21,000 Consumer Reports readers rate the care they or a relative received. What we learned can make a critical difference for you.


 

The quality of care you receive during a hospital stay can determine how quickly and how well you recover--or if you recover at all. You might expect consistently good care to be delivered at almost every hospital in a nation with the world's top doctors, most advanced technology, and highest per-capita spending on health care. But when we surveyed and invited e-mails from Consumer Reports readers about their recent hospital experiences, we found enormous variations. They ranged from an Alabama man's smooth-sailing, lifesaving, $1.5 million liver transplant to an 83-year-old Tennessee man's death after a careless emergency-room staff sent him home without treating the broken bones and internal injuries he had suffered from falling down the basement stairs.

Just how dramatically the quality of hospital care can affect your outcome was driven home to one reader, Kate Parks, 25, from Denver, when she needed surgery twice in one month for a detached retina. Both surgeries were performed by the same doctor, but for scheduling reasons the two procedures took place in different hospitals, comparable in size and facilities. At the first hospital, it took so long for anyone to answer Parks' call for assistance when she awoke after surgery that she nearly fainted while getting out of bed to use the bathroom. In contrast, after her surgery at the second hospital, a nurse not only answered her call, but also discovered the reason for Parks' lightheadedness--low blood pressure--which she treated with extra intravenous fluids. "The first time, it took me at least two or three days after I went home before I felt OK again," Parks says. "With better care the second time, I felt much better, much sooner."

Robert Brook, M.D., director of the RAND Health Institute in Santa Monica, Calif., put the matter bluntly: "Most people will just go to wherever their doctor hospitalizes them. But the hospital you're in absolutely makes a huge difference."

If, like 55 percent of our survey respondents, you have a choice of which hospital to use, this article explains the information you need to select wisely and where to find it. If you don't have a choice of hospitals because you're admitted for an emergency or the hospital is dictated by your health plan or doctor, we explain how to work around problem areas to make sure you get the best possible care.

AT RISK FOR BAD CARE

AN ACCIDENTAL COMPARISONKate Parks' back-to-back eye operations at two Denver-area hospitals were performed by the same surgeon, but her experiences were very different. At the first hospital, "very harried and uncaring nurses," she says, neglected her comfort and didn't answer her call bell in time to prevent her from nearly fainting when she got up to use the bathroom. At the second hospital, with attentive nursing care and attention to small details, like providing enough pillows, she says, "I was hugely more comfortable and felt so much better, so much sooner." Photo by Jeff Stine

A total of 21,144 readers told us about their own recent hospitalization or that of a close family member. Those who were less than highly satisfied with their hospital--22 percent--complained more often of unanswered calls for assistance, inadequate pain relief, pressure to leave the hospital too soon, or recovery prolonged by complications caused by the hospitalization.

The remaining 78 percent of respondents were highly satisfied with their stay. Overall, readers rated their hospital experiences higher than our survey respondents have rated service in banks, restaurants, or hotel chains. But unlike most other services, the care you get at a hospital can have serious long-term consequences, so any risk of receiving substandard care must be taken seriously. Hospital studies show, for example, that your odds of dying of a heart attack or in the intensive-care unit in the worst American hospitals are two times greater than in the best hospitals.

So how can you tell whether your local hospitals are up to par? The experiences of our survey respondents, together with research studies and interviews with experts across the nation, helped us to identify three crucial factors: Sufficient staff (especially registered nurses), good systems for organizing care, and lots of experience with your particular medical condition seem to make the most difference in both patient satisfaction and recovery.

Interestingly, the type of insurance you have does not. In our survey, the experiences of patients whose bills were paid by health maintenance organizations (HMOs) were every bit as good as those covered by fee-for-service or preferred-provider plans. The only way in which HMO patients stood out: Their out-of-pocket costs were by far the lowest.

But the type of condition for which you are admitted does affect your risk of having a bad experience. People hospitalized for nonsurgical treatment seem to be more at risk for poor care than those treated surgically or in the hospital to have a baby. In our survey, people who received nonsurgical treatment for diseases such as respiratory illness, heart failure, or cancer reported more problems with pain relief and lower satisfaction with care than did patients who had surgery.

"People who come in for surgery have an idea of what to expect, and their care is coordinated by a team," explains Susan Edgman-Levitan, P.A., a fellow at Boston's nonprofit Institute for Health Care Improvement. "In contrast, most people on medical wards are older, with complicated, multiple, chronic conditions for which there isn't a predictable course of treatment." Those patients are often treated by a doctor who doesn't know much about them and who has to wade through a foot-thick chart to find needed information.

