Why You Need Informed Consent

Here's how to handle this important conversation
about the tests and treatments your doctor recommends

Consumer Reports / By Orly Avitzur, M.D. / August 07, 2017

A fter seeing an ear, nose, and throat doctor for ear pain and congestion, my 21-year-old son was told to come back 2 hours later for “some testing.”

When he returned, no physician was present, and he received no explanation of why the testing (which turned out to be allergy testing) was ordered, how it would be conducted, possible side effects, or available alternatives.

Had that discussion—which is called informed consent—taken place, my son would have simply told them that he’d had allergy testing two weeks earlier.

Informed consent is important to consumers' health for many reasons. Unfortunately, it's also one of the most abused and misunderstood concepts in medical care today. That's why it's important to be truly informed about informed consent.

What Is Informed Consent?

It's intended to be a conversational process when your clinician explains the risks and benefits of a specific test, procedure, surgery, or other treatment.

During this talk, your doctor should also outline other available options and make it clear that you are helping make decisions about your care. You then confirm your understanding of what you’ve been told and agree to—or reject—the doctor's recommendation.

Today, however, some doctors have become far too casual about this process. Instead of a shared discussion, the goal in some cases has shifted to getting you to sign a piece of paper called a release. With your signing, a doctor or hospital feels legally protected in case something goes wrong.

For your consent to be considered valid, it must be voluntary. But most people feel uncomfortable—even intimidated or coerced—when a doctor asks them to sign a release. So they might not speak up, even if they have concerns.

When It Should Happen

Your doctor should initiate an informed consent discussion if he or she recommends anesthesia, surgery, or any invasive procedure (one that “invades” the body, usually by piercing the skin), or if you are asked to be in a clinical research trial.

There is no national consensus on when informed consent is required. It varies from state to state and can be influenced by a doctor or hospital’s interpretation of recommendations from professional and specialty groups.

Those interpretations are not always correct. For example, the American Academy of Allergy, Asthma & Immunology’s sample informed consent form for allergy skin testing notes that a physician or other healthcare professional will be on hand because “occasional reactions may require immediate therapy.” That didn’t happen in my son’s situation.

How the Discussion Should Go

During informed consent, your doctor should explain the procedure, test, or treatment in plain words and without medical jargon—and tell you which roles each healthcare provider plays.

This should be a thorough verbal discussion—a release form should serve as a supplement to this, not a replacement. In fact, the form should merely confirm that the discussion took place.

A good informed consent discussion also uses decision aids, interactive media, or digital tools. It should include information from medical studies, best practices, and clinical guidelines. Your doctor should pull in a qualified medical interpreter, if needed, and allow for assistance for limited English proficiency or hearing or visual impairment.

Making Sure You Understand
During an informed consent talk, you should be able to take notes, bring along a friend or family member, ask questions, get clarifications on anything that’s unclear, and have time to consider your options before you decide. Afterward, it’s useful to summarize back the highlights of what you heard.

If you feel rushed or ignored, ask whether the decision on the proposed test or treatment can be delayed until your doctor can answer your questions fully. (In emergencies, or if you are unable to communicate, informed consent may not be necessary.)

Remember, if you’re uncomfortable, you have the right to say no.

Editor's Note: This article also appeared in the September 2017 issue of Consumer Reports on Health.

Are you willing to be a Choosing Wisely Champion?

http://consumerhealthchoices.org/champion/

Nominate Yourself or Someone Else to Become a

Choosing Wisely Champion!

Consumer Reports is launching a nationwide search to recruit and recognize Choosing Wisely Patient Champions, some of whom we will train to become volunteer activists for the Choosing Wisely campaign. Think you might be one or know one? If so, the details are below, and we’d love to hear from you!

1. Why Choosing Wisely, and what is it?

• Some medical tests and treatments provide little benefit to patients. And in some cases, they even cause harm. Choosing Wisely, a long-running national campaign, promotes conversations between providers and patients with a goal of making sure everyone’s care is as safe, useful, and affordable as possible.

