from seeking hospital care.
But the CDC allows states to make that decision.
Burnsed said the Department of Health tries to walk a tight
line between notifying the public and protecting the patient’s privacy.
He said he would be more likely to identify a facility if
it’s anything more than an isolated case or if officials believed the exposure
wasn’t contained.
“What we consider is if there was a risk to a broader group
of individuals and if there was any evidence that there were a breach in lab
controls,” Burnsed said. “We didn’t put out anything at the time (on Oklahoma’s
two cases) because we didn’t think there was a greater risk to the public, but
it’s a good question to consider.”” (M)
“How many people will needlessly die from a deadly bug
sweeping through New York hospitals and nursing homes before local health
officials acknowledge the danger publicly — and act accordingly?..
Yet public-health officials here have been slow to let patients
know in which hospitals the bug is lurking. Folks are left to take their
chances. That’s outrageous.
Why are officials mum? Partly because they fear that if they
disclose the information, some people who need treatment won’t go for it.
That’s a weak excuse: As McCaughey notes, there are plenty
of local hospitals that aren’t plagued by Candida auris, so patients could get
care and avoid the risk, if they know where it’s safe to go.
More likely, no one wants to damage the reputations (or
incomes) of the affected hospitals. Yet the best way to protect those
reputations is to make sure the facilities are Candida auris-free…
Meanwhile, officials say they will reveal which hospitals
have the germ — in their next yearly report. But that could be months away;
patients need to know now.
If neither the hospitals nor their government regulators are
willing to move sooner, perhaps state lawmaker should step in and require them
to do so… (N)
Infectious disease experts tell Axios they agree with a dire
scenario painted in the UN report posted earlier this week saying that, if
nothing changes, antimicrobial resistance (AMR) could be
“catastrophic” in its economic and death toll.
Threat level, per the report: By 2030, up to 24 million
people could be forced into extreme poverty and annual economic damage could
resemble that from the 2008–2009 global financial crisis, if pathogens continue
becoming resistant to medications. By 2050, AMR could kill 10 million people
per year, in its worst-case scenario.
“There is no time to wait. Unless the world acts
urgently, antimicrobial resistance will have disastrous impact within a
generation.”..
By the numbers: Currently, at least 700,000 people die each
year due to drug-resistant diseases, including 230,000 people from multidrug-resistant
tuberculosis, per the UN. Common diseases — like respiratory infections, STDs
and urinary tract infections — are increasingly untreatable as the pathogens
develop resistance to current medications.
The Centers for Disease Control and Prevention says AMR
causes more than 23,000 deaths and 2 million illnesses in the U.S. annually…
What needs to be done: Jasarevic says the economic and
health systems of all nations must be considered, and targets made to increase
investment in new medicines, diagnostic tools, vaccines and other
interventions.”
The bottom line: Action must be taken to avoid a
catastrophic future.” (O)
“A recent study of patients at 10 academic hospitals in the
United States found that just over half care about what their doctors wear,
most of them preferring the traditional white coat.
Some doctors prefer the white coat, too, viewing it as a
defining symbol of the profession.
What many might not realize, though, is that health care
workers’ attire — including that seemingly “clean” white coat that many prefer
— can harbor dangerous bacteria and pathogens.
A systematic review of studies found that white coats are
frequently contaminated with strains of harmful and sometimes drug-resistant
bacteria associated with hospital-acquired infections. As many as 16 percent of
white coats tested positive for MRSA, and up to 42 percent for the bacterial
class Gram-negative rods.”
It isn’t just white coats that can be problematic. The
review also found that stethoscopes, phones and tablets can be contaminated
with harmful bacteria. One study of orthopedic surgeons showed a 45 percent
match between the species of bacteria found on their ties and in the wounds of
patients they had treated. Nurses’ uniforms have also been found to be
contaminated.
Among possible remedies, antimicrobial textiles can help
reduce the presence of certain kinds of bacteria, according to a randomized
study. Daily laundering of health care workers’ attire can help somewhat,
though studies show that bacteria can contaminate them within hours…
It’s a powerful symbol. But maybe tradition doesn’t have to
be abandoned, just modified. Combining bare-below-the-elbows white attire, more
frequently washed, and with more conveniently placed hand sanitizers —
including wearable sanitizer dispensers — could help reduce the spread of
harmful bacteria.
Until these ideas or others are fully rolled out, one thing
we can all do right now is ask our doctors about hand sanitizing before they
make physical contact with us (including handshakes). A little reminder could
go a long way.” (P)
E. Multi-drug-resistant fungus known as C. auris affecting hundreds in New York, by Delthia Ricks, https://www.newsday.com/news/health/multi-drug-resistant-fungus-1.30597796
PART 2. May 6,
2019. “We are getting very close to a tipping point. If (measles) cases
continue to escalate, the U.S. could lose its elimination status…”
Assignment: Develop a continuum of evidenced based strategies
for states focusing on avoiding measles cases (22 states are already
“infected”)
New PART 2 after PART 1
PART 1. April 30,
2019
“The longer these
(measles) outbreaks continue, the greater the chance measles will again get a
sustained foothold in the United States.”
“The number of measles cases in the United States has risen
to 695, the highest annual number recorded since the disease was declared
eliminated in this country in 2000, federal health officials said on Wednesday.
The total has now surpassed the previous high of 667 set in
2014, according to the Centers for Disease Control and Prevention. The virus
has been detected in 22 states.
Most cases are linked to two large and apparently unrelated
outbreaks. One is centered in Orthodox Jewish communities in New York City and
its suburbs; that outbreak began in October and recently spread to Orthodox
communities in Michigan.
The other outbreak began in Washington State…
The New York outbreak was set off by Americans who had
visited Israel, where cases have been spreading in Orthodox communities since
early last year. City officials have taken extraordinary measures to crack down
on resistance to immunization.
Mayor Bill DeBlasio declared a state of emergency and
threatened residents of four Brooklyn ZIP codes with $1,000 fines if they
refused to vaccinate.
Twelve summonses have been issued so far, the city health
department said; people who do not answer them can be fined $2,000. City
officials closed a yeshiva preschool for violating vaccination orders.
Rockland County, N.Y., the center of another outbreak,
initially barred unvaccinated children from all indoor public places, including
schools, malls, supermarkets, restaurants and houses of worship.
After a court blocked that order, the county instead barred
from public spaces anyone who had measles symptoms or who had recently been
exposed to the disease, threatening them with fines of up to $2,000 a day.” (A)
“More than 1,000 students and staff members at two Los
Angeles universities were quarantined on campus or sent home this week in one
of the most sweeping efforts yet by public health authorities to contain the
spread of measles in the U.S., where cases have reached a 25-year high.
By Friday afternoon, two days after Los Angeles County
ordered the precautions, about 325 of those affected had been cleared to return
after proving their immunity to the disease, through either medical records or
tests, health officials said.
The action at the University of University of California,
Los Angeles, and California State University, Los Angeles — which together have
more than 65,000 students — reflected the seriousness with which public health
officials are taking the nation’s outbreak…
“This is a legally binding order,” the county’s
public health director, Dr. Barbara Ferrer, told reporters.”
Anyone who violates it could be prosecuted, she said, but
added that it appears everyone is cooperating so far. She didn’t describe what
penalties those who don’t could face. (B)
Measles is making a comeback in 2019.
“Since January of this year, 22 states have experienced a
total of 695 cases of measles, an infectious disease that was supposed to be
eradicated almost two decades ago following an outbreak of more than 30,000
cases and a push to get everyone vaccinated — twice…
“This year is the worst since 2000.” said Dr. Sean
O’Leary, a pediatric infectious diseases specialist working with the American
Academy of Pediatrics. “There are more pockets now of parents who have
chosen not to immunize their kids. And when someone with measles comes into
that community, it spreads.”” (C)
CDC Measles Tracking
by State
https://www.cdc.gov/measles/cases-outbreaks.html
HISTORY (D)
Pre-vaccine Era
In the 9th century, a Persian doctor published one of the
first written accounts of measles disease.
Francis Home, a Scottish physician, demonstrated in 1757
that measles is caused by an infectious agent in the blood of patients.
In 1912, measles became a nationally notifiable disease in
the United States, requiring U.S. healthcare providers and laboratories to
report all diagnosed cases. In the first decade of reporting, an average of
6,000 measles-related deaths were reported each year.
In the decade before 1963 when a vaccine became available,
nearly all children got measles by the time they were 15 years of age. It is
estimated 3 to 4 million people in the United States were infected each year.
