Hospitals – Safe Harbor or Death Trap?

hospital_bedMuch of the annual $2 trillion spent on healthcare costs goes towards hospital care for chronic, degenerative diseases such as diabetes, cancer, heart disease and lower respiratory disease.

There is no doubt that hospitals are lifesavers when it comes to acute injuries and illnesses — things like gunshot wounds, accidents, burn injuries, poisoning, anaphylactic shock, stroke and heart attacks.  But the benefit curve changes when it comes to extended care of chronic illnesses.  This is where the risk of further injury, and even death increases.

According to a recent study involving 37 million patient records an average of 195,000 Medicare patients in the United States died due to preventable, in-hospital medical errors in each of the years 2000, 2001 and 2002  (Medicare hospital admissions accounted for 45 percent of the national total between the years 2000-2002).

In a previous study, the Institute of Medicine (IOM) estimated that around 98,000 people died unnecessarily from in-hospital medical errors in 1999.  That study estimated the national accidental, in-hospital death rate based on one years‘ data from just three states.

This latest study based its estimate on three years’ data from all 50 states and Washington DC, making its estimate more accurate.

So, what are the causes and nature of these 195,000 preventable deaths?

They are:

  • complications from anesthesia
  • death during low-risk procedures -DRGs (low mortality Diagnosis Related Groups)
  • decubitus ulcers (bedsores)
  • death during surgery for serious but treatable conditions
  • foreign object left inside body after surgery
  • accidental lung puncturing (pneumothorax)
  • infections related to hospital stay
  • postoperative hip fracture
  • postoperative hemorrhage or hematoma
  • postoperative physiologic and metabolic derangement
  • postoperative respiratory failure
  • postoperative embolism or deep vein thrombosis
  • postoperative sepsis (systemic infection of blood)
  • postoperative wound rupture (after surgical closure)
  • accidental puncture, lacerations
  • adverse blood transfusion reaction

The above are part of the 20 Patient Safety Indicators defined by the Agency for Healthcare Research and Quality (AHRQ).  These safety indicators have the notorious distinction of frequently occurring in hospitals.  You can think of them as “grim reapers” lurking around the hospital, waiting for a chance to strike.

The majority of accidental deaths in the study are associated with “low mortality diagnoses,” which are common, low-risk procedures such as a carpal tunnel release surgery or tonsillectomy.   A mistake by the surgeon, infection or unexpected complications often results in accidental death during an otherwise low-risk, relatively safe procedure.

195,000 accidental in-hospital deaths per year are like 390 jumbo jets crashing every day for one whole year.  This qualifies it as an epidemic like heart disease and cancer that warrants public health notices.  But for some reason, accidental in-hospital (nosocomial) deaths don’t get anywhere near the notoriety as heart disease and cancer.  Hospitals are still viewed, psychologically at least, as a place where one’s health is cared for; a place you go to heal and be freed of disease; not get injured or sick.  As previously mentioned, for acute illness it is certainly that place.  But for extended stays, its a different story.

The Dangers That Await You in Hospitals – A True Story

Let me tell you a story.  A relative of mine who we’ll call “Lou” was experiencing early stage dementia and chronic insomnia, but was otherwise in good health (no heart, kidney, liver or GI problems).  He was admitted to the hospital after experiencing sudden onset ataxia (loss of balance) and delirium.   Prior to this incident he was able to walk normally and engage in normal conversation, albeit with episodes of forgetfulness (he is in his early 80s).

Several hours prior to the incident he took four tablets of diphenhydramine, better known as Benadryl.  Benadryl is an over-the-counter anti-histamine commonly used off-label as a sleep aid since a common side effect is drowsiness.  But there are other side effects.   Delirium has been reported in elderly patients with mild dementia following a small oral dose of diphenhydramine (1), as well as abnormal voluntary movements (2).   This perfectly described Lou’s symptoms.  This manageable, adverse drug reaction initiated a cascade of unfortunate events, occurring in the hospital environment, culminating in tragedy.

