High rates of hospital-acquired infections at Stanford Health Care have caused Medicare to reduce payments to the hospital for the second year in a row.
Now, members of Service Employees International Union-United Healthcare Workers West (SEIC-UHW), the union that represents 1,800 employees at Stanford Hospital, claim the high rates are because of inadequate staffing and training, union members said during a press conference at Stanford Medical Center on Tuesday.
But hospital officials are disputing that assertion. They say the data is old and the union is using a strong-arm tactic to gain leverage during contract negotiations. The current contract expires in August, according to union spokesman Tom Parker.
The dispute over infection rates is focused on Stanford's Palo Alto campus alone, Parker said.
Union members said on Tuesday that the issue isn't just another ugly fight over a contract. They have been asking for more stringent changes and better staffing for a year.
"That is not a bargaining tactic," said Linda Cornell, a union member and 37-year patient-unit secretary. "We are not here today as a first course of action."
A Nov. 21 union memo to Suzanne Harris of Stanford Employee and Labor Relations shows that union members had been asking the hospital to address high-infection-rate and worker and patient safety concerns for at least several months. Two weeks ago, union representatives were to meet with hospital CEO David Entwistle to discuss the concerns related to the infection data but the hospital canceled the meeting, they said.
Stanford Health Care received a penalty reduction in reimbursements from the Centers for Medicare & Medicaid Services in fiscal years 2016 and 2017 after the hospital had higher than appropriate rates of hospital-acquired infections, including surgical site infection after colon surgery and abdominal hysterectomy; diarrhea-causing Clostridium difficile (C. diff), and catheter-associated urinary tract infections, among others, according to data from the Centers for Medicare.
The hospital-reported data was from 2016.
The Centers for Medicare Services' Hospital-Acquired Condition Reduction Program ranked 3,203 hospitals nationwide during fiscal year 2017 for their hospital-acquired infection rates and penalized 769 hospitals. Children's hospitals, VA hospitals and critical access hospitals, among others, are exempt from the reductions.
On a scale from 1 to 10, with 10 being the most severe, Stanford had an overall hospital-acquired conditions score of 7.85 in fiscal year 2017. Specific ratings that contributed to that score included:
- Central-line-associated blood stream infections: 7
- Catheter-associated urinary tract infections: 8
- Surgical-site infection: 10
- Methicillin-resistant staphylococcus aureus infection: 6
- Clostridium difficile infection: 9
In addition, the score includes the Agency for Healthcare Research and Quality Patient Safety Index (or PSI 90 Composite), which considers eight safety concerns, including pressure ulcer rate, postoperative hip fractures, postoperative sepsis, accidental punctures or lacerations, pulmonary embolism and deep-vein thrombosis (around time of surgery), among others. Stanford scored a 7.
Placing in the bottom-performing 25 percent of hospitals nationwide for hospital-acquired conditions, Stanford received a 1 percent reduction in Medicare reimbursements for each of the two fiscal years. The penalty for fiscal year 2017 runs from October 2017 through September 2018. Hospital spokeswoman Lisa Kim did not immediately know the equivalent in dollars.
Stanford maintains the figures represented by the union are outdated, coming from 2014 California Office of Statewide Health Planning and Development data that compared seven Bay Area teaching hospitals on one gastrointestinal infection, Clostridium difficile.
That data shows an infection rate at Stanford nearly double the rate for University of California, San Francisco Medical Center, which was the second worst of the other teaching hospitals.
Stanford instead pointed to U.S. Centers for Disease Control and Prevention's National Healthcare Safety Network metrics to show the hospital has greatly improved in recent years.
The Standardized Infection Ratio scores for C. diff, for example, showed rate of infection for the first quarter of 2017 is 0.871 cases per 1,000 patient days, which is better than the 1.0 benchmark, Stanford interim Chief Quality Officer Dr. Ann Weinacker said. That's an improvement over 1.09 in 2015 and 1.12 in 2016.
Weinacker did not provide scores for the other infectious disease rates that are also measured by the CDC's Healthcare Safety Network.
Data is submitted to the Safety Network monthly, Kim said.
"National Healthcare Safety Network is the only reliable source of these data because they provide training in standard surveillance methods. It's also the nation's most widely used healthcare-associated infection-tracking system," Kim said in an email.
Weinacker said that one reason Stanford's C. diff rate jumped in recent years by more than 100 percent is because the hospital began using new and much more sensitive testing procedures that are picking up more cases. The hospital began using the sensitive tests in 2012.
State data shows that Stanford first had a huge jump in C. diff cases in 2011, rising to 1.05 cases per 1,000 patient days compared to 0.30 in 2010.
Weinacker said the hospital has been tracking its data monthly so that staff can make adjustments to procedures. The hospital has signage for every room and pictograms of all precautionary procedures for a particular disease that staff and visitors must follow before entering a room, such as hand-washing and wearing a mask or a gown.
But the union claims protocol enforcement has been inconsistent, communication is poor and staffing is inadequate.
Nate Anderson, who has worked at the hospital for three years as a transporter bringing patients from the emergency room, said he was tested three times in one year for tuberculosis. Anderson said the tests came back negative, but he is still concerned about the potential for exposure.
"People come through the ER and we aren't told if they are suspected of having an infection," he said.
Anderson fears that as he moves from room to room or has passed patients and visitors in the hallways, he might be contaminating people. When patients potentially have a disease passed by droplets through sneezing or coughing, they should be wearing masks. Often they are not when they are handed off to him, he said.
"Everyone is confused about the proper protocol. Ask two different people and you get two different answers; ask three people and you get three different answers," he said.
Salyna Nevarez, a phlebotomist, said she worries on a daily basis about diseases she could bring home.
"About one month ago there was a patient with active TB (tuberculosis)," she said. The patient was placed in a unit where phlebotomists were exposed to the infected patient but not given any notice to take precautions. It wasn't until after she'd gone into other patients' rooms that management informed Nevarez that she had been exposed, she said.
Other employees said that housekeeping workers are put on a strict schedule of cleaning rooms that don't give them adequate time. Cornell said that housekeepers are given 28 minutes to clean a room of a noninfectious patient and 43 minutes to clean an isolation room. In addition, the cleaning staff must handle conference rooms, nursing stations and hallways.
"There is not enough staffing in all areas. They are under constant pressure. They are rushing to beat the clock," she said.
Anish Singh, a member of the Patient Companion Pool, which brings staff to sit with patients for up to eight hours a day, said he has also seen things left uncleaned because of staffing shortages.
Stanford staff said the number of housekeepers per bed is 98 to 100 percent of the industry benchmarks established by Vizient, a ranking organization.
Cornell and Nevarez also said because of hospital overcrowding, some infectious patients are placed in the hallways and are surrounded by screens, but they are concerned that the hallways might be contaminated.
Weinacker did not refute that some patients are placed in halls when necessary, but she said that every precaution is taken to protect them and others from being contaminated. The hospital also has an active control group that works to refine protocols.
"There are hours and hours of training for workers and managers to ensure how to protect themselves from potential infection. They receive in-person and online training. We take this very seriously," she said.
In a statement, Stanford staff said through the hospital's "escalation policy," all employees are encouraged to share concerns through established channels.
And although the hospital maintains the union's data is outdated, staff have shared the information with its quality department, which will conduct a thorough review of the information, Stanford stated.