Hospital mortality rates

A wry pathologist once explained to me the reason for post mortem examinations. “Patients die,” he said, “for one of two reasons – patient failure or doctor failure. We ought to know which.”

Today we understand that many factors contribute to hospital outcomes. It is not just what a doctor orders or what a doctor does. Hospital outcomes are affected by the doctor working with the entire caring team, as well as by the effectiveness of hospital processes and support systems. Hospitals are complex places.

Last June the federal government's Hospital Compare website began reporting risk-adjusted 30-day mortality data for hospital heart patients.[1] The government’s report shows that 98.5% and 99.5% of all hospitals treating heart attacks and heart failure, respectively, had mortality rates that were consistent with the national rates.[2] Community General and the other Syracuse hospitals were all within the mortality rate mainstream of the nation’s hospitals.

The government’s website does not show hospital-specific mortality rates, and this lack of detail has been criticized by some. USA Today said that, by not listing hospital-specific death rates, the government’s web page “leaves 98% of the hospitals in the USA statistically indistinguishable from one another.” The newspaper also quoted a source at the Robert Wood Johnson Foundation as saying, “I would want to know if my hospital has higher death rates than the hospital across town.”

But others worry that mortality rates, even after statistical risk-adjustment, do not capture underlying differences that may be affected by patients’ own decision-making, particularly the end-of-life decisions made by the sickest patients. The authors of a recent article in the Journal of the American Medical Association (JAMA) suggest that the public reporting of hospital mortality rates might actually encourage the “overly aggressive treatment” of patients in their final weeks of life at the expense of effective pain control.

Several years ago, an insurance company published misleading mortality data about the pneumonia patients cared for at Community General Hospital. As reported, the pneumonia patients’ mortality was significantly higher at CGH than at other area hospitals. After investigation, we determined that the company did not take into account patients’ advance directives.[3] An examination of the records of the patients found that that 90% of the pneumonia patients who died had a DNR order.[4] In other words, most of the pneumonia deaths occurred among patients who had decided they did not want extraordinary measures used to prolong their lives. Of the non-DNR pneumonia patients cared for at CGH, the death rate was less than one percent. I discussed this situation in 2005.

Interestingly, JAMA reports that the federal government will likely add the mortality rates of pneumonia patients to its website in the future. According to the commentary in JAMA:

“Mortality is a good quality measure for individuals with acute illness who are not supposed to die…However, mortality is a poor quality measure for the majority of patients with multiple chronic diseases who are near the end of their life, and may be engaged in…decisions that result in an earlier (or less delayed) death.”

Hospital report cards are good things, and they will improve over time. As patients and families learn to use these report cards, they will become more informed about differences among hospitals – as well as about limitations of the report cards themselves.


[1] Risk-adjustment is a complex statistical process that takes into account differences in the complexity of patient conditions and differences in hospital service programs so that the mortality rates are, in fact, comparable among hospitals.
[2] The data reflect patients discharged from hospitals from October 2005 through September 2006.
[3] Advance directives are the written instructions patients give to doctors and hospitals that specify the care the patients want to receive (or don’t want to deceive) in the event they cannot make future medical decisions for themselves.
[4] DNR (“do not resuscitate”) is one form of advance directive.

Thank you, 95%

Community General Hospital has seen an increase in the percentage of hospital people (that includes doctors and employees) who comply with proper hand hygiene. In the first three months this year, we are averaging 95% compliance, compared with a 90% average in the past two years.

Three weeks ago I quoted a newspaper obituary for David Williamson Milne, a man who died in Kingston, Ontario on October 30, 2005. “The surgery was successful,” read the obituary.

Dave’s recovery was preceding well, thanks to the care of the [hospital] staff. Unfortunately, a series of hospital-acquired infections set back his progress and ultimately caused his premature passing.[1]

According to the Hand Hygiene Resource Center, “two million people become ill each year as a result of a hospital-acquired infection,” at a cost of some $4.5 billion. This week the Wall Street Journal reported “the rising alarm” that 90,000 hospitals deaths occur each year from these infections.[2] That translates to about 250 patient deaths each day! To put that number in perspective, last year CGH had an average daily census of 192 patients.

