Why are quality and safety of patient care getting worse?

Many of us showered the highest of praise on doctors, nurses, therapists and other medical workers for their valor during the pandemic. They deserved it. 

In the meantime, though, the medical system in which they work is proving to be tough to heal. It was walloped by the coronavirus and hasn’t yet recovered. Instead, we’re learning more and more about flaws in the design and structure of treatment that have caused needless injuries and deaths of patients. 

The quality and safety of care, in a reversal of previous progress, have declined in unacceptable and dangerous ways.

It starts for many patients in emergency departments, which too many of us must go through to not only get desperately needed treatment but also admission to hospitals for further care. Conditions in ERs, slammed during the pandemic and even before, aren’t improving. With their personnel exhausted and overwhelmed, emergency departments are parking patients for far, far too long, damaging their care. And researchers say the harried conditions in ERs contribute to harmful and even fatal misdiagnoses.

Patients who finally “get upstairs” and are admitted then are encountering other serious and familiar nightmares in their treatment. The medical system had battled these before, with attention paid to improved technology, training, and staffing. But the advances have disappeared, meaning too many patients are suffering avoidable falls, getting the wrong medications, and acquiring preventable infections with major consequences.  

The suit-wearing MBAs who run too many aspects of medicine  may be fretting about institutions’ bottom lines. They may be prodding their staffs to increase patient volumes, bolster institutional finances, push for high-paying procedures, and find cheaper, faster ways for our care. When will treating patients safely and well return as a priority? We can’t wait, as alarming indicators and safety advocates are warning.

The pandemic’s 24/7 media coverage seared into the public consciousness images of overwhelmed hospital emergency departments, with patients treated in tents, lobbies, and other makeshift quarters.

Two things may have been less apparent about these distressing pictures:

1. ERs already were staggering under their loads before the pandemic.

2. The crush has not improved, as coronavirus cases have dropped and medical personnel have had to deal with a wave of other highly contagious viral respiratory conditions (influenza and RSV).

In fact, almost three dozen leading provider groups have called on the Biden Administration to deal urgently with the dangerous, long-running practice of hospitals allowing ERs to be hammered because they also have become parking lots where patients wait, and wait, for rooms and treatment. In this “boarding crisis,” patients seeking emergency care wait for hours, days, or even weeks, experts say.

The complaining organizations include the American College of Emergency Physicians (38,000 members), the American Medical Association, the American Nurses Association, American Academy of Emergency Medicine (8,000 members) and groups representing family doctors, allergists, anesthesiologists, radiologists, osteopaths, and psychiatrists. They put out a joint statement, published on the emergency physicians’ group site, saying this:

“Boarding has become its own public health emergency … EDs are gridlocked and overwhelmed with patients waiting – waiting to be seen; waiting for admission to an inpatient bed in the hospital; waiting to be transferred to psychiatric, skilled nursing, or other specialized facilities; or, waiting simply to return to their nursing home. And this breaking point is entirely outside the control of the highly skilled emergency physicians, nurses, and other ED staff … Any emergency patient can find themselves boarded, regardless of their condition, age, insurance coverage, income, or geographic area.” 

The experts explain that the law bars hospitals from turning away patients who need emergency care. But with increasing health worker burnout (especially tied to the pandemic), staff reductions, and departures (especially among nurses), and the need for ERs to work 24/7, it can be a struggle for triage to occur. Even when it does, a cascade of challenges follow as hospitals try to find space to admit patients.

The admissions ordeal is complicated, the doctors write, by multiple factors. In areas outside of the ER, hospitals may be constrained by laws requiring staffing levels, notably nurse-to-patient ratios. Administrators also must balance admissions from the ER with other patients seeking care — including lucrative scheduled procedures or treatment. Space is already spare for youngsters and other patients requiring mental health care.

Patients inarguably suffer significant harms due to delayed care, with the experts noting this:

“There is ample evidence that boarding harms patients and leads to worse outcomes, compromises to patient privacy, increases in medical errors, detrimental delays in care, and increased mortality.”

Doctors working in hospital emergency departments face chaos, violence, and high stress every day. Usually they get the diagnosis and treatment right. But  — and it’s a big but —as many as one in 17 ER visits ends with a misdiagnosis, which can have deadly consequences.

Those misdiagnosis figures have recently been estimated by Johns Hopkins medical school researchers as a significant peril for patients across the country.

Doctors in ERs fail to correctly “identify serious medical conditions like stroke, sepsis and pneumonia,” leading to the deaths of as many as 250,000 patients each year. That was the finding by researchers at the Johns Hopkins University Evidence-based Practice Center in their work for a federal health care oversight agency. The New York Times reported this of their research:

“The study … by the Agency for Healthcare Research and Quality, estimates roughly 7.4 million people are inaccurately diagnosed of the 130 million annual visits to hospital emergency departments in the United States. Some 370,000 patients may suffer serious harm as a result. Researchers from Johns Hopkins University, under a contract with the agency, analyzed data from two decades’ worth of studies to quantify the rate of diagnostic errors in the emergency room … [T]hey are most likely to occur when someone presents with symptoms that are not typical, like stroke patients complaining the room is spinning. A doctor may not immediately think that a young woman with shortness of breath is having a heart attack or that someone who has back pain could have a spinal abscess.”