(1) Tejera CA, Saravay SM, Goldman E, Gluck L “Diphenhydramine-induced delirium in elderly hospitalized patients with mild dementia.” Psychosomatics 35 (1994): 399-402

(2) Brait KA, Zagerman AJ “Dyskinesias after antihistamine use .” N Engl J Med 296 (1977): 111

The doctor ruled out stroke and attributed Lou’s behavior to the accumulation of decades of insomnia, complicated by “white matter disease” shown on MRI, which is associated with early stage dementia.

Lack of sleep in anyone, not just the elderly is known to cause the following:

  • Accidents
  • Forgetfulness
  • Lower cognitive ability
  • Decreased libido
  • Depression
  • Impaired judgment
  • Increased risk for heart disease, stroke and diabetes
  • Early death, across all causes

I know that if I was deprived of a good night’s sleep for more than ten years, I, too would be experiencing some of what Lou was experiencing.

Falling Deeper Into the Deadly Trap

The fateful day of his hospital admission marked the beginning of a gradual decline in Lou’s health.  He would not return home.

Upon being admitted to the hospital, Lou was given the drug Ativan, a benzodiazapene like the more well-known drug Valium.  This only served to further agitate him.  He became very combative with the nurses and repeatedly attempted to get out of his bed.  After that, his family requested that the doctor discontinue that drug.

Not one to give up, the ICU (Intensive Care Unit) doctor then prescribed the drug Seroquel (quetiapine).  This is a narcotic designed to treat bi-polar disorder, and as we would find out later is not (FDA) approved for elderly patients diagnosed with dementia psychosis due to increased risk of death.

Side effects of Seroquel include:

More common:

  • Chills
  • cold sweats
  • confusion
  • dizziness, faintness, or lightheadedness when getting up suddenly from a lying or sitting position
  • sleepiness or unusual drowsiness

Less common:

  • inability to sit still
  • loss of balance control
  • need to keep moving
  • restlessness
  • shakiness in the legs, arms, hands, or feet
  • shuffling walk
  • slowed movements
  • slurred speech
  • trembling and shaking of the hands and fingers

After a few days in the hospital, Lou came to and was closer to his pre-incident state.  He was more lucid; conversed with family members and able to walk with assistance.  Lou even cracked some jokes; signs of his old self breaking through the slurry of drugs that were coursing through his system.

Lou was then sent to a skilled nursing facility to help him regain strength in his legs.  However, they continued to prescribe Seroquel, along with melatonin to help him relax and sleep.   His agitation returned and became more regular.

With his aggression becoming too difficult to handle for the skilled nursing facility staff, Lou was referred back to the hospital.  The medications continued and were having less of an effect (hospital staff may have even increased his dose).  He was agitated, restless, delirious and was determined to leave his bed.   At this point, the ICU physician ordered the serotonin antagonist re-uptake inhibitor anti-depressant, anti-anxiety drug Trazodone, hoping it would calm him down since sedation is a common side effect.  Like Seroquel, this drug can cause orthostatic hypotension (light headedness/ dizziness after standing from a reclined or sitting position) especially in the elderly.

Side effects of Trazodone include:

More common:

  • blurred vision
  • confusion
  • dizziness
  • dizziness, faintness, or lightheadedness when getting up suddenly from a lying or sitting position
  • lightheadedness
  • sweating
  • unusual tiredness or weakness

Less common:

  • Burning, crawling, itching, numbness, prickling, “pins and needles”, or tingling feelings
  • confusion about identity, place, and time
  • decreased concentration
  • fainting
  • general feeling of discomfort or illness
  • headache
  • lack of coordination
  • muscle tremors

Believing they did all they could do, the ICU doctor scheduled Lou for discharge on a Friday at noon.  He was to be taken home.  Arrangements were hastily made for home care services and therapy visits.   Preparations were made to remove trip hazards at home.

