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Hospital Superbugs

The invincible “attacker”

SUPERBUGS are bacteria that are resistant to multiple kinds of antibiotics—making treatment a challenge.

I find it unbelievable that my father contracted six types of bacteria during his six weeks of hospitalisation. The sad truth is that healthcare providers are fully aware that most patients (particularly the elderly patients) will ultimately contract superbugs and die from infections, pneumonia and sepsis when they stay long enough in the hospitals.

Does it constitute medical negligence when public hospitals fail to enforce adequate infection control procedures?

“Tie renewals to hygiene” (ST, 20 Apr 2009)—the *Health Minister said that hospital stallholders which do not get the top ‘A’ or ‘B’ ratings may be told to close shop. Such a stern action was prompted by the two “Indian rojak” deaths. In May 2010, the rojak seller was given the maximum fine of $9,000.

Thinking aloud, numerous lives have been lost to superbugs and hospital-acquired infections. Yet, healthcare providers go scot-free.

Why didn’t MOH think of implementing the first “Singapore hospital hygiene/infection control grading system” in order to achieve clean and bug-free hospitals?

In some public hospitals, it is a major drawback that isolation wards are not properly equipped to look after critically ill patients with hospital bugs, coupled with the problem of insufficient isolation wards. Ironically, all public hospitals in Singapore have received JCI accreditation.

The hospital did not have an isolation room for my father—a major setback in their delivery of medical care to the critically ill patients; the “watchdog” is sleeping!

I would also like to share my observations on infection control procedures adopted by the various ICUs, MICA and Class B2 wards in the hospital.

The basic procedure––visitors are required to wear masks, gloves and gowns before going into the patient’s room/ward, and to remove them and wash their hands before leaving the patient’s room/ward. Healthcare workers have to do likewise.

SICU: On 23 August 2008, my father stayed in a dual-bed room (with an open entrance) where all visitors can enter the room to wash their hands using the common wash basin in it, after visiting isolated patients in the SICU. I told one nurse clinician that such an arrangement poses risks to the two patients because the visitors of those isolated patients may bring the bugs into this unprotected room.

On 11 September 2008, my father was transferred to the SICU as there was no available bed in the MICU. This time, he stayed in a single-bed room because he had contracted superbugs. I noticed that some doctors did not comply with the basic procedure.

MICA: For patients with hospital bugs, their visitors are required to wear masks and gloves, and practise good hand hygiene, whereas visitors of those patients who do not have hospital bugs,  need not comply with infection control procedures. The MICA is a small air-conditioned room with five beds, and I wonder if such infection control procedures are helpful at all. In most instances, healthcare workers did not adhere to it.

B2 ward (Respiratory): No infection control procedure was enforced except for the bed management policy that my father had to be given a bed near the window.

B2 ward (Internal Medicine): For patients with hospital bugs, their visitors have to adhere to the basic procedure but it will not apply to visitors of those patients who do not have hospital bugs. It is a small non air-conditioned room with six beds, and I wonder if the basic procedure is helpful at all. In most instances, healthcare workers did not comply with it.

During hot days, it can be quite uncomfortable for healthcare workers to don their gowns in a non air-conditioned ward. My father told me that one staff nurse removed it while attending to him––she told him that the heat was unbearable.

I also noticed a cohort of six patients (MRSA) in one of the rooms but the room was not insolated, and the patients were looked after by the same team of healthcare workers.

Hospitals must recognise that unclean hands, contaminated equipment and lax procedures are the key obstacles to achieving effective infection control. (Note: The spores of C. difficile cannot be destroyed by hand gel/alcohol gel.)

What struck me most in her book was that despite all the measures in place in our large hospitals, incidences where patient safety are compromised occur, and often on a daily basis. At work, we go through training on proper hand-washing, are instructed on exactly how and when we should put on our gowns, gloves and masks right down to the smallest detail; bed management units are given protocols on where best to place infectious patients; we are constantly reminded by signs in the hospital about proper hand hygiene; projects with the aim of reducing hospital acquired infections are awarded grants and are carried out. In spite of the multitude of efforts – patients still catch nosocomial infections. Does this mean our practices are wrong? Or are we still not doing enough?

Ms Lee details what happened during the hospital stay as well as how she spared little effort in trying to understand how her father’s death occurred after the fact, writing many letters to the Ministry of Health as well as to the hospital, often without any satisfactory replies.

"Writing a letter of complaint can be a daunting task, especially for those who are “interacting” with the public hospital system for the first time. Usually it can only be done by family members who are pro-active and have looked after the deceased person throughout the latter’s hospital stay in order to witness/experience and complain about the poor delivery of medical care.

From my experience, it was really a long-drawn process in trying to get an accurate account of my father’s death. It took nearly a year for me to get the final reply from the hospital.

First letter: No reply.

Second letter: Reply came five months later.

Third letter: Reply came six months later.

The last reply was received in early October 2009. Again, the hospital failed to address those crucial questions and did not release the results of the blood culture, the stool C. difficile toxin test and full blood count; and the readings of vital signs from 11:30pm (1 October 2008) to the time of my father’s last breath at 4:40am on 2 October 2008.

