Kim Smith was no stranger to stress — her job in community corrections often brought her face to face with members of Winnipeg’s violent street gangs.
But as she lay in a local hospital’s gynecology ward more than a year ago, nurses called her brother with an unusual question: Did Kim suffer from any kind of emotional troubles?
The woman, her caregivers said, had been telling them she wanted to kill herself.
It was a shocking turn of events, coming a week after Ms. Smith entered St. Boniface Hospital for a routine hysterectomy and ovary removal. In the days since the operation, however, she had been complaining of escalating pain in her gut, so intense she began to fear for her life — and then apparently wanted to end it.
By the time medical staff took the woman’s complaints seriously, an infection inside her belly had developed into necrotizing fasciitis (flesh-eating disease) and devoured large chunks of her abdomen.
Within hours of emergency surgery to drain “brown, foul-smelling liquid” and excise dead tissue, and four days after her 45th birthday, Ms. Smith was dead.
“She kept yelling at me, ‘I know my body, I know there’s something wrong in my stomach and nobody wants to listen to me. And I’m going to end up dying here,’ ” said Kym Dyck, her sister-in-law. “She died the most horrible, painful death anybody could suffer, and nobody would listen to her and reach out to her.”
Ms. Smith’s tragic demise was more dramatic than many cases of hospital-acquired infection (HAI). Necrotizing fasciitis is a frightening, but rare, complication. Still, about 8,000 Canadians a year die from bugs they contract in facilities meant to make them better, while many more see their hospital stay prolonged by such illness.
Yet after years of well-intentioned work and millions of dollars spent on combatting the scourge, the details and extent of the problem remain murky.
No national statistics, for instance, document the number of surgical-wound infections like Ms. Smith’s, one of the most common types of hospital-acquired pathogens.
A federal agency now publishes rates of sepsis, or blood infection, at individual hospitals, but their methodological value is a matter of debate. Government tracking of worrisome, drug-resistant bacteria is patchy and of questionable practical use, say infectious-disease physicians.
“There is no question that at a national level, both our surveillance for hospital-acquired infection and our surveillance for anti-microbial resistance is not serving our needs,” said Allison McGeer, an infectious-disease specialist at Toronto’s Mount Sinai Hospital. “[And] we know, very substantially, that you can’t fix what you’re not measuring.”
Meanwhile, important lessons about how diseases spread inadvertently within health facilities often come to light in fits and start.
Two hospitals in Toronto and one in Quebec, for instance, announced independently in the late 2000s that they had discovered contaminated sinks were the source of separate, deadly outbreaks of infection.
Some word of the episodes got out through specialized medical journal articles, academic conferences and sporadic news stories. But there is no systematic way of disseminating such information across the system, said Darrell Horn, a former patient-safety investigator for the Winnipeg Region Health Authority.
“It’s just totally loosey-goosey,” he said.
You could sit and call every hospital in the country, and ask them when was the last time they cleaned the sink in the [neonatal intensive care unit] and how they cleaned it, and you’d get nothing but blank stares
“You could sit and call every hospital in the country, and ask them when was the last time they cleaned the sink in the [neonatal intensive care unit] and how they cleaned it, and you’d get nothing but blank stares.”
Health care is paying much more attention, at least, to the HAI problem than it did a decade ago, said Dr. Michael Gardam, infection-control director at Toronto’s University Health Network.
After heavy media coverage of the mostly hospital-based severe acute respiratory syndrome (SARS) outbreak and deadly hospital infestations of Clostridium difficile, said Dr. Michael Gardam, infection-control director at Toronto’s University Health Network.
As health-care-related infection became a very public affair, hospitals started hiring more experts, encouraging hand-washing and generally striving to prevent infection, rather than just treating it after the fact as an unavoidable cost of doing medical business.
Dr. Gardam’s hospitals have even begun characterizing hospital-acquired infections as adverse events, akin to more traditional medical error.
Whether because of such measures or not, Ms. Smith had few fears when she entered St. Boniface on Sept. 30, 2013, for an operation for uterine fibroids, her family says.
She likely did not know that most surgical-wound infections arise from bacteria patients carry into hospital on their skin, which can then sneak inside through incisions, especially when infection-control safeguards are not optimum.
As early as the day after her operation, the Métis woman began to complain of pain in her abdomen, only to be told by nurses that she simply needed to walk about, Ms. Dyck recalls.
Some of that suffering is reflected in her patient charts, obtained by the family and provided to the National Post.
On Oct. 1, she complained of gastrointestinal bloating and discomfort; the following day, heartburn, bloating and slight nausea, the records note.
On Oct. 3, the chart refers to her feeling unwell and weak, then projectile vomiting. The next day, she had “lots of gas pains,” and the day after that abdominal pain “controlled with PO” (prescription opioids).