The researchers urged leaders in the U.S. medical system to dig into the training, support, and technology used by doctors to see how misdiagnoses occur and how they might be slashed in frequency and severity. CNN reported this of the study and its findings that a handful of conditions most often were subject to ER problems:

“The top five conditions that were misdiagnosed were: stroke, myocardial infarction, aortic aneurysm/dissection, spinal cord compression/injury [and] venous thromboembolism. These five conditions accounted for 39% of all serious misdiagnosis-related harms … Women and people of color had a 20% to 30% increase in risk of being misdiagnosed.”

The American College of Emergency Physicians has assailed the study, criticizing its data sources, methodology, conclusions, and tone. The organization, though, also has joined other leading medical groups in urging the Biden Administration to take steps to remedy what the doctors and others have called unacceptable numbers of patients kept waiting for long, risky periods in ERs because hospitals cannot find space for their further care.

It also is worth noting that doctors react defensively to critical research, including to another Johns Hopkins study that found in the time before the pandemic that medical errors claimed the lives of roughly 685 Americans per day — more people than die of respiratory disease, accidents, stroke and Alzheimer’s. Medical errors ranked as the third leading cause of death in the U.S., behind only heart disease and cancer. The researchers, led by a Johns Hopkins surgery professor, determined that medical errors claimed 250,000 lives annually.

While some health experts assailed that study, the Heartland Health Research Institute looked at Iowa and six surrounding states to assess what experts call preventable adverse events, examining studies that might offer national insights. They found that it was reasonable to conclude that “250,000 patients [die] annually in U.S. hospitals due to preventable mistakes.”

Shortly thereafter, The Leapfrog Group — a sometimes controversial national nonprofit that includes 1,800 hospitals and seeks to improve quality and safety in caregiving institutions — estimated that more than 206,000 avoidable deaths occur in hospitals annually.

Whatever the correct number is, we all can agree it’s too many.

Context matters. Medicine long has struggled to provide safe, quality care to patients. And though advocates made them a priority and have campaigned hard for years now, these issues — even before the pandemic — needed improvement.

In flusher times, when medical staff were far less stressed, their morale was higher, and their numbers were increasing, significant attention was paid to reducing patient harms. Some progress occurred, with researchers finding, for example, that adverse incidents declined between 2010 and 2019 in patients overall and notably with those with pneumonia and heart conditions, 

Still, the problems were far from being resolved in a peak period for U.S. medicine. As a retrospective study published early this year in a prominent medical journal found, in a random exam of almost 3,000 admissions in 2018 at a Massachusetts hospital:

“[W]e identified at least one adverse event in 23.6% [of admissions]. Among [these] … 22.7% were judged to be preventable and … 32.3% [were] serious (i.e., caused harm that resulted in substantial intervention or prolonged recovery) or higher. A preventable adverse event occurred in … 6.8% of all admissions …There were seven deaths, one of which was deemed to be preventable.”

The study found that problems with medications were the most common, followed by issues in surgeries and procedures. Researchers also saw faults with falls, pressure wounds and treatment-acquired infections.

Federal watchdogs have expressed high concern not only that older patients suffer excessive harms when hospitalized but also that improvements have not occurred in a decade.

As three top U.S. health officials wrote in an Op-Ed published by the science and medical site Stat, based on work by the  Office of Inspector General for the U.S. Department of Health and Human Services:

“In 2010, our office … reported that 27% of Medicare beneficiaries experienced harm during hospital stays. These harms were uncovered through an extensive medical record review by nurses and physicians trained in patient safety. They included temporary events such as low blood pressure that can cause falls and other problems, as well as serious events such as strokes and sepsis, which prolong hospital stays, cause permanent injuries, and, in some cases, contribute to death. Almost half of the harm events identified could have been prevented by better care.”

The officials wrote that safety advocates campaigned in the decade after their 2010 scrutiny for improvements. And progress seemed to be occurring. 

“Yet a new study recently released by our office shows that rates of patient harm remain disturbingly high. Based on hospital stays exactly 10 years later and using the same methodology as the 2010 report, our new study found that 25% of Medicare beneficiaries experienced harm during inpatient hospital stays, again almost half of which could have been prevented by better care.”

They noted the financial toll that bad care takes on taxpayers who pay for it under federal programs like Medicaid — an estimated half billion dollars in needless expense. They also emphasized the suffering that medical mistreatment inflicts on patients and their families, providing a few illustrative instances, including:

§ “Providers delayed for five days a patient’s urgently needed surgery. A resulting cascade of events ended in the patient’s death.

§ “A 69-year-old hospitalized for hip replacement contracted methicillin-resistant Staphylococcus aureus (MRSA), an antibiotic-resistant superbug. This infection was preventable and caused a week-long hospital readmission and repeat hip surgery.

