In additions, not all surgeries are created equal with respect to infection risk. Joint surgeries are some of the highest risk for infection. In fact, when doing open joint surgery, orthopedic surgeons will wear what looks like a space suit with helmet and air supply and work under a giant air suction device to keep the would from being contaminated. Add to that, that they were putting in foreign materials in the form of screws, and you have a recipe for disaster if there is the tiniest bit of contamination. As I have told my patients and medical students, a surgical infection is a life altering event. There is a good chance that you will never be the same after experiencing it.
I think this type of thing will be a bigger issue as we move forward. Surgical equipment is getting more intricate and more expensive. Everybody is pushing to cut costs. Having less equipment for a hospital is less capital costs, but more times that it needs to be properly cleaned, and every time you clean is an opportunity to screw up.
I think the ultimate answer might be taking the responsibility of sterilizing complex surgical equipment from the hospital to the manufacturer. Basically, the hospital would use the equipment once and send it back for reprocessing back to the manufacturer. For a lot of these surgeries, the manufacturer representatives are there at the hospital for surgeries requiring single use stuff likes screws, rods, artificial joints, etc so this would just add to the stuff they are bringing to the hospital anyway. It would be much easier for the FDA is o monitor and regulate a few reprocessing centers instead of every hospital. Simple equipment that you can just throw in an autoclave, can still be done by the hospital. Doing this would also force the manufacturers to think more about ease of cleaning since they would be the ones responsible directly for it.
Just my 2 cents.
In our hospital anything that came from a Rep, sterilized or not, HAD to be reprocessed as of it were used because there is no way to verify conditions between transport; humidity, height from floor/ceiling, biological incubation and results. On top of that sometimes Reps would only have a single tray but the doc would schedule 4 back to back caeses needing that set. Who gets the blame when it's not ready in time? Not anesthesia for putting the pt under too soon, not the doc for their inability to contact spd prior to scheduling cases, not the nurse for failure to check with the scrub, no it's the SPD staff.
Things like yankhauer and Poole suctions are impossible to clean; many packs come with disposable ones now. Hell, the vast majority of surgical equipment is disposable but hospitals are in the making money business and reuse is much cheaper. Many clinics in our hospital were unaware of how to reprocess their items and would turn in soiled items that sat all weekend covered in blood without any enzymatic cleaner; not to mention half their items were single use but are being treated as multi-use.
Man, I'm glad I moved to being an assist and even happier I left the surgical field in general.
What is it that makes such an infection is so impactful? Is there physical damage that persists, psychological trauma due to the experience, or some other factor?
Edit: Read the comments prior to reading the article.
> When Harrison awoke from that surgery, he imagined his nightmare was over. But in reality, it had just begun. Since then, what began as a simple operation has turned into a lengthy struggle that left him for months at a time dependent on hired nurses, unable to dress himself, take a shower, or work, and afraid for his life.
A few years ago there was an issue with this in Germany
Of course, my fear is that the contamination comes more from everything that's not the patient or the surgeon as it pertains to the surgery -- nurses, cleaning staff, etc. Every actor and entity in that chain needs to ensure sterility, so the screws would have to be sealed until opened, the cleaning staff would have to use these kinds of space suits (or clean remotely) and likewise for the nurses. Unless or until this all becomes possible, the whole system is not going to be set up for sterility.
I can imagine how an open joint surgery has a high infection risk for the patient. But how does it also impose a risk for the surgeon?
Can you expand on why that is? Do we know why joint surgeries are so problematic?
I had read that surgeons were moving into using disposable instruments because of the possibility of prion contamination (prions can't be destroyed by an autoclave). But maybe that was only for neurosurgery?
Why are the devices so difficult to clean? Why are processes in sterile processing units so chaotic? Why aren't decontamination errors being picked up by quality control?
It's never the fault of the guy on $8.50 an hour. The buck stops with management; the buck always stops with management.
How would you clean prions off surgical devices? This isn't a case of workers not bothering to use soap, you know.
Not really. Persistent problems are management’s fault. Individual errors are made by individuals.
All errors exist on a spectrum of foreseeability and severity. Is it foreseeable that someone might miss a spot when cleaning? Yes, clearly, even if they're exceptionally diligent and well trained. The odds of them making that error diminish with training, skill and care, but they never reach zero. How severe are the likely consequences of that error? In this case, someone could die of sepsis.
You can't just shrug and say "the guy who was supposed to clean the device didn't do it properly, it's not our fault". Why did that error happen? What could management have done to reduce the probability of that error? How could that error have been detected before a patient was put at risk? From reading the story, I think it's abundantly clear that many opportunities to reduce risk are being missed due to poor management of the process.
Managers also exist inside a structure, one which they may not have created themselves, or where they lack power to make unilateral changes. Managers also often work inside highly competitive environments (e.g. capitalism) where much deviation from the current norm can be disastrous for both the organization and themselves.
At some point, any practical moral philosophy needs to direct some individual to change their actions. Morality without responsibility is powerless.
Ultimately it's the CEO's responsibility to lead a culture of safety. If the current norm is causing death and illness, it's their moral duty to push back against it.