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Finally, early on Oct. 6, came the call about her self-destructive thoughts.
“Nurse found her confused, half-naked, pulled her IV out anxious. Saying she is at her end and is suicidal,” the chart said. A later notation suggested anxiety was prolonging her recovery and the sedative Ativan was administered.
Then, sitting at her side 12 hours later, her brother Trevor Smith noticed a strange purple discolouring of his sister’s feet, the kind of “mottling” that can be a sign of imminent death, and raised the alarm.
Ms. Smith was soon being wheeled into the operating room, where the surgeons who opened her up first observed “a large effluent of brown, foul-smelling liquid from the abdominal cavity.” They removed several abscesses, drained the liquid, then discovered the worst — necrotizing fasciitis expanding through the peritoneum (the lining of the abdomen) and abdominal muscles.
St. Boniface declined to comment on the case, saying it was prevented from doing so by provincial legislation. But Ms. Dyck said one doctor told her staff had likely not adequately disinfected her sister-in-law’s stomach before the hysterectomy, ensuring any bacteria that came with her into the operating room stayed on the outside.
While not every surgical infection is preventable, “they can be dramatically minimized” with well-documented precautions, Dr. Gardam says.
If hospital infections are at least sometimes preventable, to what extent is the problem being monitored and how much of that information becomes public?
Some provinces, such as Ontario and British Columbia, require hospitals to report to the government on a few common infections, such as C. difficile, blood infections transmitted by the “central lines” used to access major blood vessels, and pneumonia from ventilator use. Ontario hospitals must report their compliance with tactics designed to prevent surgical infections, though not the infections themselves.
Experts debate whether publicly reporting data actually benefits health care, but a 2012 study found that C. difficile rates in Ontario hospitals dropped by 25% after the province started divulging statistics on the disease.
Many provinces, though, have no such requirements, and the national picture is hazy. The Canadian Institute for Health Information (CIHI) reports rates of sepsis, and stats that indirectly address infection, such as the rate of death and re-admission to hospital following some procedures.
Some infectious-disease specialists, though, are unimpressed by its infection numbers, obtained by analyzing hospital records after the fact.
“Garbage in, garbage out,” Dr. McGeer said of the figures. “You cannot count infections using CIHI data, and CIHI knows that.”
What is needed to paint an accurate picture is experts at each hospital reporting “true cases,” she says.
That is the goal of the Public Health Agency of Canada’s Nosocomial Infection Surveillance Program, arguably the country’s premiere example of transparency on the diseases that health care gives its patients.
The program’s focus is drug-resistant bacteria, the increasingly familiar methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci (VRE) and C. difficile. It is based, though, on a sampling of just 57 teaching hospitals, a fraction of the country’s 250 or so acute-care hospitals. The SARS outbreak, for instance, erupted at a community hospital that is not part of that network.
Infectious-disease doctors have long complained that it takes too long for the data those hospitals submit to the Agency to be posted.
“If I want to know what’s happening with MRSA, I call my friends,” said Dr. McGeer.
More complete, and easier to access, is the system developed by the European Centre for Disease Control, says Lynora Saxinger, an infectious-disease specialist at the University of Alberta. It not only tracks drug-resistant bugs, but matches those stats with the use — or possible over-use — of antibiotics, considered the main cause of the problem.
The latest concern of infectious-disease specialists is a class of antibiotic-defeating organisms known as carbapenem-resistant Enterobacteriacaeae (CRE), a “game changer,” said Dr. Saxinger. The death rate is as high as 50%.
CRE is part of the public health agency’s surveillance system, meaning those 57 hospitals submit their numbers, but Dr. McGeer said all acute-care hospitals in Canada should have to report them.
Meanwhile, “the last CRE outbreak … I heard about it on the news,” said Dr. Saxinger.
There is no evidence Ms. Smith was infected with a drug-resistant organism, but by the time she went in for emergency surgery, it appears little could have saved her. Indeed, once begun, necrotizing fasciitis has a 70% death rate.
Early the next morning, her blood pressure had sunk, the tell-tale black of more dead tissue had spread around her side to her back and she went into cardiac arrest, dying minutes later.
The hospital investigated the incident and assured the family that lessons learned from it would be passed on to staff — and help future patients, says Ms. Dyck. Mr. Horn says his experience across Canada suggests it is unlikely those lessons will be shared with anyone else in the health-care system, or the public.
Meanwhile, Ms. Dyck says the sight of doctors and nurses fruitlessly attempting to revive her sister-in-law — her abdomen left open as part of the flesh-eating treatment — remains etched in her mind, as is the thought it might all have been prevented.
“What I witnessed, I was traumatized by for months and months,” she said.
“It was just a terrible, terrible, painful death. And she knew she was going to die, that’s the worst thing.”