2. Who is a Choosing Wisely Patient Champion?

• Someone who asks their healthcare provider questions to find out if certain medical tests or treatments really are needed – or if there are other options;
• Someone who encourages their friends and family to do the same; and
• Someone who understands that more care is not always better care.

3. Who can be a Patient Champion?

• Almost anyone, including a patient, parent, or caregiver – though you must be at least 18 years old. We are looking for everyday people.
• You cannot be a Patient Champion if you are a healthcare professional (such as a doctor, nurse, or medical student).

4. What does a Patient Champion do?

• Works with Consumer Reports to publicize your story online, in our magazine, via social media, and/or possibly in other ways, such as regional and national conferences; and
• Spreads the message of Choosing Wisely and the importance of talking about overuse with others, and encourages them to share their stories with Consumer Reports; and possibly,
• Considers joining a team of activists by attending and completing the Consumer Reports Consumer Leadership Academy (online and by phone), to learn how to effectively change our culture of medical overuse.

5. What is the nomination process?

• Nominate yourself or someone else by filling out the nomination form. We may contact selected individuals for more information.
• Nominations will be reviewed by a doctor, a patient advocate, and staff from Consumer Reports and the ABIM Foundation to choose 25 champions to be trained as the first group of activists.
• Nominations must be submitted by April 30, 2017.

Please use the form below to nominate yourself or someone else to become a Choosing Wisely Champion. You can also print and complete this form and mail it to us.

More questions? Contact us at HealthImpact@cr.consumer.org.

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Choosing Wisely turns 5!

Happy 5th anniversary to the

#ChoosingWisely campaign

The Choosing Wisely campaign turned 5 on April 4, 2017, and we’re doing all we can to celebrate smart conversations between patients and providers:

1. Seeking Choosing Wisely patient champions.
2. Publishing stories from healthcare providers.
3. Releasing a new video.
4. Tweeting about it.
5. Doing a little dance.

Meet the Consumer Reports' Choosing Wisely team (left to right):  
David Ansley, Yelena Dasher (no longer with us), Dom Lorusso,
Claudia Citarella, Beccah Rothschild

For 5 years Daniel Wolfson (ABIMF) @WolfsonD 
& Tara Montgomery @TaraCivicHealth 
have provided stellar #choosingwisely leadership. 

About the Choosing Wisely campaign

Family doctors know that many patients get unneeded prescriptions. Obstetricians know that too many babies are delivered by C-section. Radiologists have seen a lot of pointless chest X-rays. Blood tests, EKGs, Pap tests and MRIs all are overused.

In fact, when doctors sit down with the medical evidence within their specialties, hundreds of tests and treatments turn out to be frequently unnecessary, duplicative or even harmful.

For the U.S. health system as a whole, it means 30 percent of medical spending is wasted.

For patients? It means their time, energy and money could have been focused on smarter, safer, and more effective care.

The Choosing Wisely campaign aims to help patients and doctors talk about what’s truly needed. The ABIM Foundation has joined with more than 70 medical specialty societies to develop evidence-based lists of tests and procedures that should be questioned.

And as a partner in that effort, Consumer Reports has created more than 120 free brochures for patients and their families, addressing the most common of these concerns. We also have free posters, videos, rack cards, and wallet cards that help people ask their healthcare providers the right questions.

To distribute this material, CR has engaged with more than 50 organizations across the country, who help share it with yet more patients and families.

Skin Cancer: What Is Mohs Surgery?

Reprinted from a tweet from HealthAfter50

Published: December 15, 2016

Medically reviewed by Timothy Wang, MD

If you basked in the sun when you were younger, you may be paying the price for that exposure as you grow older. Research reports that one in five Americans will eventually develop skin cancer.

Most people are likely to develop basal cell or squamous cell carcinomas. Both are often grouped as nonmelanoma skin cancers. This distinguishes them from the most dangerous type of skin cancer, melanoma.

Nonmelanoma skin cancers carry a lower risk of metastasizing (spreading to distant parts of the body) than melanoma. Though slow growing and rarely life-threatening, nonmelanoma skin cancers can cause disfigurement and metastasize if left untreated.