Freedom Denied

The night before his discharge date Lou became combative again.  He somehow managed to get up from his bed and fell hard, striking his head on the floor.  The fall ruptured a cerebral artery resulting in a sub-dural hematoma, a large piece of coagulated blood inside the cranium.  He received emergency surgery to remove the hematoma, and since then has not regained consciousness.  The prognosis is very grim.

As I write this, poor Lou, who was admitted to the hospital for a manageable, adverse reaction to Benadryl was now fighting for his life.   All he really needed was a period of supervised rest and drug detoxification.  Should he pass away, this would be classified as a death from low mortality diagnosis related  groups (DRGs) since it was a non-life threatening condition that he was being treated for in the hospital.

Falls in hospitals are common, especially in the elderly, and result in significant injury and sometimes death.  It’s estimated that there are between 2-7 falls of patients for every 1,000 hours of hospital time.

I should mention that Lou had also been taking cholesterol-lowering drugs, called statins for many years prior to this.  Statin drugs are perhaps the most over-prescribed and harmful medication in the United States.  There is no convincing, scientific evidence to show that they protect against heart disease, either.  As statin drug prescription dramatically increased over the last twenty years, mortality rates of heart disease haven’t changed accordingly; approximately 610,000 deaths a year according to the Center for Disease Control and Prevention.

Incredibly, despite its popularity with doctors there are 900 studies that document adverse effects of statin drugs such as muscle pain and weakness (I strongly believe this contributed to Lou’s weak leg strength, which contributed to his fall), diabetes and increased cancer risk.

Some researchers believe there is a link between statin drugs and Alzheimer’s dementia, since all cells require cholesterol to maintain healthy membranes.  This is particularly important for highly specialized, active cells such as brain cells.   Cell membranes control what can enter a cell (nutrients) and what can exit a cell (waste products, enzymes, proteins).   Cell membranes also ensure proper hydrostatic pressure inside the cell so that internal components work properly.  You definitely don’t want to do anything that even remotely compromises your cell membranes!

Here’s another important reason why you don’t want to prevent your body from making cholesterol:  the sex hormones (testosterone, estrogen, progesterone); cortisol and Vitamin D are synthesized from cholesterol.  Statin drugs can impair their effects, causing a wide range of problems.   Unless your cholesterol levels are way off the charts, you are better off throwing those drugs in the trash and focus on diet, exercise and stress reduction to keep your cholesterol levels in the healthy range.

UPDATE:  On May 12, 2015 “Lou” passed away in a hospice, 18 days after his fall.  He was kept on life support for two weeks, with no signs of improvement.  He never regained consciousness after his brain surgery.

The Ongoing, Silent Travesty Against Elderly with Dementia

The over-drugging of our vulnerable seniors continues unabated.  Government inspectors say that Medicare officials need to do more to stop doctors from prescribing powerful psychiatric drugs to nursing home patients with dementia, an unapproved practice that has shockingly flourished despite repeated government warnings.

So-called antipsychotic drugs are designed to help control hallucinations, delusions and other abnormal behavior in people suffering from schizophrenia and bipolar disorder, but they’re also prescribed off-label to hundreds of thousands of elderly nursing home and hospital patients in the U.S. to pacify aggressive behavior related to dementia.   This hush-hush practice is called “chemical restraint.”  Anti-psychotic drugs like AstraZeneca’s Seroquel and Eli Lilly’s Zyprexa are known for their sedative effect, often putting patients to sleep– convenient for hospital staff; potentially deadly for the patient.

The problem is that atypical and conventional antipsychotic drugs significantly increase the risk of death in elderly patients who have a dementia psychosis.  “Atypical” antipsychotic drugs are the newest generation of mood altering drugs and include  risperidone (Risperda), olanzapine (Zyprexa), quetiapine (Seroquel), and aripiprazole (Abilify).  Conventional, or first-generation drugs are haloperidol (Haldol) and thioridazine.

