McCleary MRSA Prevention

http://www.pressherald.com/2016/05/07/mainers-call-for-more-data-to-help-prevent-medical-errors/

This morning the Portland Press Herald had this article on the front page.  The  high numbers of vulnerable sick and injured patients who die not because of their illness, but because of preventable harm is just not acceptable.  It makes me crazy that  1/4 to 1/2 million people die unnecessarily every year in the US.   Dad died in 2009, after his hospital infected him with MRSA, but he was not counted in any of the voluminous data that I read.   He suffered a great deal and died within several weeks of the infection.

I have worked, as a volunteer, in Maine and nationally since Dad’s death, to help stop this epidemic of needless deaths.  Just last week, on May 4, there was a Patient Safety conference in Augusta Maine sponsored by the Maine Sentinel events team.  I asked several times for the agenda and details for this event, so I could register and attend.  None were sent.  Then I was told that there was such an overwhelming response to this event that it was “sold out”. I could only attend if there was a cancellation.  There were no cancellations.   I was very disappointed because the patient’s voice is essential to any discussions about them or about Patient Safety.  So I asked again for an agenda so I could advise the organizers about where it would be good for them to include the patient’s voice.  None was received.   Since I got nowhere with this, I wrote to the Commissioner of the Department of Health and Human Resources of Maine, and expressed my disappointment that the State would have such a conference without inclusion of the patient’s voice.  I would be very surprised, but pleased to hear back from our Commissioner.

Coincidentally, on May 4, the very day that I was excluded from a Maine Patient Safety conference that was held about an hour away from my home, a reporter from the Portland Press Herald called me because of a recent report from Dr Marty Makary, of Johns Hopkins, that healthcare harm is the third leading cause of death.  This was not news to me, but I was certainly happy to have the opportunity to talk with this bright reporter.  He also sent a photographer to my home and this became a front page article on May 7, today.  I am very grateful to this reporter and his newspaper for recognizing the importance of awareness on this issue.

We all know the old saying “there is more than one way to skin a cat”.   Well apparently, there is more than one way to get the  word out on Medical errors and preventable healthcare harm. I missed the opportunity to bring the patient’s voice to the Patient Safety conference in Augusta, but my voice was shared with thousands of others on the front page of the Portland Press Herald this morning.  Although this is an unpleasant and for some an unpopular subject, all of us, as a society must talk about this openly and often,  and demand better.

From April 14 to April 18, I attended the Institute of Patient and Family Centered Care intensive training course.  I was alerted to this conference by my colleague Lisa Freeman.  I was unfamiliar with this approach to healthcare, but I had attended a very nice presentation by Bev Johnson, Director , for the Patient Centered Medical Home practices here in Maine.  She is a brilliant and kind teacher.  She recognizes that Patients and their families must partner  with providers to improve healthcare.   So, I knew that at least Bev’s involvement in this organization would make this training worthwhile.

I have been involved in Patient safety advocacy and activism for over 4 years now.  I belong to and affiliate with different organizations and I attend meetings, conferences, online webinars, phone conference calls, PLUS, I read everything I can get my hands on about Patient Safety.  The solutions are out there to make healthcare safer, better, and cheaper.  I know the problems and the negatives in Healthcare, but I also know that healthcare can be an miraculous cure for what ails you.  I have definite ideas about solutions for problems, but the quandary has always been…How do we get there?

The IPFCC training taught me how.  We include patients and families in every aspect of care, from the primary care office through discharge from the Hospital and into post Hospital care, whether it is in LTC, rehab, or at home.   Partnering WITH patients through out the journey of care is absolutely essential.  Patient and family advisory councils at every level are necessary.   TOs and FORs are removed from conversations regarding patients and families and in their place we put WITH.

I was skeptical.  What exactly is accomplished when providers partner with patients and honor them and their families? These are the measurable improvements that I heard about this week.

1. Reduction in HAIs (my initial reason and primary focus for doing this work!)

2. Reduction of medication and medical errors

3. Reduction of Hospital readmissions

4. Improvement of HCAPS numbers, improved Patient Satisfaction

5. Improvement of Healthcare outcomes.

6. Reductions of costs.

7. Elimination of Visiting Hours.   Family members are partners, not visitors.  Ability of all patients to have a 24 hours bedside advocate.