Also each year, among reported cases, an estimated 400 to 500 people died,
48,000 were hospitalized, and 1,000 suffered encephalitis (swelling of the
brain) from measles.
Vaccine Development
In 1954, John F. Enders and Dr. Thomas C. Peebles collected
blood samples from several ill students during a measles outbreak in Boston,
Massachusetts. They wanted to isolate the measles virus in the student’s blood
and create a measles vaccine. They succeeded in isolating measles in
13-year-old David Edmonston’s blood.
In 1963, John Enders and colleagues transformed their
Edmonston-B strain of measles virus into a vaccine and licensed it in the
United States. In 1968, an improved and even weaker measles vaccine, developed
by Maurice Hilleman and colleagues, began to be distributed. This vaccine,
called the Edmonston-Enders (formerly “Moraten”) strain has been the only
measles vaccine used in the United States since 1968. Measles vaccine is
usually combined with mumps and rubella (MMR), or combined with mumps, rubella
and varicella (MMRV). Learn more about measles vaccine.
Measles Elimination
In 1978, CDC set a goal to eliminate measles from the United
States by 1982. Although this goal was not met, widespread use of measles
vaccine drastically reduced the disease rates. By 1981, the number of reported
measles cases was 80% less compared with the previous year. However, a 1989
measles outbreaks among vaccinated school-aged children prompted the Advisory
Committee on Immunization Practices (ACIP), the American Academy of Pediatrics
(AAP), and the American Academy of Family Physicians (AAFP) to recommend a
second dose of MMR vaccine for all children. Following widespread
implementation of this recommendation and improvements in first-dose MMR
vaccine coverage, reported measles cases declined even more.
Measles was declared eliminated (absence of continuous
disease transmission for greater than 12 months) from the United States in
2000. This was thanks to a highly effective vaccination program in the United
States, as well as better measles control in the Americas region.
Photos reveal what it
looks like to get the measles when there are no vaccines, by Hilary Brueck,
Common complications from measles include otitis media,
bronchopneumonia, laryngotracheobronchitis, and diarrhea.
Even in previously healthy children, measles can cause
serious illness requiring hospitalization.
One out of every 1,000 measles cases will develop acute
encephalitis, which often results in permanent brain damage.
One or two out of every 1,000 children who become infected
with measles will die from respiratory and neurologic complications.
Subacute sclerosing panencephalitis (SSPE) is a rare, but
fatal degenerative disease of the central nervous system characterized by
behavioral and intellectual deterioration and seizures that generally develop 7
to 10 years after measles infection.
People at High Risk for Complications
People at high risk for severe illness and complications
from measles include:
Infants and children aged <5 years
Adults aged >20 years
Pregnant women
People with compromised immune systems, such as from
leukemia and HIV infection..
Healthcare personnel
Healthcare personnel should have documented evidence of
immunity against measles, according to the recommendations of the Advisory
Committee on Immunization Practices
“In asserting the constitutionality of vaccination mandates
and coercive public health orders, public health lawyers generally look back to
the Supreme Court’s 1905 case of Jacobson v. Massachusetts. In that case, the
Supreme Court upheld a law mandating smallpox vaccination stating, “Upon the
principle of self-defense, of paramount necessity, a community has the right to
protect itself against an epidemic of disease which threatens the safety of its
members.”
The Jacobson case is still the starting point for any
discussion of the constitutionality of public health emergency powers, and
courts in the modern era have continued to cite it in upholding state vaccine
mandates…
The reason Jacobson endures, while other cases and public
health practices from its era have been cast aside, is that its central message
— “there are manifold restraints to which every person is necessarily subject
for the common good” — remains as relevant today as it was in 1905. Public
health still requires some limitations on individual freedom. Still, exactly
what limitations Jacobson countenances, and how its reasoning should be applied
in our own, very different era, are deeply contested and will assuredly be
debated as the New York litigation continues.
Even if the courts conclude, as they might, that Jacobson
supports the Rockland County and New York City orders, that doesn’t mean
Jacobson provides the most effective model for stopping contemporary outbreaks.
After all, in what other areas do public officials rely upon approaches that
were used in 1905?..
No compromise is likely to be perfect, or fully effective.
Many will likely fail. But the return of measles suggests that our old,
tried-and-true methods of mandates and emergency orders don’t seem to be
solving the problem of vaccine resistance. New tools are needed before more
dangerous outbreaks of even more lethal diseases occur. “ (F)
‘Ninety-nine times our legislative bodies have passed such
legislation. And that’s gone to the governors that have represented the entire
political spectrum in the United States that have signed that legislation all
for the benefit of our children and healthier communities. Now think about that
— 99 times. That’s the epitome of democracy. Nothing that I can think of has
been so profound in affecting the health of children, because those laws have
obliged most children to be vaccinated…
But measles has been reintroduced into the Western
Hemisphere in two countries; in the United States and Venezuela. What? Two
different reasons. In the United States, it’s because some parents, whether for
cultural reasons, misunderstood religious reasons, or kind of libertarian
reasons, have withheld many children from vaccination creating pockets and
communities of susceptible children…
I think every child should be vaccinated and I will now make
a bold statement. I think there ought to be valid — valid — medical reasons
for exclusion from vaccination. I’m not a friend of either personal belief or
religious exemptions. We have three states that have such tight laws now: West
Virginia, Mississippi, and California. I think they’re leaders and the rest of
us should follow. I wouldn’t want any child to suffer measles or its
complications.
I’ll remind you of one thing before I come to a close.
Before we had [a] measles vaccine, 400 to 500 children died in the United
States annually because of measles and its complications. That number now is
zero.”… (G)
“Measles, a virus that invades the nose and throat, causing
fever, cough and phlegm, is one of the most contagious pathogens on the planet.
Before 1963, it infected some four million people every year in the United
States alone. Nearly 50,000 of them would land in the hospital with
complications like severe diarrhea, pneumonia and brain inflammation that
sometimes resulted in lifelong disability. Of the 500 or so patients who died
from these complications each year, most were children younger than 5.
Until recently, those numbers were a matter of history. The
measles vaccine, which was introduced to the United States in 1963, drove the
annual case count from four million to zero inside of four decades. Measles was
officially eradicated in America in 2000 and was largely wiped from our
collective memory soon after.
But in the shadow of that memory lapse, a different virus
has spread: anti-vaccine propaganda and vaccine misinformation. Both have
persuaded a small but growing number of parents that vaccines designed to
inoculate against infectious diseases pose a greater health risk than the
diseases themselves. As a result, these parents are skipping crucial shots for
their children. And as the number of unvaccinated children grows, some
vaccine-preventable diseases are making a comeback.
The Centers for Disease Control and Prevention has logged at
least six measles outbreaks so far this year, across five states, involving
more than 100 patients. In recent weeks, as those numbers have ticked upward,
both houses of Congress have held hearings to discuss the issue, while more
states have considered limiting vaccine exemptions for school-age children and
several prominent social media platforms have pledged to block anti-vaccine
propaganda and vaccine misinformation from their sites…
But the new rash of outbreaks has made clear that even small
pockets of vaccine hesitancy and refusal can have grave consequences. And
health officials say that if left unchecked, this outbreak crisis will only
worsen…” (H)
“The outbreak of
measles in the U.S. and around the world is due largely to inadequate
vaccination rates in some communities, not illegal immigration, as one popular
meme on Facebook claims.
The meme shows a picture of a baby who appears to be
infected with measles and says: “Thanks to a highly effective vaccination
program the Measles virus was eliminated from the U.S. in 2000. Thanks to the
immigrants who illegally cross the U.S. Mexican border, and the Democrats who refuse
to stop them, the Measles virus has been declared a public health emergency in
2019.”
The first part of that claim is correct. Measles was
eliminated in the United States in 2000 and it was eliminated across both North
and South America in 2016…
The second part of the claim, however, is incorrect.
The virus has been brought into the U.S. by people who have
traveled to places where there is an outbreak or where the disease is still
common, such as parts of Europe, Africa, Asia, and the Pacific, according to
the Centers for Disease Control and Prevention. From those travelers, the
disease can then spread in U.S. communities that have unvaccinated people,
according to the CDC.
For example, the New York City health department declared a
public health emergency on April 9. That measles outbreak, which started in
2018 and spread in the Orthodox Jewish community, was brought on by travelers
who had been in Israel, where a large outbreak is occurring, according to the
Pan American Health Organization”… (I)
“The Washington state Senate narrowly passed a measure late
Wednesday that would make it harder for parents to opt out of vaccinating their
children against measles in response to the state’s worst outbreak in more than
two decades.
