23 October 2002

Medical Error: Every Additional Patient for a Nurse Increases Mortality by 7%

Medical error is the third leading cause of death in the United States and the medication error component is the 4th leading cause of death. This is largely caused by systemic problems in the management of our healthcare system and lack of deployment of available information technologies. I have been doing presentations at major conferences for years on medical error pointing out that poor financial performance (due to lack of automation) leads to nursing shortages which directly leads to patient death. This week, the Journal of the American Medical Association published the numbers. Every additional patient for a nurse increases the risk of death for all patients by 7%.

Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction
Linda H. Aiken, PhD, RN; Sean P. Clarke, PhD, RN; Douglas M. Sloane, PhD; Julie Sochalski, PhD, RN; Jeffrey H. Silber, MD, PhD
JAMA. 2002;288:1987-1993

Context: The worsening hospital nurse shortage and recent California legislation mandating minimum hospital patient-to-nurse ratios demand an understanding of how nurse staffing levels affect patient outcomes and nurse retention in hospital practice.

Objective: To determine the association between the patient-to-nurse ratio and patient mortality, failure-to-rescue (deaths following complications) among surgical patients, and factors related to nurse retention.

Design, Setting, and Participants: Cross-sectional analyses of linked data from 10 184 staff nurses surveyed, 232 342 general, orthopedic, and vascular surgery patients discharged from the hospital between April 1, 1998, and November 30, 1999, and administrative data from 168 nonfederal adult general hospitals in Pennsylvania.

Main Outcome Measures: Risk-adjusted patient mortality and failure-to-rescue within 30 days of admission, and nurse-reported job dissatisfaction and job-related burnout.

Results: After adjusting for patient and hospital characteristics (size, teaching status, and technology), each additional patient per nurse was associated with a 7% (odds ratio [OR], 1.07; 95% confidence interval [CI], 1.03-1.12) increase in the likelihood of dying within 30 days of admission and a 7% (OR, 1.07; 95% CI, 1.02-1.11) increase in the odds of failure-to-rescue. After adjusting for nurse and hospital characteristics, each additional patient per nurse was associated with a 23% (OR, 1.23; 95% CI, 1.13-1.34) increase in the odds of burnout and a 15% (OR, 1.15; 95% CI, 1.07-1.25) increase in the odds of job dissatisfaction.

Conclusions: In hospitals with high patient-to-nurse ratios, surgical patients experience higher risk-adjusted 30-day mortality and failure-to-rescue rates, and nurses are more likely to experience burnout and job dissatisfaction.

13 October 2002

Superbug Strike Again: Staphylococcus Aureus

Nature Science Update: Superbug Strikes Again
"A drug-resistant superbug has resurfaced, doctors announced today, leaving researchers scrabbling for the next line of antibiotic defence. The rogue Staphylococcus aureus bacteria, identified in the foot ulcer of a Pennsylvania patient, are resistant to vancomycin, one of the last lines of antibiotic defence. More cases were widely anticipated after reports of the first such strain earlier this year. Today's announcement coincided with confirmation of the case by the US Centers for Disease Control and Prevention in Atlanta, Georgia."

When antibiotics fail, these bugs can be dealt with using a frequency generator such as the FSCAN or F100, or by a rife plasma tube device such as the EM6C. They typically cover a spectrum of frequencies that must be treated at 1HZ increments through the entire spectrum. Misuse of antibiotics has caused these pathogens to generate a broad spectrum of strains. For resistant strains, virtually any conventional treatment affects only part of the spectrum and the infection regrows no matter what you treat it with.

Most people are lightly infected with these organisms. Using a microscopic slide of the organism, I identified the frequency for the pathogen and tested postive for hosting a strain of the organism. I then treated myself for a couple of minutes to get rid of it. Serious infections require more extended treatment across a wide band of frequencies.

© 2002 Kenneth Todar University of Wisconsin-Madison Department of Bacteriology
Pathogenesis of S. aureus infections
"Staphylococcus aureus causes a variety of suppurative (pus-forming) infections and toxinoses in humans. It causes superficial skin lesions such as boils, styes and furuncles; more serious infections such as pneumonia, mastitis, phlebitis, meningitis, and urinary tract infections; and deep-seated infections, such as osteomyelitis and endocarditis. S. aureus is a major cause of hospital acquired (nosocomial) infection of surgical wounds and infections associated with indwelling medical devices. S. aureus causes food poisoning by releasing enterotoxins into food, and toxic shock syndrome by release of pyrogenic exotoxins into the blood stream."

CDC Fact Sheet
Eight cases of infection caused by vancomycin-intermediate Staphylococcus aureus (VISA) have been detected in the United States (Michigan, New Jersey, New York, and Illinois, Minnesota, Nevada, Maryland, Ohio. Some of the VISA infections developed in persons with previous infections with methicillin-resistant Staphylococcus aureus (MRSA). Normally, vancomycin is the most reliable and effective drug for treating MRSA. The appearance of Staphylococcus aureus with reduced susceptibility to vancomycin is concerning. The patients with VISA infections were chronically ill and probably developed their VISA infection in a healthcare setting. No spread to family members, household contacts, other patients, or healthcare workers was detected.

Sequencing the Genome
The Sanger Institute has been funded to sequence the 2.8 Mb genomes of two strains of Staphylococcus aureus in collaboration with Prof. Tim Foster of the Department of Microbiology, Trinity College, Dublin, Prof. Brian Spratt of the Department of Infectious Disease Epidemiology, Imperial College School of Medicine, Mark Enright of the Department of Biology and Biochemistry, University of Bath, and Dr. Nicholas Day and Dr. Sharon Peacock of the John Radcliffe Hospital, Oxford.