8. Increased honor and respect of patients and patient dignity.

9. Improved employee satisfaction and improved employee retention.

10. Patient Portals to Electronic Records and how to use them.

11. Addresses all 3 arms of the IHI Triple Aim.

This is the short list.  I heard stories of success, from patients and patient advisers,  and from Hospital administrators, providers and workers.  I learned that this work is not easy, but it is worth every minute of effort.    It is an approach that is inclusive of everyone involved and affected by healthcare  in a collaborative partnership.

Now what?  I plan to tell my colleagues at the Maine Quality Counts Consumer Advisory Council about my training.  I hope to mobilize them and MQC to do a survey of Maine Hospitals and to assess where Maine is at in PFCC. How many Patient and Family Advisory councils do we have in Maine, and are they honored, valued and included in the work of caring for patients?   Then we will go from there.  I has to happen.  I hope that it will happen very soon.  We need the change. We need to do whatever it takes to make patients safer, control costs, and preserve our ability to access care.

Last week I attended the Maine Quality Counts annual conference about achieving the Triple Aim in Maine.  This week I connected some big ole dots on how to do the work.

A local guest editor, Dr Eric Steele, Bangor, ME, writes about transparency regarding Medical Errors in today’s Bangor Daily news.  This link tells the story of an unfortunate man who lost his life in a small Maine Hospital because of a huge overdose of Epinephrine.  Dr Steele, while recognizing the tragedy of the mans death, also applauds the hospital because they accepted the responsibility of this error ,made changes to correct the problem and apologized to the family.

If only this same thing could be done for the thousands of people who die each hear from Hospital Acquired Infections.  Many things are being done, but the most important one for MRSA is not being done as practice in the State of Maine.  Active Detection and Isolation is a proven method of prevention for MRSA.  Mandatory public reporting as also been successful in making hospitals accountable and transparent about these infections, and yet the Maine Hospital Association and Epidemiologists and other representatives from all Maine hopsitals have rejected and fought both of these measures.

I hope that Dr Steele is as serious about HAIs as he is about other Medical Errors. 

http://www.bangordailynews.com/detail/147267.html?comment_result=posted#comments-post

In the midst of heated debate about health care reform, our noble legislators are going on a month long vacation.  While many thousands of people are losing their healthcare insurance every day, the debate will stop until our entitled legislators are well rested and tanned. Oh, and lest we forget, if they get a sunburn or a sprain on vacation, they are covered by a very generous insurance package.

Healthcare reform is so needed and so overdue, and yet our leaders just take off and enjoy themselves. Those who oppose HC reform think this delay will hurt the reform act.   Part of reform is to improve the quality of our healthcare by reducing medical errors and hospital acquired infections.  Congresswoman Jackie Speier’s HR 2739 will be part of the reform if we are successful.  So until HC reform happens, not only are US citizens losing healthcare insurance every day, the healthcare consumer will continue to receive treatment in our nations hospitals, most of them having  inadequate infection control and rising numbers of preventable infections. 

Millions of American citizens fight every day with insurers who deny claims because of a pre existing ailment, or any other reason they can come up with.  Millions of others have no insurance at all and hundreds of thousands contract preventable infections because there is no solid mandate to prevent them.  Many thousands of those exposed to MRSA and other hospital acquired infections will die or become disabled.  Our healthcare system is in a mess and healthcare consumers suffer because of that every day.

President Obama continues to work every day, campaigning and fighting for Health Care reform, but our lawmakers need a vacation.  I admire our new president for knowing his priorities.

If just one senator or one representative had to be hospitalized and then contracted MRSA while there, that would be it.  We would have measures to stop MRSA infections.   I wouldn’t wish a MRSA infection on my worst enemy, but it is fact.  Unless someone is personally effected by the horrible infections that can be contracted in our hospitals, they are unaware and uninterested.  It is our job as families, vicitims, healthcare consumers, and others to MAKE THEM AWARE!   The staff of both of Maine’s representatives are aware because a staff member in the House caught MRSA in the gym in their office building, and because other activists and I informed them.  MRSA came close to them, and to their place of work .  They know they are not immune, and that nobody is.

Make your representatives work, the long hard hours it takes, to make a difference through healthcare reform, and to make our hospitals safer.