Inside the Health-Care Crucible
Reports from a hospital in a time of upheaval.
One hospital's simple measure to defeat infections
TOM GRALISH / Staff Photographer
Catherine “Pat” Zakrzewski, with husband, Henry, died last year from complications resulting from a hospital-acquired infection. He died months later. Their son, Kevin Zakrzewski, a primary-care physician who practices at Abington says, "We can't just think of this as 'infection out there.' To really create change, we had to understand this. That's what my parents' story did for the staff. It gave them a picture."
One in an occasional series.
Catherine "Pat" Zakrzewski of Roxborough was her family's matriarch, hosting 90 people - including 23 grandchildren and five great-grandchildren - every Easter, her favorite holiday.
But arthritis was crippling her - she could barely walk - so she decided four years ago to have her knees replaced at Abington Memorial Hospital.
"She sailed through surgery, rehab, and went home," said Kevin Zakrzewski, her son, a primary-care physician who practices at Abington.
But at home, a kneecap split, which happens from time to time, requiring more surgery.
Back in the hospital, Pat Zakrzewski acquired an infection, one of the worst kinds, MRSA, resistant to antibiotics.
What followed was a nightmare: removal of her new knee, amputation of a leg, and, ultimately, after a combination of 20 surgeries and hospitalizations, her death April 13 at age 77.
The hospital infection led to her death.
And "almost certainly," said John J. Kelly, the hospital's chief of staff, that infection was carried to her bedside "on the hands of someone in the hospital."
"She was a lovely woman, vibrant and energetic," said Kelly, who said he was at times in tears as he left her hospital room. "We failed in our ability to protect her from infection."
One could argue that the infection also killed Pat's husband of 58 years, Henry, who was holding her hand as she took her last breath.
"He died two months after his wife of a broken heart," Kelly said. "There wasn't anything wrong with him."
What happened to Pat Zakrzewski has happened at virtually every American hospital.
Nearly 100,000 patients die every year in the U.S. from infections they get in hospitals, according to the federal Centers for Disease Control and Prevention.
"None of us likes to believe these things happen in our hospital," said Kelly, Abington's top doctor. "And any hospital that says, 'It doesn't happen here,' is not being honest. . . . Our goal is to continually push down the risk of preventable harm."
A major cause of hospital-acquired infections, remarkably, is poor hand-washing.
Bacteria can travel from one room to the next on the hands of doctors, nurses, and technicians, much like bees carrying pollen. And weakened patients are vulnerable.
More than 150 years ago - before anyone understood germ theory - a Hungarian doctor, Ignaz Semmelweis, showed how washing hands in a Vienna hospital cut down dramatically on the frequency of infection.
Washing hands saved lives.
U.S. hospitals didn't forget that lesson from Semmelweis, but in the last few decades, with the increase in high-technology medicine, nurses and doctors came to regard infections as inevitable.
Tubes entering the body are ideal vessels to carry infection past the skin and the body's normal defenses.
"We used to accept infections as the result of medical progress," Kelly said. In the last few years, however, there has been a complete "frame change," he said. "We've moved away from this notion of inevitability."
A landmark Michigan study published in December 2006 in the New England Journal of Medicine showed the world that hand-washing and other safety efforts could nearly eliminate infections.
In 2005, Pennsylvania became the first of 27 states to require hospitals to report rates of hospital-acquired infections. (The health bills stalled in Congress would require it of all states.)
Pennsylvania's most recent report, covering half of 2008, shows Abington was in the normal range.