The bill, which would eliminate personal or philosophical
exemptions from the measles, mumps and rubella (MMR) vaccine, is a victory for
public health advocates who had not expected it to make it to the floor…
The bill is expected to pass the House, where a nearly
identical measure was approved last month, and be signed into law by Gov. Jay
Inslee (D). It would be the first time in four years a state has removed
personal exemptions in the face of growing anti-vaccine sentiment. California
and Vermont removed personal exemptions in 2015. Other states have tightened
vaccination requirements but have not removed exemptions…
The stricter rule would apply only to immunizations for
measles, mumps and rubella. Parents would still be able to cite personal or
philosophical exemptions to avoid other required school vaccinations for their
children. Religious and medical exemptions will still be allowed for all
vaccinations, including MMR.
Advocates and lawmakers were able to overcome strong
lobbying by anti-vaccine groups, which are among the most vocal and organized
in the country. Those groups mobilized hundreds of supporters, who telephoned
and sent emails to lawmakers, turned out for public hearings and proposed
poison-pill amendments, intended to weaken a bill or ruin its chances of passing…
Campaigns to toughen state requirements in Iowa, Colorado,
Maine and Oregon also face strong opposition. Washington is one of 17 states
that allow exemptions from required immunizations for personal or philosophical
beliefs.” (J)
California would give state public health officials instead
of local doctors the power to decide which children can skip vaccinations
before attending school under legislation proposed Tuesday to counter what
advocates call bogus exemptions.
The measure would also let state and county health officials
revoke medical exemptions granted by doctors if they are found to be fraudulent
or contradict federal immunization standards. The proposal comes amid measles
outbreaks in New York, Washington and elsewhere that are prompting states including
Maine and Washington to consider ending non-medical exemptions.
California eliminated all non-medical immunization
exemptions in 2016, as have Mississippi and West Virginia. The lawmakers want
California to now follow West Virginia’s lead in having public health officials
rather than doctors decide who qualifies for medical exemptions. Doctors would
send the state health department the reason they are recommending the exemption
and would have to certify that they examined the patient….(K)
“In a statement this week, U.S. Secretary of Health and
Human Services Alex Azar reiterated a tactic that has proven ineffective at
reaching skeptical populations in recent years: telling them what to do.
“Vaccines are a safe, highly effective public-health solution that can prevent
this disease,” he said. “The measles vaccines are among the most extensively
studied medical products we have, and their safety has been firmly established
over many years in some of the largest vaccine studies ever undertaken.”…
Research suggests that the reason informed people fall into
conspiracy-theory mind-sets often has less to do with a lack of information
than with social and emotional alignment. Facts are necessary, but not at all
sufficient. Websites and YouTube videos where a federal employee in a suit
states various statistics are unlikely to be effective against targeted
disinformation campaigns that only need to plant the seed of doubt in the mind
of people already skeptical of the medical establishment. The work of global
inoculation requires first rebuilding a social contract, which means meeting
people on the platforms where they now get their information, in the ways they
now consume it.” (L)
“It was actually measles outbreaks in the 1960s that
inspired a push to have states require children get inoculated before starting
kindergarten. By the 1980s, all states had mandatory immunization laws in
place. The idea behind these laws was simple: Near-universal vaccinations
sustain herd immunity.
Still, there’s a lot of variation across the country when it
comes to immunization requirements. Even though all 50 states have legislation
requiring vaccines for students entering school, almost every state allows
exemptions for people with religious beliefs against immunizations, and 17
states currently grant philosophical exemptions for those opposed to vaccines
because of personal or moral beliefs. (The exceptions are Mississippi,
California, and West Virginia, which have the strictest vaccine laws in the
nation, allowing only medical exemptions.)
In these places, opting out can mean simply listening to a
doctor or health official explain the benefits of vaccination or getting a
signed statement about your religious beliefs notarized. It’s often harder for
parents to sign their kids out of school for the day than to help them avoid
vaccines.
In 45 states, even without an exemption, kids can be granted
“conditional entrance” to school on the promise that they will be vaccinated,
but schools don’t always bother to follow up…
California has made it tougher to opt out of vaccines — with
mixed and instructive results
Some states have been moving to crack down on vaccine
avoiders — most notably California — and the experience there is instructive
for states that might want to close some of their loopholes…
There is indeed evidence from Mississippi and West Virginia
that strict vaccine laws can work — but again, interpret it with caution.” (M)
“If the U.S. loses its “measles elimination” status, it will
join Venezuela as the only other country in North and South America with this
distinction. Measles was declared eliminated across the Americas in 2016, but
within a year, an outbreak sparked in Venezuela that has persisted up to the
current day.
For most Americans, these outbreaks are a bittersweet
wake-up call about the importance of the measles-mumps-rubella (MMR) vaccine.
Thanks to the success of vaccination programs, most people are unfamiliar with
measles itself — which means they may be unsure about how to approach these
outbreaks and protect themselves.” (N)
“And although the majority of people getting the illness now
were never vaccinated, the expanding outbreaks have raised new questions about
whether some older adults — including many of those born before the mid-1960s —
should be revaccinated, along with some younger people uncertain of their
immunization status.
According to the Centers for Disease Control and Prevention,
people who were vaccinated prior to 1968 with an early version of the vaccine,
which was made from an inactivated (killed) virus, “should be
revaccinated” with at least one dose of live attenuated measles vaccine.
Today’s recommended vaccine is known as MMR and protects
against measles, mumps and rubella.
“This recommendation is intended to protect those who
may have received killed measles vaccine, which was available in 1963-1967 and
was not effective,” according to this Q & A on measles from the CDC…” (O)
“We are getting
very close to a tipping point. If (measles) cases continue to escalate, the
U.S. could lose its elimination status…”
“ON AN OTHERWISE normal Thursday in November 2018, the doors
to the Lowell Community Health Center in Massachusetts opened at 8 a.m., as
they always do, and the first of 802 patients who would walk through those doors
began trickling in…
This routine — a seemingly banal choreography repeated
hundreds of times each day — continued until around 12:50 p.m., when a mother
arrived with her two-year-old daughter. The child had measles, and suddenly,
this was no longer an ordinary day. For virtually anyone not immune to the
virus who crossed paths with the toddler, infection was almost certain, and so all
of those places the child had been and the rooms where she may have coughed or
sneezed became critical evidentiary artifacts in a crisis that had all the
potential to spin quickly out of control.
Indeed, the arrival of mother and child set off a chain of
events and triggered longstanding but rarely tested protocols aimed at
containing a measles outbreak. It involved hundreds of staff not just at the
Lowell Community Health Center, but also the Massachusetts Department of Public
Health (DPH), the City of Lowell Health Department, and the local hospital —
with thousands of emails and a weeklong flurry of activity that strained the
center’s capacities to the limit…
That the center managed to contain the highly-contagious
measles virus is a testament to its modernized records system, its staff’s
military-style precision, and its location in a resource-rich region. But even
here there were occasional missteps, bouts of confusion, and administrative
second-guessing and finger-pointing. There were also 179 exposed people with no
evidence of vaccination — even though the center tried to reach them —
suggesting that the fallout at a less-prepared facility could be disastrous…
ON NOVEMBER 7, the child’s mother called the center for an
appointment. She said her daughter had a cough and a rash and some sores in her
mouth, and asked if they could come in.
Here, the staffer on the phone made the first crucial
mistake. Lowell is an old New England mill town with weathered red-brick
buildings interconnected by canals, and as a large suburb of Boston, it is
heavily populated these days by immigrants; nearly 40 percent of the center’s
patients don’t speak English. Protocol would have dictated that center staff
ask the mother about recent travel while she was still on the phone, but that
didn’t happen. Had the question been asked, staff would have learned that the
mother and child had just returned from a month-long trip to an African country
where measles is endemic. Although the toddler had received one shot of the
measles, mumps, and rubella (MMR) vaccine at the center when she was one, and a
single dose is supposed to be 93 percent effective, it may have been no match
for the heavy exposure.