Not every individual mistake can reasonably be averted with changes to the system, but it's vitally important that we at least ask the question of how the system failed. Otherwise we're virtually guaranteed to wind up with a pile of "unrelated incidents" that might have been prevented at little to no cost.
Management should have no reason to expect high standards at those prices.
But when someone is earning $8.50 an hour, and the manager overseeing them earns $100 an hour, I know who is responsible for the work.
The notion that people with low wages can’t be held accountable for errors EVER is... not reasonable
Well, who manages that guy? Even if literally everyone but the CEO barely earns a living wage, and you end up with results like those, I still know who is to blame.
Just go up the chain until you find someone who is paid enough to shoulder responsibility, even if it means you have to go all the way up to upper management.
For the other cases without prions, normal sterilization works. And you don’t want to throw away all your equipment after each surgery. A neurosurgical power drill can cost around $20,000 - $40,000
Sub-sanitized instruments should not be a possibility given our current understanding of infections and their root causes.
In my case, I’d rather have one less test to confirm something, if it means I get to have my surgical implements experience one more run through the UV sterilizer or the autoclave before they are used on me. Better yet, why not use a whole new set of virgin tools following a time-proven blueprint?
They barricaded the roads and only let locals come in.
They told their people "Don't go to the white man's hospital." because you would go to the hospital for a fixable problem, like a broken leg, and die of ebola contracted at the hospital.
They quarantined the sick. You couldn't leave your hut. They would leave food on your doorstep to provide care. If three days food accumulated, they burned the hut down without verifying if you were dead or alive.
Antibiotic resistant infections and the like are partly a product of our modern mentality that tech can fix anything. Often, it can't. Old fashioned procedures still have their uses and we don't rely upon them enough.
It would be interesting to see whether these findings led to any improvements, although there's a good chance that many of the same individual pieces of equipment are still in use. In also curious whether some of the changes in Medicare reimbursement rates for return visits made any difference since they were targeted specifically at unplanned returns and complications (Modifier 78, https://www.emblemhealth.com/Providers/Claims-Corner/Coding/...).
I read several years ago about manufacturers sterilizing medical tools with radiation before they left the factory. I could imagine that the setup for doing that is too complex and dangerous for a regular hospital to run, but could it be offered as an outside service? Tools that can't undergo autoclaving could be sent out for irradiation after every surgery.
But this is very much not my area, so there are probably a hundred things wrong with my suggestion that I'm too uneducated to see.
Edit: Did some research, Gamma radiation can't kill prions.
That's one though SOAB.
Granted you could have a database and hospital customers could retrieve that information from there but what happens when they can't?
There are definitely places where the SPD process could be improved but outsourcing isn't a very handsome one.
The article by Consolidated Sterilizer Systems does reference an Oxford Journal’s opinion that there is no method of prion decontamination or sterilization that has proven 100% effective.
Interesting fact: Consolidated Sterilizer Systems is in the business of selling autoclaves, and at the end of the article there’s their lead collection form.
It’d be very unfortunate if future shows that financial interests of conventional sterilization equipment makers played a part in delaying the establishment of effective prion contamination management practices (which may or may not involve disposable instruments—being not an expert myself, I can only speculate).
If the manufacturers are not out in the field inspecting the devices and how they operate, how will they improve their designs in beneficial ways?
If the government regulators are not doing spot inspections of the equipment, how do they know they haven't made a mistake in approving something, or that a hospital has not trained people properly, or whatever?
If you're a patient, faced with these failures on the part of the regulators, the hospitals, and the manufacturers, what do you do? The whole system has failed here.
Last year I was in the hospital for 1 day and it cost me $10,000. What a travesty. How can doctors ever properly wash surgical tools with that paltry amount of money? Doctors and hospitals deserve better.
> A new Navigant study analyzed for-profit and nonprofit provider networks and found that the average operating margin declined by almost 39% over the same time span, from 4.15% in 2015 to 2.56% in 2017.
Contrary to your assumption, hospitals are about as profitable as grocery stores. It would be useful to introspect about that a bit, because I imagine many people have similar misconceptions. What was your assumption that hospitals are “extraordinary profit centers” based on? Do you think peoples’ attitudes toward hospitals might change if they knew the real facts? Does the truth change your attitude about who should go to jail?
In situations where large sums of money are vanishing on a continuing basis, Hanlon's razor ("don't attribute to malice what can be explained by incompetence") must reversed.
“In 2010, there were 2.1 million arthroscopic procedures of the knee performed and yet total adverse events from all causes was 1 percent.”
That’s all causes, not even 1 percent caused by contamination specifically, and does not tell us anything about how severe the AE was.
So yes by all means we should be testing cleaning instructions in real-world conditions and make sure instructions are clear and clearly followed.
But articles like this are part of the reason that hospital stay costs $10,000 in the first place.
One involved surgery and anesthesia. The other involved a pair of tweezers. Same price.
Add: Some people here don't seem to understand sarcasm.