There is no closure for me, and the cause of my father’s death remains an “unsolved mystery”—“What Killed My Dad?” Some friends feel that it was my father’s fate to die in this manner. Another friend reckons I can find the answers in my father’s Nadi leaf. My reply to them: “If I have been a firm believer in destiny, I would not have written this book. The sad truth is that my father had an unsafe hospital stay.”

In a recent survey carried out in the United States, the findings are as follows:

• More than half of the doctors surveyed said that they have been involved in a serious medical error; and

• 50% of the people surveyed said that they or a family member have been a victim of a medical error.

Do we have such statistics readily available in Singapore? Are our healthcare workers and administrators (as fortunate as our former Health Minister, and those who do not have relatives dying from poor delivery of medical care) able to play their roles effectively without experiencing the “dark side” of the public hospital system?

A passionate healthcare worker wrote:

“It is a matter of time that healthcare policymakers and workers run out of good fortune and good luck. Based on a survey published by the Commonwealth Fund in 2006, a sicker adult will have a one-in-five chance of experiencing an error.”

Ms Lee's book tries to make sense of how hospitals can turn into dangerous places by highlighting a few shortfalls of our public healthcare system. Singapore’s healthcare system is in constant flux, as can be demonstrated by a forever changing structure and the emergence of so many health systems. In a short time, we have moved away from the two-cluster system – National Healthcare Group (NHG) and the Singapore Health Services (SingHealth) to a pyramid model, anchored by Regional Hospitals. This change was effected in April 2008, and allows Regional Hospitals to have more autonomous control over how they operate. It has also resulted in the development of a completely new health service, Jurong Health Services, which will serve the population living in the west of Singapore.

Our public hospitals are run as private companies, and receive an annual government subvention or subsidy for the provision of subsidized medical services to the patients, and are managed like not-for-profit organizations. All seven hospitals in Singapore are Joint Commission International (JCI) accredited.

Increasing healthcare services ideally improves healthcare provision for our ever-growing population, and an ageing one at that, but only if its expansion and growth is managed well. One issue, which is pressing, is the sheer lack of manpower to run these expanding services and growing hospitals. Our hospitals run on a lean patient to nurse ratio, and nurses are often asked to work back-to-back shifts, often miss their break times and to put in extra hours just to complete their tasks. Many nurses also undertake continuing education, and rush off for lessons at the end of their shift. Doctors are on-call very often, working for up to 48 hours without a break and junior doctors can sometimes find themselves working without a senior to consult with. Allied healthcare professionals are also in short supply. Our healthcare workforce is heavily supplemented by foreign staff, who are usually hired on 2-yearly contracts.

In 2000, the World Health Organization ranked Singapore’s healthcare system top in Asia and sixth in the world.  With the recent restructuring and massive changes to the health system, it will be interesting to see if our healthcare system will be able to maintain its position.

Ms Lee’s hope is that individuals from within the public healthcare system will champion the cause for patient safety in Singapore.

“I got to know your book while attending a Patient Safety Course. What you have written really touches my heart. It is really a good book to read and share, and it will constantly be kept with me—reminds me, always to be a patient advocate. What touches me most is that you gave me the ‘smartchips’ thingy!! It will definitely be kept with me to strengthen my passion—caring for the sick.” - Healthcare worker (April 2010).

How can one advocate for patients here in Singapore?

Quote from “Ethics and Healthcare: Patient Advocacy and its Role in Singapore”, SGH Proceedings Volume 17 Number 1 2008:

“Despite a call for an initiative towards patient advocacy in 2000 to assure patients of appropriate and optimum care, there has been little literature available on the practice of patient advocacy on a microsocial level in Singapore. There are no trained independent patient advocates in hospitals, and the views of healthcare providers on the role of patient advocacy remain uncertain. The understanding of Singaporean patients of advocacy also remains questionable. It may be that many patients are not as yet prepared or ready for greater autonomy, and are unwilling to exercise greater accountability and responsibility for their own healthcare.”

Knowing your rights as a patient makes a big difference. All hospitals, as part of being JCI accredited, will have clearly stated patients’ rights and responsibilities, often as posters and on their websites. You may also request for an appointment with a medical social worker for counseling, and all hospitals have a quality assurance unit where feedback will be welcomed.

Adjusting expectations during hospitalization may be necessary. Not everything is a nurses’ job. I have met many patients’ family members who do not touch their loved one, even to wipe their tears, as it is seen as a nursing task because they have ‘paid for it’.

Being aware and educated on changes in the healthcare system, working towards better representation for those who are unable to speak up for their rights can make a difference.

And finally, consider devoting your career to one in healthcare. We need more people who are passionate enough to give up their time and energy in serving our fellow man. It does not pay as much as it should, and the sacrifices are plenty, but a good healthcare system cannot exist without people who care about other people.

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You can find Lee Soh Hong’s book in the National Library of Singapore.

1. Lee, Soh Hong, 1962 - What killed my dad? : are hospitals safe (2011)

2. Lee, Soh Hong, 1962 - Are hospitals safe? : what killed my dad (2009)

3. Lee, Soh Hong, 1962 - What killed my dad? : reflections on how to make your hospital stay safer (2009)