Had the staffer asked, mother and daughter would likely have
been directed straight to an isolation room, intended for anyone with a
contagious illness, on the center’s ground floor. Instead, they came to the
center and disclosed to a medical assistant upon arrival that the child had
contracted measles abroad…
At approximately 2 p.m., they gathered in a conference room
to strategize and to connect with other officials via conference call. Health
care organizations are required to have an emergency plan in place, and the
center’s chief information officer, Henry Och — an infantry officer in the
National Guard, with stints in Kosovo and Afghanistan — would play the role of
incident commander…
“If this happened in
a school and not a health center — who’s responding, and how is it being
managed?” Vigroux asked. “I think our community is not ready for that.” (A)
“Incidence of measles in Europe spiked dramatically from
2016-2018 in a handful of countries, led by the Ukraine, researchers found…
The World Health Organization’s (WHO) European Region, which
contains countries outside of what is traditionally thought of as Europe, went
from a little under 5,300 reported cases of measles in 2016 to nearly 83,000
reported cases of measles in 2018 — a fourteen-fold increase, the authors
wrote in the Morbidity and Mortality Weekly Report…
When citing reasons for ongoing measles transmission, the
authors pointed to factors that appear to be playing a role in the U.S.’s
ongoing measles outbreak — namely “an accumulation of susceptible young
children in marginalized communities with suboptimal coverage.” Other
reasons included persistent measles virus reservoirs in WHO European Region
countries “with limited resources and weak immunization systems.”
The majority of measles cases were from the Ukraine — which
was previously cited by CDC researchers as one of the top three countries
exporting measles to the U.S. In 2018, there were over 53,000 cases in the
Ukraine, comprising two-thirds of all measles cases in this region. Second was
Serbia, with around 5,000 cases (6% of the total) followed by France and Israel
with about 2,900 cases each (each 4% of the total)…” (B)
“New Jersey’s growing measles outbreak appears to have roots
in Israel, New York City and New York’s Rockland County, according to Garden
State officials.
Department of Health Commissioner Dr. Shereef Elnahal said a
combination of travelers returning from countries where measles is rampant, and
individuals crossing back and forth between neighboring states, is largely
responsible for the situation in New Jersey. Fourteen Garden State residents have
been diagnosed with the virus this year, in addition to the 33 infections
detected last fall. Another case is expected to be confirmed this week.
But with New York City experiencing a more severe outbreak,
with at least 420 cases, and another 200-plus diagnosed in nearby Rockland
County, the threat of cross-border contamination is significant, Elnahal said.
Most of the infections have been found within Orthodox Jewish communities in
both states, including Ocean County’s Lakewood.
Since community members often travel back and forth for
family visits, work or worship, Elnahal said “the transit between New York and
New Jersey is the biggest concern now. And the collaboration with (local and
state health officials in New York) has been critical.” International travelers
have long been the source of viral infections in the United States, Elnahal
said, but with more people refusing the vaccine there is a greater chance that
infected voyagers can transmit the disease, which spreads quickly in
communities with low immunization rates…
Exemptions are permitted for medical reasons (those with
compromised immune systems are at risk) and also for religious reasons,
although lawmakers in New Jersey and several other states are looking to
eliminate the religious opt-out. Elnahal said all the religious leaders he has
encountered, including prominent Jewish officials, have urged their followers
to comply with vaccination laws.” (C)
“The country is experiencing the worst year for measles in a
quarter century, according to the Centers for Disease Control and Prevention
(CDC), with 704 reported cases. And New Jersey is right in the middle of an
outbreak…
While it’s unlikely New Jersey would ever see hundreds or
thousands of cases at once, the state could see localized epidemics with
“pockets of people with low vaccination rates getting many infections,”
Dr. David Cennimo, an infectious disease expert at Rutgers New Jersey Medical
School, said via text
Cennimo said the state is already seeing a “disruption in
medicine because of concern for measles.” Treating a measles patient is often
tedious and cumbersome, he said.
“Measles is airborne, so people need to stay in special
negative-pressure rooms. … These rooms aren’t plentiful,” Cennimo said in an
email. “You cannot have a patient walking into a waiting room with measles
without a mask on because they can infect everyone.”
Measles is so contagious that 90% of susceptible people
exposed to an infected person will become infected, according to the CDC. If
outbreaks continue, experts worry about measles patients walking among the
public or in hospitals, potentially spreading the disease to vulnerable
populations, like babies who’ve yet to receive the vaccine. Those with weakened
immune systems, like cancer patients undergoing treatment, would also be
at-risk.
Medical personnel may have to ramp up protocols for dealing
with patients reporting vague symptoms like a rash or fever. They may have to
meet potentially infected patients in the parking lot with masks, diverting
staff from other serious health matters.
“All of this is cumbersome and, if it delays care,
potentially dangerous,” Cennimo said. “It is difficult for your average primary
care doctor or pediatrician to do all of this in a busy office. The measles
rash is not very specific and can be confused with other viral rashes.”
He added, “This can really slow down the flow in an
(emergency department).” “ (D)
“If you visited the South Plainfield Sky Zone Trampoline
Park at 600 Hadley Road on the afternoon of April 22 or the River 978 Banquet
Hall at 978 River Ave. in Lakewood on the night of April 23 you may have been
exposed to measles, according to the state Department of Health.
A New Yorker with a confirmed case of the virus visited both
locations, according to the DOH. The department is warning anyone who visited
Sky Zone from noon to 5 p.m. April 22 or the banquet hall from 6 p.m. April 23
to 1 a.m. April 24 that they may have been exposed.
“Anyone who suspects an exposure is urged to call a
health care provider before going to a medical office or emergency
department,” the department’s statement read. “Special arrangements
can be made for evaluation while also protecting other patients and medical
staff from possible infection.”
Anyone who may have contracted the virus in this most recent
incident may not develop symptoms until as late as May 14, according to the
DOH.
On April 22, the DOH announced that a Middlesex County
resident with “a highly suspect case of measles” had visited
Rosalita’s Roadside Cantina on Route 9 in Marlboro on April 19. The DOH later
issued an update, advising that the possible carrier had also visited a
Manalapan LabCorp diagnostic center on April 17 and 19.” (E)
‘The return of measles may be an early warning sign of a
resurgences of other vaccine-preventable diseases such as rubella, chickenpox
and bacterial meningitis, some experts say…
The use of quarantines and other orders are driven in part
by a growing concern that outbreaks of measles and other diseases could get
worse, despite the availability of effective vaccines, some health experts
said.
“I think there’s a sense of anxiety and even a little
panic in the public health community” as officials see high levels of
mistrust of government and science from a surprising number of people, said
Lawrence Gostin, a Georgetown University public health law expert.
That anxiety has led to what Gostin believes are missteps by
officials.
It’s one thing to isolate someone with measles or to
quarantine someone who has been exposed, he said. Those people are infection
risks, and short-term limitations of where they can go and who they can meet
are legally and medically appropriate, Gostin said.
But it’s another thing to take the kind of step Rockland
County initially did, in which unvaccinated kids were placed under house arrest
— not because they were infection risks, but because their parents weren’t
listening to public health officials, he said.
One community had success without taking such measures.
Officials in Vancouver, Washington, declared an end Monday to a measles
outbreak that began in January but apparently stopped at 71 cases a month ago.
It was a much smaller community than New York City or Los Angeles and was tamed
by an intense investigation and vaccination campaign that involved 230 health
workers tracking down infected people and those they had contact with, at a
cost of about $865,000.” (F)
“California public health officials are warning moviegoers
who went to see “Avengers: Endgame” and other films at an Orange County movie
theater last Thursday that they may have been exposed to measles by a woman in
the audience.
The woman attended a midnight screening of the “Avengers”
blockbuster at the AMC Dine-In Fullerton 20 on Thursday from 11 p.m. to 4 a.m,
the Orange County Health Care Agency said.
Everyone who was in the building may have been exposed, not
just at that particular screening room, the agency said.
The warning also applies to people who went to buildings at
5 Hutton Centre Drive in Santa Ana from last Wednesday through Friday.
The woman, who is in her 20s, reported having recently
traveled to a country with widespread measles activity, the agency added.” (G)
“A cruise ship was quarantined Tuesday in Saint Lucia after
the island nation’s chief medical officer cited concerns that crew members and
passengers possibly infected with measles might spread the highly contagious
virus, causing an outbreak…
Quarantines are one of many measures used by public health
officials to limit the spread of disease, especially to vulnerable populations,
such as pregnant women, unvaccinated children, and those with weak immune systems.
According to the Centers for Disease Control and Prevention,
a quarantine separates and restricts the movement of people who were exposed to
a contagious disease to see if they become sick. This is different than
isolation in which sick people are identified and separated from people who are
not sick.