Patricia Seidle, age 36, who has insulin-dependent diabetes and severe heart disease, has almost come to expect uncoordinated care from the Pennsylvania hospital where she is a regular inpatient. "Every time I go in, they don't give me my insulin," she says. One time Seidle's blood sugar rose to 425 milligrams per deciliter (normal is between 60 and 110 mg/dL) before she was given insulin. Nonsurgical patients and their families need to be particularly careful to follow the recommendations below, which can help them work around hospital deficiencies.


FOR WANT OF A NURSE'

IN SEARCH OF PAIN RELIEFHospitalized for a week with a serious infection following arthroscopic knee surgery, John-Michael Kramer, 54, repeatedly endured long waits for pain medication. "The nursing care was so poor, they'd take 45 minutes to an hour to show up" after he asked for pain relief, Kramer recalls. To add to his troubles, he developed a herniated disc in his back, which he blames on a sagging hospital mattress. Photo by Cade Martin

Of all the factors measured in the Consumer Reports survey, satisfaction with care and attention from nurses, doctors, and other hospital staff members made the most difference by far in overall satisfaction. Moreover, only 2 percent of the survey respondents who reported attentive nursing care ended up with a serious health complication, compared with 8 percent of those who found it more difficult to get a nurse to help them.

Other evidence confirms our finding that the care that keeps patients happy also improves their health outcomes. The lower the patient-to-nurse ratio, the lower the risk of common hospital-related complications, such as urinary-tract infection, pneumonia, or gastrointestinal bleeding, researchers from the Harvard School of Public Health reported last spring in The New England Journal of Medicine. The study showed that alert nursing care made a life-or-death difference. Hospitals with ample nurse staffing had 9.4 percent fewer cases of cardiac arrest and shock than hospitals with lower staffing levels.

And the risk of death is directly related to a nurse's caseload. Every additional patient over four increases the risk of death following surgery by 7 percent, according to a study of 232,342 surgical patients in 168 Pennsylvania hospitals, published last fall in the Journal of the American Medical Association.

But just 60 percent of our survey respondents said unequivocally that their hospital was adequately staffed, and only 55 percent strongly agreed that nurses responded promptly to calls for help.

Michelle Kellett, of Rochester, N.Y., says when her grandmother was hospitalized, "The nurses had about 14 patients each." The staff were spread so thin that nurses failed to keep a written record of one of the medications her grandmother received, and they sent her home with a bedsore on her heel so bad that she spent three extra weeks in a rehabilitation facility.

This is not an isolated incident. The shortage of nurses--particularly registered nurses--and other staff at the nation's hospitals has reached critical proportions. On average, 13 percent of nursing positions at U.S. hospitals are unfilled, with some hospitals reporting vacancy rates of more than 20 percent. And the pressures of working in understaffed units is making hospital jobs less desirable. Hospital administrators report that despite strenuous recruiting efforts, higher salaries, and sign-on bonuses of up to $10,000, they are having more and more trouble filling their nursing positions.


HOSPITAL-CAUSED ILLNESS

 

ADVICE FROM AN EXPERIENCED R.N.After 16 years in nursing, Sylvia Steiger has plenty of ideas about how to improve your hospital stay. "My biggest piece of advice is to have someone with the patient to make those obnoxious demands," she says. Another tip: Bring a complete list of medications with you, including name, dose, and administration schedule. But she says the main quality variable is one patients can't control: the nurse-patient ratio. Photo by Kevin Poch

Even in well-staffed hospitals, care can suffer because of inefficient systems and poor communication. A 2001 study of health-care quality by the National Academy of Sciences said the mismatch between America's highly advanced medical technology and the chaotic system used to deliver it is "the medical equivalent of manufacturing microprocessors in a vacuum-tube factory."
The result: From 3 to 4 percent of hospital patients experience some kind of "adverse event" caused by medical error or mismanagement, major studies have found. In our survey, 12 percent of the respondents said they were aware of a medication error, misdiagnosis, or similar problem during their stay. For 5 percent of all respondents, such problems led to serious health complications.
Problems with medication delivery in hospitals have been well documented. For instance, in a study of 36 randomly selected hospitals in Georgia and Colorado, reported in the Archives of Internal Medicine, researchers directly observed hospital staff administering medications. They found mistakes--including staff forgetting to give the medication, giving an unauthorized drug, and giving a drug at the wrong time or in the wrong dose--in 19 percent of the doses given.
Six percent of our survey respondents reported developing an infection during or within one week of their hospital stay. Knowing a hospital's infection rate might be a good way to rate the quality of its care. But this information, though collected by hospitals and accrediting groups, is not released to the public.


IT STILL HURTS Inadequate pain relief is one of the most disturbing consequences of overworked and poorly organized staff. In our survey, 37 percent of all respondents, and 49 percent of the nonsurgical patients, reported suboptimal pain relief.

