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When a Surgical Site Infection Sends a Friend Through Hell

 |  By cclark@healthleadersmedia.com  
   February 16, 2012

Once in a while, you hear a story that synthesizes all the talk about infection prevention and surgical checklists into a real-life horror that is as painful as it is urgent. That's when an arguably avoidable, and especially terrible, adverse event happens in a hospital to someone you know personally.

In this case, the patient is an editor and friend I worked with 15 years ago.

John Muncie is now a college journalism program administrator who lives with his wife, Jody Jaffe, on a Lexington horse farm braced against Virginia's Blue Ridge Mountains. But a few weeks ago, his life went from idyllic to horrific in just a few days.

Troubled with back pain from shoveling gravel and other ranching chores, on Nov. 28 he entered the brand new Martha Jefferson Hospital in Charlottesville for spine surgery. The $275 million facility's opening in August was a regional point of pride, with the facility's 177 beds set in soothing Craftsman-style architecture atop Pantops Mountain.

An elective, routine laminectomy with a 23-hour stay would fix his back, Muncie was told. He was discharged on schedule. Recovery proceeded until just before New Year's, when he became feverish, with renewed pain in his back.

Then the pain got worse.

Several calls to the doctor led to an MRI, but nothing conclusive. On Jan. 7, he was so sick he was rushed back to Martha Jefferson and readmitted.

Over the next 12 days Muncie was treated with multiple drugs—many of which failed—to see what worked as the lab tried to grow and identify the culprit bugs. He underwent two biopsies. A few days after readmission, he underwent a 2.5-hour surgery to remove an abscess that had amassed.

Later a propion acne bacteria and a candida-like fungus were confirmed.

"For those 12 days I was either writhing in agony, and crying—the first time I have ever cried in public—or drugged to the eyeballs on Dilaudid," Muncie told me.  He became drug-dependent. As the pain abated and dosages were reduced, he went into a drug withdrawal so frightening hospital personnel thought he was having a heart attack, his wife said. He was put back on Dilaudid.

"This was a psychological as well as a physical nightmare," Muncie said.

"Martha Jefferson doesn't deny that I got these infections at the hospital," said Muncie, who continues his recovery at home. "But what they do say, what all hospitals say, is that there's no way of knowing who's to blame." 

Muncie and Jaffe don't understand how hospital officials can say that. His life-threatening ordeal might have been avoided if appropriate infection control personnel and procedures had been in place, they say.

For example, Jaffe says her husband was never given a pre-surgical self-scrub kit that she now knows is standard.  And they say the hospital does not have a full-time infection control professional, which they think it should.

Michael Ashby, MD, vice president for medical affairs at Martha Jefferson, spoke with me at length about infection control practices at his hospital. He declined to discuss Muncie's case in particular, but he did say this:

"I feel awful that there was an infection after surgery at our hospital. And it's taken a re-hospitalization, a reoperation, and prolonged antibiotics. It's terrible. And I'm sorry."

However, Ashby insists that his community hospital appropriately preps all surgical patients before their procedures.

"Do we follow sterile technique? I believe we follow sterile technique.  Do we give them prophylactic antibiotics within an hour before incision? I believe we give them prophylactic antibiotics before the incision.  Do some patients still get infections?

"Unfortunately yes. And so yes, if I've done all that I know to do to prevent that—and this is a national discussion—how do we address that? I understand that for the individual, this is 100% and it's awful and it's expensive."

Martha Jefferson does monitor infection rates within its specialties, although it does not yet publicly report them, he continued. That day is coming. The hospital's relatively small surgical caseload means it doesn't have a good risk adjustment tool, although its recent merger with Sentara Healthcare may help integrate electronic data.

In recent years before and since the new building, Ashby said, Martha Jefferson has reduced rates of MRSA. It conducts root cause analyses when infections occur, and uses black lights and secret shoppers to screen for cleaning and handwashing protocols. And, he said, patients are asked to wash their skin with a Hibiclens kit, a chlorhexadine solution prior to surgery.

A nurse works part time in infection control to oversee procedures.

Muncie and Jaffe say much more can be done. They want tougher state and federal laws requiring infection disclosure, so the public can compare surgical infection rates for orthopedic procedures before they choose a hospital.  Martha Jefferson's central line infections are not listed on the federal Hospital Compare, which shows that the hospital has too few cases.

It's clear hospitals have a lot of work to do. According to a Centers for Disease Control and Prevention paper last month, hospitals reporting to the National Healthcare Safety Network had a 1.9% surgical site infection rate in 2006-2008 across 849,659 operative procedures.

"SSIs remain a substantial cause of morbidity and mortality among hospitalized patients," the CDC paper said. "In one study, among nearly 100,000 HAIs reported in one year, deaths were associated with SSIs in more than 8,000 cases."

And then there is the issue of who pays for Muncie's much-extended care. Muncie and Jaffe are outraged that they and their PPO insurance plan, Anthem KeyCare 15, are having to pay an as-yet-undetermined share, with his co-pay for continued IV clindamycin, the drug that finally worked, until he is fully cured, at $62 per day.

"We believe that if a hospital breaks it, they have to fix it for free," Muncie said.

That's the way it is with Medicare. As of fiscal year 2012, the Centers for Medicare & Medicaid Services rejects higher rate payouts to a hospital "for the sole reason of treating a beneficiary who acquires one of the conditions on the Hospital-Acquired Condition list during a hospital stay."

"Surgical site infection following certain orthopedic procedures," are included, as well as surgical site infection of mediastinitis following coronary artery bypass graft and bariatric surgeries.

Anthem spokesman Scott Golden declined comment, saying he didn't have Muncie's Health Insurance Portability and Accountabilty Act release. But he said in an e-mail that "not reimbursing hospitals for claims submitted as a result of a hospital-acquired infection is a policy change that we have made across the board. However, the change may not yet be reflected in all hospital contracts. The contractual language is being added to hospital provider contracts upon renewal of those agreements."

Muncie and Jaffe are trying to spotlight the issue with "John's law," which would legislate greater transparency of hospital infection rates as well as specify who should pay for them. If hospitals knew they couldn't get paid by private plans, or anybody else, for extra care their mistakes necessitate, they might be less likely to make them, Muncie said.

Muncie and Jaffe have yet to interest any legislators. But the Virginia Hospital and Healthcare Association, which represents hospital, health plan,  and doctor groups in the state, crafted this statement in June 2009:

"We are engaged in several initiatives to measure, report and support improvement in patient safety and care quality. However we recognize that despite these efforts situations and errors may occur while caring for patients that can have serious and sometimes fatal results.

"These events are tragic for all involved–patients, families and caregivers." There are inherent risks, the statement continues, "not all of which can be predicted or prevented.

"But when errors do occur and preventable serious adverse outcomes result, Virginia's hospitals and health systems believe that information about the error should be promptly and openly communicated to patients and their families, and that those financially responsible for the related healthcare service ­ patients, insurers or employers – should not be asked to pay for that care."

Doug Gray, the association's executive director who had heard about Muncie's case, said, "this is an issue that should fall in an area of discussion for non-payment. The golden rule is what we ought to be practicing. In this case, did they do what they could to avoid a surgical site infection?...If I were the hospital's attorney, I would be worried."

I hope my friend Muncie and his wife get through this ordeal quickly. Sometimes terrible events like this expose system flaws that zeal and transparency serve to fix.

"We want to save lives," Muncie said. We believe very strongly that if these safeguards were put into effect, these systems, these rates will plummet. And if the monetary system is also put into place that incentivizes hospitals to save patients, more people won't get infected during surgery."

Well said, John.

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