Nonmelanoma skin cancers often begin as a small bump or tender area that may bleed and/or scale or crust. Although skin cancers can develop anywhere, most occur in sun-exposed areas such as the face.

According to an analysis published in the April 2012 Archives of Dermatology, a growing number of Medicare patients are undergoing surgery to treat nonmelanoma skin cancers, which are typically associated with accumulated exposure to ultraviolet rays from the sun.

Nonmelanoma skin cancers can be treated in a variety of ways. Your doctor will choose the best option based on your tumor’s size, location, and growth pattern. Standard forms of treatment include:

• Conventional excisional surgery
• Scraping & burning
• Radiation therapy
• Cryotherapy (freezing & destroying)
• Topical medication such as imiquimod

Another procedure, called Mohs micrographic surgery, is being used more and more, particularly to treat skin cancers on the face.

Mohs surgery has a high cure rate and preserves more healthy, noncancer-containing tissue. It can leave a smaller defect and, subsequently, a smaller scar.

How Mohs works

Mohs surgery is named after Frederic E. Mohs, M.D., the surgeon who developed the original technique in the 1930s. It is used predominantly to treat facial lesions, especially those on the lips and eyelids, where tissue preservation is critical. Mohs also has a high cure rate in treating recurring nonmelanoma skin cancers.

Not everyone is a candidate for Mohs surgery. Having other health conditions may preclude some people from undergoing the procedure, especially patients ages 85 and older. Also, undergoing the faster excision surgery instead of the lengthy Mohs procedure may be more practical for elderly patients.

The Mohs technique is a specialized outpatient procedure using local anesthesia performed by a doctor who has been trained to act as both surgeon and pathologist (an expert in analyzing tissue). Mohs also requires a specialized technician and laboratory to process the tissue.

You are awake during the surgery, and the surgical site is locally anesthetized. The Mohs surgeon removes your tumor in layers and examines each layer under a microscope to look for remaining evidence of cancer. (The lab work takes about an hour.)

If the surgeon finds any portion of the tumor remaining, he or she removes additional layers, repeating the process until the cancer is absent. The entire procedure typically lasts two to four hours and sometimes longer depending on the extent of cancer. The surgeon typically removes one to four layers.

Once the cancer has been completely removed, the defect can be reconstructed, often on the same day.

Wound reconstruction

After the cancer is removed, your Mohs surgeon can choose from a number of options when deciding how to repair the defect. They range from simple—the defect is allowed to heal on its own over the following weeks—to very complicated—a series of surgical procedures are performed.

Many Mohs surgeons are specially trained to perform both Mohs excision and repair. Sometimes, however, depending on the defect’s size and location, other specialists may be called on to complete reconstruction.

Your doctor may give you pain relievers to ease any discomfort from the surgery and/or oral antibiotics to prevent infection immediately after the procedure. Mohs surgical complications are rare but can include excessive bleeding, nerve damage, infection, wound reopening, and formation of a keloid (a tough, raised scar) at the surgical site.

Post-Mohs

As with any type of surgery, Mohs leaves some degree of scarring. As your wound heals, you can expect to see firm scar tissue and some discoloration. All scars soften and improve with time, but it may take months to a year or more for the scar to heal completely.

Some patients may need additional procedures such as sanding, laser treatment, or injections for the scar to look its best. Be sure to talk with your doctor before your surgery about your expectations, including wound-healing, scarring, and post-operative care issues.

You’ll need to visit your doctor for regular checkups. Once you’ve had skin cancer, you’re at a higher risk for developing it again.

In fact, 40 percent of patients who’ve had a basal cell carcinoma develop another one within five years, so it's important to watch for new lesions and visit your doctor regularly.

And of course, adopt safe sun practices, such as wearing lip balm and sunscreen with a sun protection factor (SPF) of at least 30.

