McCleary MRSA Prevention

On September 13, 2013, I was recognized  for my work  by the Maine Patient Safety Academy.   It was their inaugural  award ceremony and I am extremely humbled and proud  to have been chosen for this award.  I was in the company of  a nurse from Maine Medical Center who dropped the CLABI rate to ZERO in her NICU and  a doctor whose serious determination, dedication and teaching has made patients at MMC and all over the State of Maine safer.

Maine Patient Safety Academy, Rising Tide Award

I am very grateful for this recognition from the PSA and to the people who nominated me for this award.

I remember the first time I attended the PSA.  3 years ago, I walked into the event, alone, and not knowing anyone.  I had been working hard at that time on MRSA prevention in Maine and on the national level.  I knew that many  in the Maine Hospital community were against what I proposed for the State,  Active Detection and Isolation for the prevention of MRSA in Maine Hospitals.  I am still a firm believer in that approach to MRSA prevention.  Not knowing who was at the event, except for Judy Tupper, the organizer of the event, I felt a little skeptical and nervous.  At the same time I knew I had to broaden my knowledge base and collaborate with others who are doing the work.    During my attendance,  I learned about the work that dedicated professionals were doing in my own State.  I was so impressed with this energetic conference, that I promoted it to my national group of Patient Safety Advocates with the Consumers Union Safe Patient Project.  By the following year, the CU  had formed a sub group called NEVER, or Northeast Voices for Error Reduction.   This smaller group joined me at 2012 at the Maine PSA!  I was so proud and excited to welcome them to Maine and to introduce them to some of the Patient Safety work that Maine was doing.  Three of us did a co presentation on Patient Safety as a break out session.  Inclusion of healthcare consumers and the Patient’s voice was a significant gesture of the PSA.

I continued to work doggedly for the past year.  I attended, helped to plan and participated in conferences here in Maine and nationwide.  This year when I attended the PSA, I knew a lot of the attendees, and even the keynote speaker.  I  met him at the Institute of Medicine event I attended last spring, and he  remembered me and came up to me to chat!  He is a wonderful young ER doc from Boston.  He and I share  similar tragic healthcare experiences with a parent.     My new participation in the Maine Quality Counts Consumer Advisory Council has opened even more doors for me to bring my ideas and the patient’s voice to healthcare reform in my State.  I also continue to advocate for individual patients, which is my most gratifying work of all.    More recently, I have reached out to my own city’s healthcare leadership to field the possibility of forming a Patient and Family Advisory Council in our community.

I don’t have a guidebook to do this work, but my path  becomes clearer as I go along.  My goals never change… they are accessible and affordable, safer, infection free care for all and inclusion of the patient’s voice in all levels of healthcare decision making.    I feel more comfortable in my own skin every time I go to another conference, event or meeting.

I have my beautiful award prominently displayed on my living room mantle.  I will bring it to my MQC Consumer Advisory Council meeting on Sept 20, 2013 and proudly share it with my consumer colleagues there.  But, I will not allow my head to swell, and I will keep my feet firmly planted on the ground and keep plugging away to make patients safer.

Heather Nichols

In mid August,  on the front page of the Bangor Daily News, I saw a stricken, young and vulnerable new Dad holding his beautiful new baby girl.  The story was about Heather Nichols, a first time Mom, who contracted Flesh Eating bacteria or Necrotizing Faciitis, after an episiotomy during delivery of her daughter.  One week after delivery, she died.  The few days leading to Heather’s death brought suffering and pain that nobody should have to endure.  This shouldn’t happen to anyone.

http://bangordailynews.com/slideshow/bangor-man-warns-of-rare-flesh-eating-infection-that-killed-his-wife-days-after-childbirth/?ref=comments

http://bangordailynews.com/2013/08/15/health/a-look-at-hospital-infections-after-young-bangor-mothers-death/?ref=search

This tragedy brings tears to my eyes every time I hear or think about it.  Matt Nichols carried out his TV and newspaper interviews one day after his wife’s funeral.  He did it to raise awareness in the community about this horrible infection and how it can kills otherwise healthy young people, more specifically, his beloved wife.  His generosity and concern for the community astounds me.

