Recommendation and reality

 

Sunday, May 06, 2007

James T. Mulder Staff writer

Surgery patients are less likely to develop costly and potentially deadly infections if they receive antibiotics within one hour before the procedure starts.

All too often, this is not happening in Central New York, according to statistics hospitals report to Medicare, the federal health care program for people over 65 and the disabled.

At Cayuga Medical Center, in Ithaca, 61 percent of surgery patients received antibiotics at the right time between July 2005 and June 2006. The rates were 62 percent at Oswego Hospital, and 66 percent at A.L. Lee Memorial in Fulton and Community General in Syracuse. St. Joseph's Hospital Health Center in Syracuse had the best rate in the region, 85 percent.

The national average was 77 percent.

Patients should be taking antibiotics within the one-hour time frame more than 90 percent of the time, said Lisa McGiffert, manager of Consumers Union's national Stop Hospital Infections campaign.

"This is a proven technique so it's something that every hospital should be doing," McGiffert said. "It falls through the cracks because people get busy, distracted, and emergencies happen."

Infections patients pick up in hospitals exact a heavy toll. Every year, they kill almost 100,000 people nationwide and cost more than $5 billion, according to the Association for Professionals in Infection Control and Epidemiology.

Hospitals are under increasing pressure to address the problem. To comply with a state law passed in 2005, New York is collecting infection information from hospitals and will begin publicly reporting some of the data next year.

Medicare includes statistics about the percentage of patients who are given antibiotics within one hour of incision on its "Hospital Compare" Web site (www.hospital compare.hhs.gov).

It is one of several measures on the site that show how often patients receive recommended care at nearly every U.S. hospital.

The government created the site to help improve hospital quality. Surgical infection prevention data for all Central New York hospitals was added to the site earlier this year.

Medicare says scientific evidence indicates a dose of antibiotics within an hour of incision helps prevent infections after colon surgery, hip and knee replacement, abdominal and vaginal hysterectomy and cardiac surgery.

Some area hospitals blamed their low scores on internal reporting problems. "We identified this as a documentation problem as opposed to a delivery problem," said Dr. Rob Mackenzie, president of Cayuga Medical Center. More recent internal data shows the hospital's score on this measure is 82 percent, according to Mackenzie. He said his hospital was recognized last year by the state Health Department for reducing infection rates.

Community General also blamed its low percentage on record-keeping problems. The clocks in its operating rooms were not synchronized, part of the reason why its percentage was so low, according to hospital spokeswoman Maria Damiano.

But Betsy McCaughey, New York's former lieutenant governor and founder of the Committee to Reduce Infection Deaths, a national patient advocacy group, doesn't buy those explanations.

"That's an indication hospitals aren't being rigorous enough about maintenance of patient records," she said. "So that's certainly not an excuse."

For the past two years, St. Joseph's has been re-examining its processes and making changes to reduce infections.

"We had to make sure we had everyone on the same page on what the correct antibiotic is for the surgery in question," said Chris Pine, manager for patient safety at St. Joseph's. The hospital charged its anesthesiologists with the task of administering antibiotics to surgery patients. "They are the best persons to deliver it in the correct time frame," she said.

Dr. Brian Anderson, chief of surgery at Crouse Hospital, said every surgery patient does not need antibiotics, especially if it's a "clean" case involving a part of the body where there is no bacterial contamination.

Using antibioticsas a preventive measure subjects the patient to the risk of the antibiotic's potential negative side effects, some of which can be life-threatening, Anderson said. "You have to determine if the benefit outweighs the risk," he said. "Most of the time most people think the benefit outweighs the risk."

Emergencies can throw off the timing of a surgery patient's antibiotic. A patient scheduled for elective surgery may have his or her operation delayed if another patient comes in who needs emergency surgery for a ruptured appendix. If the elective surgery patient had already received an antibiotic before the delay, a doctor will have to decide whether to administer another dose or rely on the dose already given, according to Mackenzie, of Cayuga Medical Center.

"There could be good legitimate clinical reasons why someone had a dose given 70 to 90 minutes before surgery," he said. "That might be felt to be perfectly fine, depending on what kind of surgery that was."

While antibioticscan help prevent infections, they usually should be stopped within 24 hours after routine surgery, according to Medicare. If they are not stopped within 24 hours, patients are at greater risk of developing side effects such as stomachaches, diarrhea and antibiotic resistance, meaning the drugs won't work anymore.

There are exceptions to this guideline, such as cases where the surgical site has become contaminated, according to Medicare.

The Hospital Compare Web site shows antibiotics were stopped within 24 hours for 71 percent of surgery patients nationwide. Among Central New York hospitals, A.L. Lee Memorial in Fulton had the best rate on this measure. It stopped antibiotics on time for 100 percent of patients. University Hospital had the worst rate on this measure, 48 percent.

Dr. Paul Cunningham, University's surgery chair, said the hospital is trying to figure out why that number is so low. It may be because the hospital cares for many seriously ill patients, he said.

"Many of our patients are non-elective and come with critical issues and their antibiotics are not stoppable in 24 hours," he said. It's also possible the information is not being documented accurately, he said.

While the Medicare statistics show how well hospitals are doing when it comes to starting and stopping antibiotics on time, they don't show how many patients developed infections or died from them.

Bruce Boissonnault, president of the Niagara Health Quality Coalition, a Buffalo-area nonprofit research group that publishes a report card on New York hospitals, said outcome measures are more meaningful for patients than process measures like the ones tracked by Medicare.

"Process measures are a highly inadequate substitute for results," he said.

His group'slatest report card, based on billing data from 2005, showed Crouse, University and St. Joseph's had higher rates of infection than the state average, which is 0.165 percent. Other hospitals in the region were at the state average. That report card looks at infections related to intravenous lines and catheters.

McGiffert, of Consumers Union, also says outcome measures are better. Her group has been pushing states to mandate public reporting of hospital infection rates, a process New York will begin next year.

McGiffert, however, says the Medicare statistics on surgical infection prevention are helpful, too.

"It's sort of a little window into how well the hospital is standardizing care," she said. "Reporting these kinds of measures can educate the public on what should be happening to them."

James T. Mulder can be reached at 470-2245 or jmulder@syracuse.com

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