§ “A patient admitted with chronic diarrhea, fever, and sepsis was unable to move. Due to a failure of nursing care, the patient was not turned regularly in bed and developed pressure injuries in two different locations. Such injuries are often very painful and can lead to infection and tissue damage; some require surgical intervention.

§ “A patient experienced cardiac arrest while being transported within the hospital from the patient’s room to the medical imaging department. The emergency response team could not locate the patient to initiate timely resuscitation, and the patient died.”

The data lag, but indicators point to alarming declines in patient safety during and after the pandemic.

The Joint Commission, an industry group that accredits hospitals, gives institutions huge leeway in reporting “sentinel” events — defined as incidents involving “death, permanent harm, or severe temporary harm” to patients. The commission underscores that hospitals should deal with such occurrences with rigor. But reporting them to the commission is voluntary, and reports may happen for as little as 2% of such incidents.

Still, commission data for 1995-2021 shows a major spike in sentinel events in the most recent year — 1,197 versus 607 total such incidents in ‘95. This was the highest level of such negative reporting since 2007, according to industry reports. The commission’s latest data for the first two quarters of 2022 shows a decline in total events versus ‘21 but the data lag for the full year.

Leapfrog, the private and independent medical safety and hospital rating organization, has looked for several years at federal patient survey data as a prime measure of the safety and excellence of treatment. The group has found disturbing plunges in this metric, especially in medical staff communications with patients about crucial aspects of their care, including just responding to them, as well as discussing the medications they receive and their transition home. 

“[S]ignificant challenges persist across all domains of patient experience, indicative of serious safety and quality problems that must be addressed,” Leapfrog reported.

The federal Centers for Disease Control and Prevention (CDC) and the Center for Medicare and Medicaid Services (CMS) have taken note of declining patient safety, while also calling on those across the U.S. health care system to recommit to desperately needed improvements in this area. In a commentary published in a major medical journal, leading safety advocates within the federal agencies reported:

“We have observed substantial deterioration on multiple patient-safety metrics since the beginning of the pandemic, despite decades of attention to complications of care. Central-line–associated bloodstream infections in U.S. hospitals had decreased by 31% in the 5 years preceding the pandemic; this promising trend was almost totally reversed by a 28% increase in the second quarter of 2020 (as compared with the second quarter of 2019). There were also increases in catheter-associated urinary tract infections, ventilator-associated events, and methicillin-resistant Staphylococcus aureus bacteremia. 

“Safety has also worsened for patients receiving post-acute care, according to data submitted to [CMS] Quality Reporting Programs: During the second quarter of 2020, skilled nursing facilities saw rates of falls causing major injury increase by 17.4% and rates of pressure ulcers increase by 41.8%.”

The federal officials also wrote:

“The [pandemic-related] strains on the system have also affected routine safety practices. Overworked clinicians have often had no time for safety rounds, safety audits, or error reporting …
Standard safeguards, such as checklists, quickly became inadequate. Moreover, the pandemic starkly highlighted health disparities, including inequities in the safety of patients and health care personnel.”

Let’s state loudly what should be a fundamental, inarguable idea: Patients who are so ill or injured as to require intensive medical treatment and hospitalization should not have their conditions worsened by preventable infections acquired in medical care. 

This, unfortunately, is an increasing occurrence, as the Washington Post reported:

“On any given day, 1 in 31 hospital patients and 1 in 43 nursing home residents has an infection acquired while seeking medical care, according to the Centers for Disease Control and Prevention. Candida auris, the fungus spreading primarily in long-term acute-care hospitals and skilled-nursing facilities, is considered a serious global public health threat because it can be difficult to detect and resists some antifungal drugs and disinfectants. It’s just one of the infections acquired in health-care settings that are ripe for transmission because patients are on invasive devices and are susceptible to infections healthy people do not contract. There’s a wide range of other pathogens — from methicillin-resistant Staphylococcus aureus to E. coli bacteria that cause urinary tract infections — that are more rampant. ‘Infection control within health care is extremely neglected,’ said Saskia Popescu, an assistant professor at George Mason University who is an expert in infection prevention …”

The newspaper also reported this:

“[T]he risk [of patient harm] can be mitigated with infection-prevention protocols that include regular surveillance, isolation of infected patients, protective equipment, proper hand hygiene, and deep cleaning. The coronavirus pandemic upended those efforts as hospitals scrambled to keep up with a deluge of Covid patients, often amid staff and supply shortages in the pandemic’s early months. Ventilator use soared. As a result, CDC scientists found that infections from invasive devices surged alongside Covid hospitalizations in the winter and summer of 2021. The pandemic also disrupted the nation’s progress against antimicrobial-resistant pathogens, with Candida auris being just one of eight showing alarming increases from 2019 to 2020.”

Federal and state regulators have prodded health workers and hospitals before to step up the battle against infections, especially those involving antibiotic-resistant bacteria and fungi, aka “superbugs.”

It is past time for a renewed crackdown, notably due to the dire consequences of failing to act — not only for today’s sickened patients but also for the calamity of a “post–antibiotic” world where common, familiar, and once-powerful disease-fighting agents lose their effectiveness