How did this happen? Who is going to answer the hundreds of questions that Matt and his family have?  Who is going to answer this community’s questions? EMMC, the hospital where Healther delivered her baby and later died, hasn’t answered anything yet.  The shroud of secrecy has fallen.  Rather than secrecy, the better path is to join with the family and  community, and use this horrible tragedy as a way to educate everyone about these serious infections and ways to prevent them.  The Hospital would do well to follow Matt Nichol’s lead on fostering awareness.

Matt Nichols, his infant daughter, his family and this community  deserves answers.

1. Why is there only an internal investigation?

2. Is the Maine CDC or some other unbiased regulatory agency involved?

3. Where did this infection come from?

4. Could it have come from a contaminated environment, unsterile instruments, or poor sterile technique?

5. Could pre-delivery screening and decolonization for Strep A have helped, or could simple bathing with anti bacterial soap have helped?

6. Is Home delivery a safer alternative, and is episiotomy absolutely necessary?

7. Did caregivers miss early signs of infection?

8. Did Heather Nichols get the RIGHT CARE, at the RIGHT PLACE, at the RIGHT TIME?

9. Would Hyperbaric treatments have helped?

10. Has this tragic infection and death been reported to the Maine or National CDC, the Maine DHHS, the Joint Commission or other regulatory/oversight agencies?

11. Why isn’t  this tragedy being used as an educational opportunity for everyone, including EMMC staff?

12. Where is the transparency and accountability?

13. Were there enough qualified nurses on duty when Heather was a patient there (ie. appropriate nurse to patient ratios)

14. How many others have become infected while staying at EMMC (and other Maine Hospitals), with Necrotizing Faciitis, MRSA, C Diff  or other deadly infections?

15. How many have died because of infections contracted at EMMC, and other Maine Hospitals?

16. How many have become disabled,  maimed or disfigured by infections that were contracted at EMMC and other Maine Hospitals?

17. Why is there no detailed quality information on the Hospital website?

18. How can I learn detailed and real time facts  about Hospital and provider quality and safety when I am shopping here in Maine,  for healthcare services?  Existing public information is superficial and incomplete.

19. Would a community Patient and Family Advisory Council help to make patients safer, and to make healthcare more transparent?

20. How can we all (patients, families and caregivers) work together to make infections like Heather’s a thing of the past?

I had a lot of these same questions almost 5 years ago when my father contracted MRSA  (Methicillin Resistant Staph Aureus) at his community Hospital.  He died as a result.  My father’s preventable infection and death ignited a passion in me and I have worked as a volunteer Patient Safety Advocate and Activist since then.  There has been some progress in preventing some infections and in patient safety, but it obviously isn’t enough and it certainly is not fast enough. We shouldn’t have to ask the same questions today, that I asked 5 years ago.

I live in Bangor, ME.  EMMC is my hospital of choice.  I worked there for a total of around 20 years, off and on.  Many colleagues and friends continue to work there.  I know their dedication and also their grief and pain when something this tragic happens.  But, secrecy and image control are not the way to handle horrific outcomes like Heather’s.  Learning the “truth”  through Hospital gossip that leaks into the community is not acceptable and it is also a violation of the family’s right to privacy. Matt Nichols and his family get to decide what information will be shared and what will not,  but as far as I know,  they are not privy to the actual facts around Heather’s case.    Bringing in the family, listening to them, answering their questions, involving them in the investigation of the event, and being transparent are the only ways to handle this.  EMMC will never have a complete investigation until they ask the family what their observations were. Patients and families deserve the right to share what they heard, saw and went through.    EMMC has gone secret and silent…and that fosters distrust.  Struggling and grieving  families sue Hospitals when they don’t get the answers and other support that they need during their time of need.

We, as patients and families, must use our voices  to shine a light on the dark problem of healthcare harm and lack of transparency and accountability.  My place at the table with the new Maine Quality Forum Healthcare Associated Infections council gives me an opportunity to represent healthcare consumers and to invite and inform patients and their families to come and speak out during public comments.  Then next meeting is September 23, 9am at 211 Water Street in Augusta (Dirigo Health building).  Please come with your questions and concerns.  If you can’t make it, email me at kathydayrn@aol.com.