“Isolation is used to separate ill persons who have a
communicable disease from those who are healthy. The most important thing is
that a distance is created between the respiratory secretions of the infected
person and others. The person on the cruise ship has to stay in their room and
not come into contact with others, especially those who are not vaccinated,”
said Dr. Mirella Salvatore, a travel medicine and infectious diseases expert at
Weill Cornell Medicine and New York-Presbyterian…
Quarantine times vary, but typically last for at least 21
days — the typical the time from the moment of measles exposure to the time
when signs and symptoms of the disease disappear — or until public health
officials can prove that everyone is immune and safe.” (H)
“The cruise ship that was placed under quarantine by St.
Lucia because of a confirmed case of measles onboard is bound for Curaçao. It’s
not clear what will happen when the vessel, called the Freewinds, arrives there…
Health authorities in St. Lucia made the decision to
quarantine the Freewinds after a female crew member was confirmed to have
measles. There was concern that others onboard might have been infected and
that measles could spread to the Caribbean island, which has been free of local
transmission of the disease since 1990. St. Lucia’s Ministry of Health and
Wellness said on Thursday it had provided 100 doses of measles vaccine to
people on the ship…
As we reported Thursday, the Church of Scientology says its
members rely on the advice and treatment of medical doctors, but several high-profile
Scientologists have spoken out against vaccination.
Curaçao’s vaccination rate is 97% in children born since
2007, according to the Pan American Health Organization.” (I)
“Authorities in Curacao on Saturday boarded a ship that
arrived in the Dutch Caribbean island under quarantine, to start vaccinating
people to prevent a measles outbreak.
Health officials said only those who already have been
vaccinated or have previously had measles will be free to leave the 440-foot
(134-meter) ship Freewinds, which reportedly belongs to the Church of
Scientology.
Curacao epidemiologist Dr. Izzy Gerstenbluth told The
Associated Press that a small team is assessing more than 300 people aboard the
ship, and that the process might take more than a day.
“We will go on board and do our job,” he said, adding that
authorities have an international obligation to avoid spreading the disease.
“If we allow that to happen, measles spreads in places where the risk of severe
complications is much bigger, especially when we’re talking about poor
countries where people have a lower level of resistance.” (J)
“New York City saw its first and only patient with the
deadly Ebola virus 4½ years ago. Since then, emergency and health-care workers
have been training for the next patient.
To test their preparedness for treating a patient with Ebola
or another similar deadly infectious disease, fire, police, city and medical
workers ran a drill, acting out the steps, over two days late last week, while
nurses and doctors evaluated them.” (K)
“In order to prepare for viral outbreaks occurring in other
parts of the world, New York City and State partnered with first responders in
New Jersey to conduct an emergency exercise last week to transport a person
pretending to be an Ebola patient to NYC Health + Hospitals / Bellevue.
Agencies that participated in the drill included the Health Department, NYC
Health + Hospitals, the Fire Department of the City of New York, New York State
Department of Health, the Robert Wood Johnson University Hospital, and health
and law enforcement agencies from New Jersey. The exercise entailed the
transfer of a person pretending to be an Ebola patient from Robert Wood Johnson
University Hospital in New Jersey to the Regional Ebola and Other Special
Pathogen Treatment Center at NYC Health + Hospitals / Bellevue in New York City…
This exercise – the first of its kind between New York City
and New Jersey – tested the health care system’s ability to safely move a
patient to a clinical setting where Ebola can be most effectively treated. In
particular, the exercise assessed the ability of participants to coordinate
patient transportation to NYC Health + Hospitals / Bellevue, safely use
biocontainment devices and personal protective equipment while caring for the
patient, and appropriately decontaminate and dispose of equipment after
transportation. Today’s unprecedented exercise involved over 70 staff from
participating health care facilities and state and local agencies.”(L)
“Nearly 70 of the city fire department’s emergency medical
techs and paramedics are not vaccinated for measles, according to sources…
The FDNY’s Bureau of Health Services went through all the
immunization records after the outbreak, and realized that they had a
population of unvaccinated members who were vulnerable to the disease.
The obvious danger was that they could contract the illness,
officials said. But they could spread it as well.” (M)
“Maine could soon prohibit parents from citing religious or
personal beliefs to avoid vaccinating their children, making the U.S. state one
of a half dozen cracking down during the nation’s largest measles outbreak in
25 years.
State legislatures in New York, New Jersey, Oregon, Vermont,
Minnesota and Iowa are looking at similar bills that would only allow exemptions
from vaccinations for medical reasons as determined by the child’s doctor…
Maine has one of the lowest vaccination rates in the
country, with 5 percent of kindergartners holding a non-medical exemption from
vaccination, compared to a national average of 2 percent, according to CDC
data.
The World Health Organization has said at least 95 percent
of a community must be immunized against measles to achieve the “herd
immunity” needed to protect those unable to get the vaccine such as
infants and people with compromised immune systems.
No measles cases have been recorded in largely rural Maine
since 2017, but state officials have been worried by outbreaks of whooping
cough, another childhood disease that can be prevented by vaccination.” (N)
“The measles vaccines are among the most extensively studied
medical products. The safety of both vaccines has been firmly established over
many years in some of the largest vaccine studies ever undertaken. Before the
vaccines’ approval, clinical data developed through animal studies and human
clinical trials were evaluated by FDA scientists and clinicians.
In addition, the FDA pays careful attention in reviewing the
quality of raw materials and other ingredients used to make vaccines, the
production process, and the procedure for assessing their safety and efficacy.
Like many medical products, measles vaccines have known potential side effects,
but they are generally mild and short-lived, such as rash and fever.
The bottom line is that there are safe and effective vaccines
that provide lasting protection against the measles virus. Both contain live,
but weakened versions of the measles virus, which causes your immune system to
produce antibodies against the virus without causing you to contract the
illness. Should you be exposed to actual measles, those antibodies will protect
you against the disease.” (O)
“The U.S. is experiencing the greatest spike in measles
cases in 25 years, but Merck, the sole producer of the measles vaccine for the
U.S., says it has production in hand…
“In response to the measles outbreak that has occurred this
year, Merck has taken steps to increase U.S. supply of our MMR-II vaccine so
availability of the vaccine is maintained,” the company said in an emailed
statement today. The statement emphasized the safety and effectiveness of the
vaccine has been scientifically affirmed over decades of use against the highly
contagious and sometimes fatal disease…
Merck Chief Marketing Officer Mike Nally told Reuters in an
interview that the company has upped production but that there has not been a
big boost in orders in the U.S., even from the Centers for Disease Control and
Prevention. The CDC provides vaccines through the government’s Vaccines for
Children program…
“As measles outbreaks
have occurred in different parts of the world over the last few decades, we’ve
always been able to surge capacity, and we feel confident about our ability to
do so in the U.S,” Nally told the news service.” (P)
“In New York, which has seen hundreds of measles cases since
last fall, the state’s Department of Health has given doctors the go-ahead to
lower the vaccination age to six months in areas with ongoing outbreaks,
according to Erin Silk, a spokesperson for the department. New York City Mayor
Bill de Blasio has ordered that everyone — including babies as young as six
months old — get their measles vaccinations. The measles vaccine is safe and
effective, despite the thoroughly debunked myth that vaccines cause autism. An
extra measles vaccine at six months is very safe, too, according to Peter
Hotez, dean for the National School of Tropical Medicine at Baylor College of
Medicine. It just isn’t the norm because, under typical, non-outbreak
circumstances, the vaccine may not be as effective for babies that young.
“However, some babies could still benefit from early immunization during a true
measles outbreak,” he says in an email to The Verge.” (Q)
“After a measles outbreak in Brooklyn and Rockland County
and amid growing concerns about the anti-vaccine movement, a pair of state
legislators are proposing allowing minors to receive vaccinations without
permission from their parents.
The bill would allow any child 14 years or older to be
vaccinated and given booster shots for a range of diseases including mumps,
diphtheria, whooping cough, tetanus, influenza, hepatitis B and measles, which
seemed to be the primary reason for alarm after the recent outbreaks.
“We are on the verge of a public health crisis,” said one of
the bill’s sponsors, Assemblywoman Patricia Fahy, a Democrat from Albany,
citing lower-than-recommended inoculation rates in some communities, spurred by
unconfirmed suspicions about vaccines causing autism. “We’ve become complacent
over the last couple of decades.”