A review of 34 studies shows that “hand washing adherence among health care workers…varied from 5% to 81%” – with the average “only 40%.” Yesterday Sue Chamberlain, CGH’s Infection Control Program Director, told me there is a 1999 study by the Centers for Disease Control (CDC) that shows an average 54% of health care workers wash their hands as required. From this I conclude that the average hospital’s compliance is in the 40-50% range.

“‘It is no longer tolerable to accept noncompliance rates of more than 50% when we are dealing with critically ill patients,’” according to Dr. Don Goldman of the Institute of Healthcare Improvement (IHI) who was quoted in the Journal article. Dr. Goldman noted that computer-chip makers have better hand-cleaning performance than some hospitals.

At CGH nothing we do is more important than keeping safe the patients entrusted to our care. So I thank you for the increased vigilance that has boosted our hand hygiene compliance to 95%. We are at the very top of nationwide performance, ]something we should be proud of – and something very important for patients.

I do have a nagging question about the remaining 5%. Who would fail to wash hands and raise the risk of a potentially life-threatening infection for a patient in the next room, a colleague in the cafeteria …or for that matter, a loved one at home?



[1] “A Tipping Point,” CGH Family Letter, March 18, 2006.
[2] “Hospitals Get Aggressive About Hand Washing,” Wall Street Journal, April 5, 2006

A tipping point

“Some day, we may look back at this and say it represented a tipping point in public consciousness.”

That is a message I received yesterday from my colleague Peter McGinn, PhD, who is the President and CEO of United Health Services in Binghamton, NY. Peter copied me on an e-mail that he sent to his staff about an obituary that appeared in a Canadian newspaper five months ago.

In reprinting the obituary, I repeat Peter’s words to his staff: “Please read this very carefully – all the way through.”

On October 30, 2005, David Williamson Milne passed away at Kingston General Hospital after a battle with hospital-acquired infections. He was loved and is deeply missed by many.

David Milne was the kind of person that you got to know, and like, quickly. His friends were among society’s small and society’s great, and he treated each with equal respect and appreciation. His Scottish humor and laugh were infectious. Even in his last days he could make us laugh.

His family was the joy of his life and sustained him throughout. As the youngest of a large Manitoba farm family, he was his mother’s joy and primary recipient of her loving largess. He wedded his first love and childhood sweetheart, Catherine, who followed him from posting to posting, with one and then two children, Catherine Jr. and Jacqueline.

As a long-service pilot in the Canadian Armed Forces David Milne’s life was not without risk, but risk balanced in an equation with skill. His heart surgery was a risk, but it was balanced against the outstanding skill of Dr. Hamilton at Kingston General Hospital. The surgery was successful and Dave’s recovery was preceding well, thanks to the care of the KGH staff. Unfortunately, a series of hospital-acquired infections set back his progress and ultimately caused his premature passing.

Every year hospital-acquired infections cause or contribute to the death of more people than breast cancer, heart disease, and car accidents combined. Most of these infections are initiated by otherwise caring healthcare workers who forget or neglect to clean their hands.

And for each of those who, like our friend David, succumb to one of these unnecessary infections, there are many more who ache for their loss. These are not numbers on month-end reports. These are our fathers, our mothers, our children, and our dear friends, who are dying prematurely because of unclean hands. The little bit of extra time that it takes for healthcare workers to wash or to use an alcohol sanitizer is pittance compared to the waste of so many productive, loved and loving lives.

In honour and memory of David Williamson Milne a donation will be made in his name to the Community and Hospital Infection Control Association of Canada. His family and his extended group of friends openly urge those at Kingston General Hospital as well as healthcare workers everywhere to clean their hands before and after every patient contact. It is absolutely a matter of life and death.

Farewell to a dear husband, father and friend.