John-Michael Kramer, a 54-year-old government consultant from Maryland, ran into both organizational and understaffing problems when he was hospitalized for a week with a knee that had become severely infected following arthroscopic surgery. Rather than receiving medication on a regular schedule, a widely recommended procedure that would have kept his agonizing pain under better control, Kramer was required to ask for every dose.

"I'd hit my call button, but the nurses would take 45 minutes to an hour to show up," he recalls. "I finally hit on the tactic of calling the hospital switchboard and asking them to patch me through to the nurse's station on my ward."

Experiences such as Kramer's are the all-too-predictable result of nurse understaffing, says Patricia Rowell, R.N., senior policy fellow at the American Nurses Association. "When you're faced with a patient who wants a pain pill and another who is bleeding, the life-threatening situation is going to get attention first," Rowell says.

Better systems, such as making sure that doctors order pain medications in advance or that hospitals provide "patient-controlled analgesia" machines that enable you to safely administer your own pain medication, can reduce nursing labor and make prompt pain relief available.

"There are both medical and financial arguments in favor of treating pain," says Dennis Turk, Ph.D., a professor of anesthesiology and pain research at the University of Washington. "When their pain is well controlled, people get out of the hospital faster. When they have a lot of pain, they recover more slowly and with more complications." Yet deficiencies in pain control persist despite reform efforts and national guidelines developed by phalanxes of experts, going back two decades or more.


THE IMPORTANCE OF EXPERIENCE Along with good systems management and adequate staffing, the amount of experience a hospital or doctor has with a particular health condition seems to play a key role in the quality of care delivered. For many procedures and conditions, research shows that the more cases a hospital handles, the better the patients fare.

A 2002 study headed by John Birkmeyer, M.D., chief of general surgery at Dartmouth-Hitchcock Medical Center, found that the risk of death following surgery for pancreatic cancer--an especially difficult operation--is 360 percent greater at the lowest-volume hospitals than at the highest-volume ones.

In general, the experience of the hospital and surgeon are most important for uncommon, complicated, and inherently dangerous procedures, such as surgery for esophageal or pancreatic cancer, experts say. Most hospitals have plenty of experience with more common operations, such as hip replacement, breast-cancer surgery, hysterectomy, and appendectomy.

"If you're having your hernia fixed or your blood pressure dealt with, volume probably doesn't matter," says R. Adams Dudley, M.D., assistant professor of medicine and health policy at the University of California-San Francisco. "But if you've got an aneurysm in your brain or your kid has spina bifida, you're better off with a high-volume specialist."

For some surgeries, experience may not be a matter of life or death, but it still affects results. In prostate removal, for example, the mortality risk is fairly low, but the risk of bad functional outcomes, such as impotence and incontinence, seems to be lower with more experienced surgeons, notes Birkmeyer.

Fortunately, some hospital "report cards" now give consumers information on the volume of particular surgeries they perform.


RECOMMENDATIONS The nation's $450-billion-a-year hospital industry includes some 6,000 institutions employing more than 5 million people. All too aware of its shortcomings, the industry is constantly undertaking self-improvement programs. For instance, its powerful accrediting agency, the Joint Commission on Accreditation of Healthcare Organizations, announced last summer that all hospitals are required to have systems in place to prevent patient identification mix-ups and medication errors.

But you can not and should not rely on quality-improvement programs to protect you. Here are steps that patients and their family members can take to improve their chances of surviving and thriving after a hospital stay.

Make an informed choice. Among the most satisfied patients in our survey were the 20 percent who chose their hospital based on a good previous experience or because it had a good reputation. In a growing number of states and localities, it's now possible to judge hospital quality based not only on word-of-mouth but also on hard facts in publicly available hospital report cards that contain information on volume, mortality rates, and adverse outcomes.

For a list of available report cards and advice on how to use them, see Hospital report cards.

Just 30 of the respondents to our questionnaire said they picked their hospital based mainly on a public report card. "People aren't used to having this information, so they don't think to use it," says Judith Hibbard, Dr.P.H., a professor of health policy at the University of Oregon who is studying ways to make the report cards more useful and understandable.

The bad news is that report cards aren't available in all areas. Neither is information on several of the key factors we've identified. Hospitals don't routinely measure coordination of care, adequacy of pain relief, error rates, or functional outcomes.

Hospitals know the size of their nursing staffs. But, says Patricia Rowell, senior policy fellow at the American Nurses Association, "it's sensitive information that hospitals do not wish to share." The American Hospital Association collects annual information on nurse staffing levels, but this information is available only to customers willing to purchase a costly database.

Plan ahead. Most hospitals have clinical "pathways" for various conditions, and consumers should ask for a copy, says Edgman-Levitan, of the Institute for Health Care Improvement. "Then you know what to expect, and if something doesn't happen in the right sequence, you and your family can let someone know about it," she says.

Our survey respondents were generally satisfied with the presurgical information they received. And 97 percent said the surgeon explained the surgery in a way they or their relative could understand.