FDA Bacteriological Analytical Manual
Staphylococcus aureus is highly vulnerable to destruction by heat treatment and nearly all sanitizing agents. Thus, the presence of this bacterium or its enterotoxins in processed foods or on food processing equipment is generally an indication of poor sanitation. S. aureus can cause severe food poisoning. It has been identified as the causative agent in many food poisoning outbreaks and is probably responsible for even more cases in individuals and family groups than the records show.

FDA Bad Bug Book
Foods that are frequently incriminated in staphylococcal food poisoning include meat and meat products; poultry and egg products; salads such as egg, tuna, chicken, potato, and macaroni; bakery products such as cream-filled pastries, cream pies, and chocolate eclairs; sandwich fillings; and milk and dairy products. Foods that require considerable handling during preparation and that are kept at slightly elevated temperatures after preparation are frequently involved in staphylococcal food poisoning.
Staphylococci exist in air, dust, sewage, water, milk, and food or on food equipment, environmental surfaces, humans, and animals. Humans and animals are the primary reservoirs. Staphylococci are present in the nasal passages and throats and on the hair and skin of 50 percent or more of healthy individuals. This incidence is even higher for those who associate with or who come in contact with sick individuals and hospital environments. Although food handlers are usually the main source of food contamination in food poisoning outbreaks, equipment and environmental surfaces can also be sources of contamination with S. aureus. Human intoxication is caused by ingesting enterotoxins produced in food by some strains of S. aureus, usually because the food has not been kept hot enough (60°C, 140°F, or above) or cold enough (7.2°C, 45°F, or below).

11 October 2002

Medication Error: Error Rates Double 1996-2000

Medication error rates in hospitals are well known to be the fourth leading cause of death in the United States. Outpatient errors are probably much higher than inpatient errors, although little data exists for outpatient studies in the literature. I have argued for years that the number of unnecessary deaths is increasing every year from medication error because more drugs are given and they have more dramatic impact on the patients physical system. This combined with nursing shortages and underfunding of information techologies to prevent these errors have doubled the rate of medication error from 1996 to 2000 in the study below.

Prescribing Errors Involving Medication Dosage Forms
Timothy S. Lesar, Pharm D
Journal of General Internal Medicine, Volume 17 Issue 8 Page 579 - August 2002

CONTEXT: Prescribing errors involving medication dose formulations have been reported to occur frequently in hospitals. No systematic evaluations of the characteristics of errors related to medication dosage formulation have been performed.

OBJECTIVE: To quantify the characteristics, frequency, and potential adverse patient effects of prescribing errors involving medication dosage forms .

DESIGN: Evaluation of all detected medication prescribing errors involving or related to medication dosage forms in a 631-bed tertiary care teaching hospital.

MAIN OUTCOME MEASURES: Type, frequency, and potential for adverse effects of prescribing errors involving or related to medication dosage forms.

RESULTS: A total of 1,115 clinically significant prescribing errors involving medication dosage forms were detected during the 60-month study period. The annual number of detected errors increased throughout the study period. Detailed analysis of the 402 errors detected during the last 16 months of the study demonstrated the most common errors to be: failure to specify controlled release formulation (total of 280 cases; 69.7%) both when prescribing using the brand name (148 cases; 36.8%) and when prescribing using the generic name (132 cases; 32.8%); and prescribing controlled delivery formulations to be administered per tube (48 cases; 11.9%). The potential for adverse patient outcome was rated as potentially "fatal or severe" in 3 cases (0.7%), and "serious" in 49 cases (12.2%). Errors most commonly involved cardiovascular agents (208 cases; 51.7%).

CONCLUSIONS: Hospitalized patients are at risk for adverse outcomes due to prescribing errors related to inappropriate use of medication dosage forms. This information should be considered in the development of strategies to prevent adverse patient outcomes resulting from such errors.

07 October 2002

Homocysteine, Heart Disease, and Alzheimer Disease

There are a lot of reasons based on published experimental evidence to worry more about homocysteine in heart disease than cholesterol. This month it looks like it is correlated with Alzheimer disease as well. Homocysteine is easily controlled by nutritional supplements, particularly B vitamins and folic acid. See Life Extension Foundation protocol.

Moderately Elevated Plasma Homocysteine, Methylenetetrahydrofolate Reductase Genotype, and Risk for Stroke, Vascular Dementia, and Alzheimer Disease in Northern Ireland.
McIlroy SP, Dynan KB, Lawson JT, Patterson CC, Passmore AP.
Stroke 2002 Oct 1;33(10):2351-2356

Background and Purpose- Elevated plasma homocysteine level has been associated with increased risk for cardiovascular and cerebrovascular disease. Variation in the levels of this amino acid has been shown to be due to nutritional status and methylenetetrahydrofolate reductase (MTHFR) genotype. METHODS: Under a case-control design we compared fasting levels of homocysteine and MTHFR genotypes in groups of subjects consisting of stroke, vascular dementia (VaD), and Alzheimer disease patients and normal controls from Northern Ireland. RESULTS: A significant increase in plasma homocysteine was observed in all 3 disease groups compared with controls. This remained significant after allowance for confounding factors (age, sex, hypertension, cholesterol, smoking, creatinine, and nutritional measures). MTHFR genotype was not found to influence homocysteine levels, although the T allele was found to increase risk for VaD and perhaps dementia after stroke. CONCLUSIONS: We report that moderately high plasma levels of homocysteine are associated with stroke, VaD, and Alzheimer disease. This is not due to vascular risk factors, nutritional status, or MTHFR genotype.