That sentiment was amplified recently by the World Health
Organization, which listed “vaccine hesitancy” as one of the Top 10 global
threats. In Rockland County, officials are reporting 145 confirmed cases of
measles, with the vast majority of those afflicted aged 18 and under. Of those,
four out of five have received no vaccinations for measles, mumps and rubella..
“ (R)
“U.S. doctors are tapping into their electronic medical
records to identify unvaccinated patients and potentially infected individuals
to help contain the worst U.S. measles outbreak in 25 years.
New York’s NYU Langone Health network of hospitals and
medical offices treats patients from both Rockland County and Brooklyn, two
epicenters of the outbreak. It has built alerts into its electronic medical
records system to notify doctors and nurses that a patient lives in an outbreak
area, based on their Zip code.
“It identifies incoming patients who may have been exposed
to measles and need to be assessed,” said Dr. Michael Phillips, chief
epidemiologist at NYU Langone Health.
Alerts in a patient’s medical record also prompt
conversations with their visitors – who may also have been exposed to the virus
– about their own health, prior exposure to measles and vaccination history.
Mount Sinai Health System in New York rolled out a similar
program last week, said Dr. Bruce Darrow, its chief medical information
officer.
Darrow said it was important because although a patient who
comes from a measles-affected Zip code may have passed the screening, family
members who visit may have been exposed.”
He said the alert system raises awareness for doctors and
nurses “to be on lookout not just for our patients, but anybody who comes into
the building.” (S)
“At first, the virus moved slowly through Orthodox
communities in Jerusalem and Tel Aviv. Then in September, Dr. O’Connor said, a
major outbreak in Ukraine supercharged Israel’s modest one — and probably led,
indirectly, to outbreaks in Britain and in the United States.
Ukraine is suffering through a measles outbreak that began
in 2017. The country has had almost 70,000 cases — more than any other country
in recent years…
But the real problem appears to have begun at Rosh Hashana.
Each year on the holiday, tens of thousands of Orthodox men
travel to Uman, a Ukrainian city where the grave of Rabbi Nachman of Breslov,
founder of one branch of Hasidism, has become a popular pilgrimage site. (The
festivities have been called the “Hasidic Burning Man.”)
Last year, Rosh Hashana fell in early September. Later that
month, measles cases exploded in Israel, rising to a peak of 949 in October.
The cause? Numerous pilgrims came back from Ukraine with the virus, experts
believe.
New York’s outbreak began in October; the first patient was
a child in the Bensonhurst section of Brooklyn who had visited Israel. At the
same time, a measles outbreak began among Orthodox Jews in London.” (T)
“In 2000, the Pan-American Health Organization announced a
monumental public health achievement: Widespread vaccination efforts, overseen
by the Centers for Disease Control and Prevention, had effectively eliminated
measles from the United States.
The disease, which before the vaccination era affected 3 to
4 million people in the U.S. each year, was now isolated to small, contained
outbreaks connected to international travel.
This year’s record-setting outbreak threatens that
achievement.
Since January, over 700 cases of measles have been reported
in 22 states. Most of the affected have never been vaccinated. Sixty people
have been hospitalized, and the case numbers continue to climb, although in
some regions, like the Pacific Northwest, outbreaks have subsided.
Though the current numbers are dwarfed by the scale of cases
in the first half of the 20th century, they’re still meaningful, says Rene
Najera, an epidemiologist and editor of the vaccine education website History
of Vaccines.
“We are getting very close to a tipping point. If cases
continue to escalate, the U.S. could lose its elimination status,” says
Najera.
A disease is considered eliminated from a country when it
can no longer be contracted within its borders, though cases tied to
international travel — like those that have happened since 2000 — can still
occur.
Losing elimination status would mark a failure of one of the
biggest public health achievements in our history.” (U)
“Why is handwashing so important?
Put simply, your hands are dirty. As they come into contact
with various people, animals, foods, and surfaces, they pick up thousands of
germs, bacteria, viruses and other assorted nastiness that can make you sick if
they enter your body. “We touch our eyes, noses, and mouths with our hands more
than we think, and this can allow direct inoculation of germs into our mucous
membranes,” explains Janet Haas, PhD, RN, Director of Epidemiology at Lenox
Hill Hospital. “We also use our hands to prepare and eat foods, so hands that
are not clean can contaminate foods that we and others will eat.” But washing
your hands has the power to minimize or even eliminate those risks—for you and
those around you. For example, teaching people about handwashing can reduce
diarrheal illnesses in immunocompromised people by up to 58 percent, according
to the CDC. Another FYI: You should wash your hands immediately after touching
these 10 things.
You’re probably washing your hands wrong
Believe it or not, only 5 percent of people wash their hands in a way that actually gets them clean, according to a study in the Journal of Environmental Health. Haas says the trick is to rub soap onto every part of your hands, since the friction is what removes the germs from skin, and to wash for a long enough period of time. “Keep rubbing for 20 seconds, making sure to get soap between fingers and on the backs of hands—and don’t forget the thumbs!” she advises. “Avoid turning off the tap with your clean hands: A towel, a wrist or elbow is preferred to keep your hands clean.” .. (V)
“U.S. health officials are increasingly relying on an
informal network of community groups, religious leaders, and local medical
practitioners in their efforts to fight the biggest measles outbreak in the
nation in more than 25 years. Standard public-health tools are falling short in
the face of an aggressive antivaccination campaign, growing exposure to measles
in countries such as Israel, and a longstanding distrust of government or other
outside sources of information. Grassroots approaches are becoming more
important in public health, with infectious-disease outbreaks around the world
increasingly erupting in remote or insular communities, conflict zones, and
other areas where disease fighters have to grapple with economic, cultural, or
security challenges. CDC has formed a work group to seek new ways to counter an
increasingly vocal antivaccine movement. Trusted sources within a community’s
own networks “can be more effective than we can” in educating people
about vaccination, says Nancy Messonnier, an expert on immunization and
respiratory diseases at the agency.” (W)
“Last May, an elderly man was admitted to the Brooklyn
branch of Mount Sinai Hospital for abdominal surgery. A blood test revealed
that he was infected with a newly discovered germ as deadly as it was
mysterious. Doctors swiftly isolated him in the intensive care unit.
The germ, a fungus called Candida auris, preys on people
with weakened immune systems, and it is quietly spreading across the globe.
Over the last five years, it has hit a neonatal unit in Venezuela, swept
through a hospital in Spain, forced a prestigious British medical center to
shut down its intensive care unit, and taken root in India, Pakistan and South
Africa.
Recently C. auris reached New York, New Jersey and Illinois,
leading the federal Centers for Disease Control and Prevention to add it to a
list of germs deemed “urgent threats.”
The man at Mount Sinai died after 90 days in the hospital,
but C. auris did not. Tests showed it was everywhere in his room, so invasive
that the hospital needed special cleaning equipment and had to rip out some of
the ceiling and floor tiles to eradicate it.
“Everything was positive — the walls, the bed, the doors,
the curtains, the phones, the sink, the whiteboard, the poles, the pump,” said
Dr. Scott Lorin, the hospital’s president. “The mattress, the bed rails, the
canister holes, the window shades, the ceiling, everything in the room was positive.””
(A)
“Back in 2009, a 70-year-old Japanese woman’s ear infection
puzzled doctors. It turned out to be the first in a series of hard-to-contain
infections around the globe, and the beginning of an ongoing scientific and
medical mystery.
The fungus that infected the Japanese woman, Candida auris,
kills more than 1 in 3 people who get an infection that spreads to their blood
or organs. It hits people who have weakened immune systems, and is most often
found in places like care homes and hospitals. Once it shows up, it’s hard to
get rid of: unlike most species of fungi, Candida auris spreads from person to
person and can live outside the body for long periods of time.
Mount Sinai wasn’t the first hospital to face this task: a
London hospital found itself with an outbreak in 2016, and the only way to stop
it was to rip out fixtures…
Scientists still aren’t sure exactly where this happened or
when. That’s one of the things they’re working on now, says Cuomo, because
figuring out how the fungus evolved could help researchers develop treatments
for it…
Although the “superbug” moniker might sound alarmist,
Candida auris qualifies for two reasons, says Cuomo. First, all strains of the
yeast are resistant to antifungals. There are three major kinds of antifungals
used to treat humans, and some strains of Candida auris are resistant to all of
them, while other strains are resistant to one or two. That limits the
treatment options for someone who has been infected—someone who is probably
already in poor health. The other reason is “this really scary property of not
being able to get rid of it,” Cuomo says.” (B)
“Superbugs are a terrifying prospect because of their
resistance to treatment, and one superbug that is sweeping all over the world
is the Candida auris.