At a medical conference in 2002, the FDA reported statistically significant deaths occurring in a sample of 1,452 patients with dementia in placebo-controlled trials of atypical antipsychotic drugs.  The placebo (control) group suffered 164.7 per 1000 patient-years, and the atypical and conventional drug groups had higher rates of 242.5 and 276.3 per 1000 patient-years, respectively.

On April 11, 2005, the FDA issued a health advisory warning of an increased risk for death with atypical antipsychotic drugs in persons with dementia.  These drugs now have this clear and specific warning on their packaging (called the “Boxed Warning”).

However, the message wasn’t loud enough.

Rampant Medical Insolence Unchecked

A 2010 report by the Inspector General of the Department of Health and Human Services (HHS) found that 83 percent of 2007 Medicare claims for antipsychotics were for residents with dementia, the condition specifically warned against in the drugs’ labeling!  Fourteen percent of all nursing home residents, nearly 305,000 patients, were prescribed antipsychotics that year, ostensibly for their “safety.”

The problem was so widespread and unchecked that the HHS recommended to the Senate Committee on Aging that nursing homes that continue to prescribe antipsychotic drugs to elderly with dementia be penalized.   But based on Lou’s case, it appears that this recommendation was ignored.  I would not be surprised if aggressive lobbying by the pharmaceutical industry blunted this effort.

As the problem continued to rear its ugly head, victims’ families fought back.  Two, recent civil lawsuits against manufacturers of antipsychotic drugs for false advertising (marketing unapproved uses to doctors; i.e. off-label uses) sent a strong message:

In January 2009, drugmaker Eli Lilly agreed to plead guilty and pay $1.4 billion for illegal promotion of Zyprexa, including marketing to nursing home doctors.  The company told its sales representatives to use the slogan “5 at 5,” to persuade doctors that giving 5 milligrams of the drug at 5 p.m. would make dementia patients sleep through the night.

AstraZeneca PLC paid nearly $529 million in two separate settlements with federal and state prosecutors over alleged off-label promotion of its drug Seroquel.  “AstraZeneca targeted its illegal marketing of Seroquel towards doctors who do not typically treat schizophrenia or bipolar disorder, such as physicians who treat the elderly, primary care physicians, pediatric and adolescent physicians, and in long-term care facilities and prisons.”

http://www.huffingtonpost.com/2011/12/01/elderly-dementia-antipsychotic-drugs_n_1123195.html

Sadly and tragically, despite these lawsuits and warnings it is evident that the practice of prescribing antipsychotic drugs to elderly with dementia psychoses is still going strong in 2015, ten years after that FDA warning.  My relative Lou is just another casualty of this ongoing, epic failure.   Thousands more will follow.

Lesson Learned

I’ve understood for some time that extended hospital stays and drug management of disease, which go hand-in-hand have dubious benefit and cause more harm than good.  The vast majority of drugs don’t cure; they suppress symptoms or unnaturally change your body chemistry/physiology in a way that temporarily and artificially arrests the advance of a disease process while creating a new set of health problems; oftentimes more serious than the original disease.

With Lou’s experience, it strikes close to home.

If you are faced with having to be admitted to a hospital for an illness, make it clear to your doctor that you wish to spend only the necessary time there and be discharged at once, after the danger has passed.  Tell your next of kin of this directive as well, in case you are incapacitated and can’t speak for yourself.   The numbers show that one’s home is safer than a hospital room where the chance of something wrong happening to you is much greater.

If you have a loved one, especially an elderly loved one get admitted to the hospital, the same rules apply.   Danger lurks in the form of adverse drug reactions, misdiagnoses, accidental falls, incompetent staff, botched procedures and nosocomial infections.  You do not want to be part of the 195,000 people who die accidentally each year in hospitals.  You don’t want to end up like poor Lou.

Posted in Preventive Health.