Advance planning is a good way to ensure postsurgical pain relief. After suffering excruciating pain during a stay in a Texas hospital following a total knee replacement, Consumer Reports reader Mary Stark Love, age 54, was determined not to have the same problem when the knee needed surgery again. "I researched pain management and talked with my surgeon about pain control, and he was totally sympathetic to my concerns," she says. The advance planning worked: Her pain stayed in check, and her recovery went much faster than after the first surgery.

Bring your own medical history. "I can't count the number of times I've admitted a patient to the hospital and asked them what meds they take, only to receive a reply like 'a blood-pressure pill in the mornings, a heart pill at dinner, and something for my arthritis,'" says Paula Estey, R.N., an Oregon intensive-care nurse.

In your wallet, carry an up-to-date list of your medication names and dosages; insurance information; names and phone numbers of your regular physicians; and key elements of your medical history, such as diabetes or a recent stroke.

Bring your own help. Patients, nurses, and national quality experts concur: Given the shortage of nurses, the most important thing to bring with you to the hospital is a reliable family member or friend to run interference for you.

"No one who is basically helpless--a child, a person with a cognitive impairment, a person who cannot ambulate, a person who is sedated--should be left alone in the hospital unless they are in intensive care," says Kathleen Maynard, a Florida nurse who saw her Alzheimer's-afflicted father through four hospital stays in three years. "I am speaking as both an R.N. and a family caregiver. Hospital staffing is so strained that patients do not get the care they need."

The job of the family caregiver can range from chasing down forgotten meals to alerting someone about a worrisome symptom. For example, when Kristen Fulton's father was hospitalized for pneumonia in Ohio, she and other family members took turns staying with him. They stepped in when a nurse brought him the incorrect medication. "I don't like to think what might have happened if one of us weren't there looking after him," she says.

Another option, elected by 2 percent of our respondents, is to hire a private-duty nurse as a "sitter" for times when family or friends can't be there. For a list of available nurses, try your hospital or local home-health-care agency. Be aware, though, that insurance rarely covers this service.

Know the staff, and make sure they know you. Keep a list of current doctors and nurses where both you and family members can see it. If you don't recognize the health-care professional at your bedside, ask who he or she is. Also make sure all staff members check your identification bracelet before giving medication or taking you away for a test.

Write things down. Keep a notebook at your bedside, accessible to you and your family caregivers. Write down information such as medication changes, questions for the doctor and notes about his or her visit, and any significant changes in your condition. Be especially vigilant during transitions from one type of care to another--from intensive care to a regular unit, or from a hospital to a nursing home, for example. Mistakes are especially likely to occur at those times.

Double-check your medications. Ask what the medication is before you take it; if you have doubts, insist that the staff double-check the order. Sylvia Steiger, a nurse from Wyoming, says she is never insulted when a patient does this. "Usually, the doctor has changed the medication or dose, and I am able to explain that to the patient," she says. "Rarely, I have read something wrong--I'm a good nurse but far from perfect."

Be assertive about pain relief. Ask your doctor whether you are eligible for a patient-controlled analgesia machine. If you're the caregiver, don't be shy about demanding that pain medicine be given on time; it's much more difficult to get pain under control once it has become severe. And don't forget that nonsurgical patients are often in significant pain.
Help nurses work efficiently. Find out when the hospital nursing shift changes, and try to avoid asking for anything complicated immediately after a new shift starts; nurses are especially busy then, catching up on their patients. "Batch nonurgent requests into one call-light summons," suggests Estey, the Oregon nurse. And don't be insulted if a clerk or aide responds to your call; his or her job is to separate requests that need nursing attention from those that don't.

Keep visitors under control."Well-meaning friends and relatives simply don't realize how tiring they can be, and the patient is usually too polite to say, 'I'm exhausted, go away,'" says Steiger. Keep down the number of calls that family members make to the nursing station; designate one contact person to call for updates on the patient's condition, and organize a phone tree.

Plan your discharge. You should start preparing for discharge practically as soon as you're admitted, says Edgman-Levitan. "Start talking to the staff about what you'll be able to do when you go home and what kind of services you'll need."

Under pressure from managed care, hospitals are moving faster than ever to discharge patients as soon as they no longer need intensive hospital technology and nursing care. Seven percent of our survey respondents said the hospital tried to discharge them or their family member before they felt physically ready to leave. It pays to be assertive. About half of our respondents appealed their early discharge, and of those, two-thirds were allowed to stay longer.

Before you leave, make sure you receive a formal discharge plan from the hospital that includes provisions for follow-up care, such as doctor visits, home care, or transfer to a nursing home or rehabilitation hospital. The plan should also give explicit instructions about medication, wound care, any limits on physical activity, dietary restrictions, and which symptoms are to be expected and which are cause for concern.