C. auris is a fungus that causes serious infections in
various parts of the body, including the bloodstream and the ear.
While its discovery has been relatively recent in 2009, this
fungus has already wreaked havoc in hospitals in more than 20 different countries,
including the United States, United Kingdom, and Spain, among others.
In the United States, CDC reports a total of 587 clinical
cases of C. auris infections as of February. Most of it occurred in the areas
of New York City, New Jersey, and Chicago.” (C)
“The CDC issued a public alert in January about a
drug-resistant bacteria that a dozen Americans contracted after undergoing
elective surgeries at Grand View Hospital in Tijuana, Mexico. Yet when similar
outbreaks occur at U.S. hospitals, the agency does not issue a public warning.
This is due to an agreement with states that prohibits the CDC from publicly
disclosing hospitals undergoing outbreaks of drug-resistant infections,
according to NYT.
Patient advocates are pushing for more transparency into
hospital-based infection outbreaks, saying the lack of warning could put
patients at risk of harm.
“They might not get up and go to another hospital, but
patients and their families have the right to know when they are at a hospital
where an outbreak is occurring,” Lisa McGiffert, an advocate with the
Patient Safety Action Network, told NYT. “That said, if you’re going to
have hip replacement surgery, you may choose to go elsewhere.”..
The CDC declined NYT’s request for comment. Agency officials
have previously told the publication the confidentiality surrounding outbreaks
is necessary to encourage hospitals to report the drug-resistant infections.”
(D)
“New Jersey is among the states worst affected by an
increasing incidence of the potentially deadly fungus Candida auris, whose
resistance to drugs is causing headaches for hospitals, state and federal
health officials said on Monday.
There were 104 confirmed and 22 probable cases of people
infected by the fungus in New Jersey by the end of February, according to the
federal Centers for Disease Control and Prevention, up sharply from a handful
when the fungus was first identified in the state about two years ago.
The state’s number of cases — now the third-highest after
New York and Illinois — has risen in tandem with an increase, first overseas,
and now in the United States, in a trend that some doctors attribute to the
overuse of drugs to treat infections, prompting the mutation of infection
sources, in this case, a fungus.
The fungus mostly affects people who have existing
illnesses, and may already be hospitalized with compromised immune systems,
health officials said.
Nicole Kirgan, a spokeswoman for the New Jersey Department
of Health, said she didn’t know whether any of the state’s cases have been fatal,
and couldn’t say which hospitals are treating people with the fungus because
they have not, so far, been required to report their cases to state officials.
Although the fungus has been known to medical professionals
in New Jersey for two or more years, it was not widely known to the public. Its
profile was raised by a front-page story in The New York Times on Sunday
describing its growing presence in overseas hospitals and, increasingly, in the
U.S.
The best defense against spreading the fungus is rigorous
handwashing, and disinfecting hospital rooms and equipment that have come into
contact with a patient, Kirgan said.
But Dr. Ted Louie, an infectious disease specialist at
Robert Wood Johnson University Hospital in New Brunswick, said many hospitals
don’t know how to eradicate the fungus once it has occurred.
Some disinfectants commonly used in hospitals have proved
ineffective in removing the fungus, Dr. Louie said, so hospitals have been
urged to use other disinfecting agents, although it’s not yet clear which of
them work, if any.
“This is a fairly new occurrence and we are still learning
how to deal with it,” he said. “We have to figure out which disinfectant
procedures may be best to try to eradicate the infection, so at this point, I
don’t think we have good enough information to advise.” (E)
“Adding to the difficulty of treating candida auris is
finding it in the first place. The infection is often asymptomatic, showing few
to no immediate symptoms, said Chauhan. The symptoms that do appear, such as
fever, are often confused for bacterial infections, he said.
“Most routine diagnostic tests don’t work very well for
candida auris,” he said. “They’re often misidenfitied as other
species.”
The best way to identify candida auris is by looking under a
microscope, which often takes time because it requires doctors to grow the
fungus, Chauhan said.
As with most infectious diseases, the best course of action
is good hygiene and sterilization protocol. Washing your hands and using hand
sanitizer after helps to prevent transmission and infection, Chauhan said.
Doctors and healthcare workers should use protective gear,
and people visiting loved ones in hospitals and long-term care centers should
take proper precautions, he said.
The Center for Disease Control recommends using a special
disinfectant that is used to treat clostridium difficile spores. The
disinfectant has been effective in wiping out clostridium difficile, known as
c. diff, and disinfects surfaces contaminated with candida auris, as well.” (F)
“Hospitals and nursing homes in California and Illinois are
testing a surprisingly simple strategy against the dangerous,
antibiotic-resistant superbugs that kill thousands of people each year: washing
patients with a special soap.
The efforts — funded with roughly $8 million from the
federal government’s Centers for Disease Control and Prevention — are taking
place at 50 facilities in those two states.
This novel approach recognizes that superbugs don’t remain
isolated in one hospital or nursing home but move quickly through a community,
said Dr. John Jernigan, who directs the CDC’s office on health care-acquired
infection research.
“No health care facility is an island,” Jernigan said. “We
all are in this complicated network.”
At least 2 million people in the U.S. become infected with
an antibiotic-resistant bacterium each year, and about 23,000 die from those
infections, according to the CDC…
Containing the dangerous bacteria has been a challenge for
hospitals and nursing homes. As part of the CDC effort, doctors and health care
workers in Chicago and Southern California are using the antimicrobial soap
chlorhexidine, which has been shown to reduce infections when patients bathe
with it. Though chlorhexidine is frequently used for bathing in hospital
intensive care units and as a mouthwash for dental infections, it is used less
commonly for bathing in nursing homes…
The infection-control work was new to many nursing homes,
which don’t have the same resources as hospitals, Lin said.
In fact, three-quarters of nursing homes in the U.S.
received citations for infection-control problems over a four-year period,
according to a Kaiser Health News analysis, and the facilities with repeat
citations almost never were fined. Nursing home residents often are sent back
to hospitals because of infections.
In California, health officials are closely watching the CRE
bacteria, which are less prevalent there than elsewhere in the country, and
they are trying to prevent CRE from taking hold, said Dr. Matthew Zahn, medical
director of epidemiology at the Orange County Health Care Agency. “We don’t
have an infinite amount of time,” he said. “Taking a chance to try to make a
difference in CRE’s trajectory now is really important.”” (G)
“The C.D.C. declined to comment, but in the past officials
have said their approach to confidentiality is necessary to encourage the
cooperation of hospitals and nursing homes, which might otherwise seek to
conceal infectious outbreaks.
Those pushing for increased transparency say they are up
against powerful medical institutions eager to protect their reputations, as
well as state health officials who also shield hospitals from public scrutiny…
Hospital administrators and public health officials say the
emphasis on greater transparency is misguided. Dr. Tina Tan, the top
epidemiologist at the New Jersey Department of Health, said that alerting the
public about hospitals where cases of Candida auris have been reported would
not be useful because most people were at low risk for exposure and public
disclosure could scare people away from seeking medical care.
“That could pose greater health risks than that of the
organism itself,” she said.
Nancy Foster, the vice president for quality and patient
safety at the American Hospital Association, agreed, saying that publicly
identifying health care facilities as the source of an infectious outbreak was
an imperfect science.
“That’s a lot of information to throw at people,” she said,
“and many hospitals are big places so if an outbreak occurs in a small unit, a
patient coming to an ambulatory surgical center might not be at risk.”
Still, hospitals and local health officials sometimes hide
outbreaks even when disclosure could save lives. Between 2012 and 2014, more
than three dozen people at a Seattle hospital were infected with a
drug-resistant organism they got from a contaminated medical scope. Eighteen of
them died, but the hospital, Virginia Mason Medical Center, did not disclose
the outbreak, saying at the time that it did not see the need to do so.
Art Caplan, a bioethicist at the NYU School of Medicine,
said the issue of full disclosure can be tricky, especially when large
hospitals that see huge numbers of seriously ill patients are compared with
smaller institutions. “If you’re a hospital of last resort, you’re going to see
repeat customers with tough infections, many of them drug resistant,” he said.
Still, he thought there was a greater value in promoting
transparency. Public awareness about the lives lost to drug resistant
infections, he said, could pressure hospitals to change the way they deal with
infection control.