I can't help but think that a similar law might not be helpful. Make doctors and hospital administrators randomly subjected to these devices in a mostly-not-invasive procedure where sterile water is flown over the devices and then onto a finger-prick.
In both cases making people have true skin-in-the-game is the solution to the problem.
The GP's proposal, while a bit over the top, would actually at least change the coffee talk between doctors from flaunting their last acquisitions (boats, cars, ...) back to medicine... if it would ever be put into practice. Suddenly they would conjure myriads of verification systems to ensure for example that their employer or stock manager wasn't secretly recycling disposables and having them repackaged...
Edit: spelling correction, thank you
Also, the way you're talking about seems super dismissive of these people, so it seems a lot more like a fancy way of saying you don't like or value doctors than a useful discussion.
Also, you seem to know a lot about cannons but not how the word is spelled.
This complicated scheme is used in order to ensure relatively balanced fields, which is important for wagering. If favorites are too heavily favored, then no one will bet. So, you can enter a horse worth $25k in a $10k claiming race, and you'll have a great chance of winning, but you'll also have a great chance of selling your horse for much less than it's worth.
The concept of "skin in the game" is fine, but I'm not sure this cascading infection scheme is the way to go. For one thing, physicians are rarely in charge of cleaning equipment. They have other expertise.
To be clear -- this mechanic (forced sale of vehicle) is not common in auto-racing. Very few sanctioning bodies do this, and they're all bottom-barrel (funding wise) groups like the Lemons endurance events or derby-style cars that aren't expected to have any longevity, anyway.
Also, that mechanic has been cheated numerous times. Since the Lemons series doesn't hold the car in escrow or in any other financially or legally binding manner it's up to the seller to be polite and abide by the rules. Plenty of people haven't. They're not usually welcomed back as drivers', they just move to another team and cheat there, instead.
The real way to do what you're trying to achieve (create a fair place for those with limited budget to compete in) in automobile racing is by strict classing rules and strict scrutineering. A good example of this is SCCA Solo autocross racing. It's extraordinarily cheap to compete in, and highly competitive. This is achieved through strict rules, tons of bureaucracy, and the threat of tattle-tales in the form of competing teams or drivers.
I don't know how that moral can be related back to surgery, but I do believe the Lemons' style of fairness-by-threat-of-sale is flawed.
Do you as an administrator attest that the instruments are clean? Perfect! We're going to use them on you.
Doctor, would you be willing to have this knife used on yourself? No? Well who better to get to the bottom of the problem than the people who can grind a hospital to a halt?
It is not OK to give a doctor HIV just because the maintenance people didn't service the machine correctly, causing it to output clean-looking but infected instruments.
a lot of people think increased discussion means bad news
it's not because a measure increases the amount of discussion that it can't be a good measure, if it helps unearth the actual problems
The point isn't to infect doctors. The point is to make them (potentially) subject to the tools they're about to use as a way to ensure that they are sufficiently involved in designing and overseeing the systems that ultimately move the needle on patient outcomes.
When things are done sufficiently well these kinds of steps aren't necessary. We don't make the engineering team that designs a bridge walk/drive across it first because bridges have an exceedingly low failure rate and the failures that do happen aren't infant mortality (you designed it wrong) they're old (you maintained it wrong).
It is self-evident that enough care is not currently taken on washing instruments. Or else we wouldn't hear about these kinds of things. If instrument washing was 99.9999% effective there wouldn't be a problem needing solving.
So what kind of feedback mechanism would be strong enough to get the doctors and hospital administrators to really be interested in the absolute level of quality of the cleaning and sterilization process? I don't know for sure, but I can say that anything that ties people's own personal outcomes to those of the folks they're supervising tends to get better results.
I (obviously?) don't want doctors or administrators to get horrible diseases for fun. What I want is for them to exercise an appropriate level of oversight and care.
I went to school for Electrical Engineering and while doing so I heard stories about people that went to work for GE designing things for MRI machines. Those people then were the first ones who had to test out the machines as people before they were allowed to be used on other people. I can't help but think that this kind of a policy makes people willing to double, triple and quadruple check their work when their own lives are on the line.
Similarly by making the people who should be exercising significant oversight (but seemingly aren't) subject to the results of the processes that they have designed it's very, very likely that they will do all the things that they need to do in order to ensure that their outcomes will be what we all expect: boring. That might mean that pay has to go up, or that minimum cleaning times need to be specified or that better inspection methods need to be utilized or any one of another dozen things.
If a doctor wouldn't be willing to use an instrument on themselves that they're going to use on another person I have a hard time understanding how they are adhering to their oath of "first do no harm" and I can't help but feel that anyone managing doctors should be similarly bound.
> Except when an important person or a doctor’s family member is on the table, that is. “They call and say, ‘Dr. Jones’ wife is having surgery,’”
So randomly forcing teams to be separated from their cars seems almost cruel. Like, how do we even know that the buyer has the expertise to maintain it or make it go faster? What if they can't even comprehend the technology, so they just run it till it breaks and then toss it on the scrap heap?
Danica Patrick won a single race (Japan) in her career of 116 IndyCar races and was eventually "retired" because she couldn't win often enough.