“Who’s speaking up for the baby that got the flu from a
hospital worker or for the patient who got MRSA from a bedrail?” he asked,
referring to a potentially deadly bacterial infection. “The idea isn’t to
embarrass or humiliate anyone, but if we don’t draw more attention to
infectious disease outbreaks, nothing is going to change.” (H)
“Many have heard of the rise of drug-resistant infections.
But few know about an issue that’s making this threat even scarier in the
United States: the shortage of specialists capable of diagnosing and treating
those infections. Infectious diseases is one of just two medicine
subspecialties that routinely do not fill all of their training spots every
year in the National Resident Matching Program (the other is nephrology).
Between 2009 and 2017, the number of programs filling all of their
adult-infectious-disease training positions dropped by more than 40 percent.
This could not be happening at a worse time.
Antibiotic-resistant microbes, known as superbugs, are pinballing around the
world, killing hundreds of thousands of people every year. The Times recently
reported on Candida auris, a deadly new fungus that has infected hospital
patients in Illinois, New Jersey and New York.
Everyone who works in health care agrees that we need more
infectious-disease doctors, yet very few actually want the job. What’s going
on?
The problem is that infectious-disease specialists care for
some of the most complicated patients in the health care system, yet they are
among the lowest paid. It is one of the only specialties in medicine that
sometimes pays worse than being a general practitioner. At many medical
centers, a board-certified internist accepts a pay cut of 30 percent to 40
percent to become an infectious-disease specialist.
This has to do with the way our insurance system reimburses
doctors. Medicare assigns relative value units to the thousands of services
that doctors provide, and these units largely determine how much physicians are
paid. The formula prioritizes invasive procedures over intellectual expertise.
The problem is that infectious-disease doctors don’t really
do procedures. It is a cognitive specialty, providing expert consultation, and
insurance doesn’t pay much for that…
Infectious-disease specialists are often the only health
care providers in a hospital — or an entire town — who know when to use all of
the new antibiotics (and when to withhold them). These experts serve as an
indispensable cog in the health care machine, but if trends continue, we won’t
have enough of them to go around. The terrifying part is that most patients
won’t even know about the deficit. Your doctor won’t ask a specialist for help
because in some parts of the country, the service simply won’t be available.
She’ll just have to wing it…
We must hurry. Superbugs are coming for us. We need experts
who know how to treat them.” (I)
People visiting patients at the hospital, and most
hospitalized patients, have little to fear from a novel fungal disease that has
struck more than 150 people in Illinois — all in the Chicago area — a Memorial
Medical Center official said Friday.
“For normal, healthy people, this is not a concern,” Gina
Carnduff, Memorial Health System director of infection prevention, said in
reference to Candida auris infections.
Carnduff, who is based at Memorial Medical Center, said only
the “sickest of the sick” patients are at risk of catching or spreading the C.
auris infection or dying from it.
Those patients, she said, include people who have stayed for
long periods at health care facilities — such as skilled-care nursing homes or
long-term acute-care hospitals — and who are on ventilators or have central
venous catheter lines or feeding tubes…
Officials from both Memorial Medical Center and HSHS St.
John’s Hospital said their institutions already are using the bleach-based
cleaning solutions known to prevent the spread of C. auris and other
infections.
The Illinois Department of Public Health’s website says more
than one in every three people with “invasive C. auris infection” affecting the
blood, heart or brain will die…
The state health department says 154 confirmed cases of C.
auris and four probable cases have been identified, all in the Chicago area.
Ninety-five cases were in Chicago, 56 were in Cook County outside of Chicago,
and seven were spread among the counties of DuPage, Lake and Will.
Eighty-five of the 158 people making up the confirmed and
probable cases have died, but only one death was “directly attributed” to the
infection, Arnold said. It’s not known whether C. auris played a role in the
deaths of the other 84 people, she said. (J)
“There is also the fact that some lab tests will not
identify the superbug as the source of an illness, which means that some
patients will receive the wrong treatment, increasing the duration of the
infection and the chance to transmit the fungus to another person.” (K)
“Hospitals, state health departments and the Centers for
Disease Control and Prevention are putting up a wall of silence to keep the
public from knowing which hospitals harbor Candida auris.
New York health officials publish a yearly report on
infection rates in each hospital. They disclose rates for infections like MRSA
and C. Diff. But for several years, the same officials have been mum about the
far deadlier Candida auris. That’s like posting “Wanted” pictures for
pickpockets but not serial murderers.
Health officials say they’ll disclose the information in
their next yearly report. That could be many months from now. Too late.
Patients need information in real time about where the risks are…
Dr. Eleanor Adams, a state Health Department researcher,
examined all the facilities in New York City affected by Candida auris over a
four-year period. Adams found serious flaws, including “inadequate disinfection
of shared equipment” to take vital signs, hasty cleaning and careless
compliance with rules to keep infected patients isolated…” (L)
“Remedies for curtailing the advance of C. auris are
familiar. Health care facilities must undergo stringent infection controls,
test for new cases and quickly identify any sources passing it along. Visitors
and medical workers must wash their hands after touching patients or surfaces.
The yeast spreads widely throughout patients’ rooms. Some cleanups have
reportedly required removing ceiling and floor tiles.
C. auris isn’t simply an opportunistic infection. Its rise
is additional evidence that becoming too reliant on certain types of drugs may
have unintended consequences. Exhibit A is the overuse of antibiotics in
doctors’ offices and on farms that encourages the development of drug-resistant
bacteria. Researchers suspect a similar situation involving C. auris and
agricultural fungicides used on crops. So far the origins of C. auris are
unclear, with different clusters arising in different areas of the world.
There’s no need to panic. But vigilance is required to track
C. auris and raise awareness in order to combat it. Officials typically are
eager to spread the word about potential health crises, from measles to MRSA.
In this case, the CDC issued alerts about fungus to health care facilities, but
the New York Times encountered an unusual wall of silence while investigating
superbugs such as C. auris. Medical facilities didn’t want to scare off
patients.
Any attempts to hide the spread of a communicable disease
are irresponsible. Knowledge leads to faster prevention and treatment. Patients
and their families have a right to know how hospitals and government agencies
are responding to a new threat. Medical workers also deserve to be informed of
the risks they encounter on the job.
Battling the superbugs requires aggressive responses and,
ultimately, scientific advancements. Downplaying outbreaks won’t stop their
rise.” (M)
“The rise of C. auris, which may have lurked unnoticed for
millennia, owes entirely to human intervention — the massive use of fungicides
in agriculture and on farm animals which winnowed away more vulnerable species,
giving the last bug standing a free run. Sensitised to clinical fungicides, C.
auris has proved to be difficult to extirpate, and culls infected humans who
cannot fight diseases very effectively — infants, the old, diabetics, people
with immune suppression, either because of diseases like HIV or the use of
steroids. The new superfungus has the makings of a future plague, one of
several which may cumulatively surpass cancer as a leading killer in a few
decades.
The origin of C. auris is known because it broke out in the
21st century, but the plagues from antiquity lack origin stories. Even their
spread was understood only retrospectively, in the light of modern science. The
father of all plagues, the Black Death, originated in China in the early 14th
century and ravaged most of the local population before it began its long
journey westwards down the Silk Route, via Samarkand. At the time, the chain of
hosts that carried it would have been incomprehensible — the afflicting
organism Yersinia pestis, the fleas which it infested, the rats which the fleas
in turn infested, which carried it into the homes of humans….” (N)
“WebMD: Most of us know candida from common yeast infections
that you might get on your skin or mucous membranes. What makes this one
different?
Chiller: It’s not acting like your typical candida. We’re
used to seeing those.
Candida — the regular ones — are already a major cause of
bloodstream infection in hospitalized patients. When we get invasive
infections, for example, bloodstream infections, we think that you sort of
auto-infect yourself. You come in with the candida already living in your gut.
You’re in the ICU, you’re on a broad spectrum antibiotic. You’re killing off
bad bacteria, you’re killing off good bacteria, so what are you left with?
Yeast, and it takes over.
What’s new with Candida auris is that it doesn’t act like
the typical candida that comes from our gut. This seems to be more of a skin
organism. It’s very happy on the skin and on surfaces.
It can survive on surfaces for long periods of time, weeks
to months. We know of patients that are colonized [meaning the Candida auris
lives on their skin without making them sick] for over a year now.
It is spreading in health care settings, more like bacteria
would, so it’s yeast that’s acting like bacteria” (O).