_____________________

My note: When dealing with any medical issues--don't be afraid to have a conversation with your doctor and discuss your concerns and ask questions. 

http://consumerhealthchoices.org/

New Packaging Law Aims to Protect Kids From E-Cig Liquid Nicotine Exposure

Poison-control centers last year received more than 3,000 

reports of exposure  to these dangerous liquids

Consumer Reports / Lauren Cooper/ January 28, 2016

President Obama today signed into law a bill that requires child-resistant packaging for liquid nicotine containers used for e-cigarettes and other vaping devices.

Liquid nicotine, used in battery-operated vaping devices such as e-cigarettes and vape pens, is extremely dangerous. One teaspoon is potentially lethal to a child, according to the American Association of Poison Control Centers.

Poison-control centers last year received 3,067 exposure reports across all age groups. In 2014, poison-control centers responded to 3,783 e-cigarette and liquid nicotine exposure cases. More than half of those involved children under age 6 who might have ingested or inhaled liquid nicotine or gotten it on their skin or in their eyes. In December 2014, a 1-year-old boy from Fort Plain, N.Y., died after ingesting liquid nicotine.

Consumers Union, the policy and advocacy arm of Consumer Reports, supported the Child Nicotine Poisoning Prevention Act since its introduction in January 2015 by Senator Bill Nelson (D-Florida), Senator Kelly Ayotte (R-New Hampshire), and 20 other senators.

E-cigs and related devices have been on the market for only about a decade, and experts are still evaluating many aspects of their safety. But “the danger that liquid nicotine poses to young children is undeniable,” says William Wallace, a policy analyst for Consumers Union, which partnered with the American Academy of Pediatrics, the Consumer Federation of America, and Kids In Danger to help educate lawmakers about the threat of young children being poisoned by liquid nicotine.

“Coming in a variety of bright colors and in flavors like cotton candy and gummy bear, liquid nicotine refills used in e-cigarettes have found their way into the hands of children across the country, causing serious and even deadly health consequences.” says Kyran Quinlan, M.D., chair of the American Academy of Pediatrics' Council on Injury, Violence, and Poison Prevention.

Under the new law, liquid nicotine can only be sold in child-resistant bottles and containers packaged in accordance with the Consumer Product Safety Commission's standards. That means that they must meet the same standards as other potentially poisonous household substances as set forth in the Poison Prevention Packaging Act of 1970. Among other stipulations, the law requires that the packaging must be difficult for children under 5 years old to open. Manufacturers have six months to comply.

The American Vaping Association agrees that requiring child-resistant packaging makes sense.

“Parents are recognizing that these products should be kept away from children,” says Gregory Conley, president of the organization. “Requiring child-resistant caps on e-liquid products is a reasonable regulation and is already the law in fifteen states,” he says, adding that, “The Child Nicotine Poisoning Prevention Act [brings] uniformity across all 50 states on this issue."

Next up: preserving the FDA’s ability to regulate e-cigarettes, which is under threat by some members of Congress.

“The new law helps address a known safety risk to children, but e-cigarettes have not been around long enough for us to know the long term effects of using them. It’s critical that the FDA retains the ability to address additional health risks that may emerge with these untested products,” Wallace says.

How to Cancel Travel Plans Due to the Zika Virus

Consumer Reports / By Jeff Blyskal / Feb 5 2016

Travel insurance helps, but be prepared to haggle as well

If you plan to cancel the tropical vacation you've booked to avoid coming down with the Zika virus, you're probably in good company. Worries over travel have picked up in recent days with the news that at least 31 people in the U.S. have been diagnosed with the virus including a pregnant woman in New York City, according to the Centers for Disease Control and Prevention.

But canceling raises more questions. Will you be hit with cancellation penalties? Will you be able to get a refund?

The good news is that some major airlines and cruise lines are bending their usually strict rules on cancellation for passengers with tickets to the affected areas. But at the same time, you may also need to negotiate for a refund to cancel travel plans.

Airlines

JetBlue, which was rated the most highly among airlines in our 2015 airline Ratings, has the most forgiving policy among the five largest U.S. carriers we contacted. Customers concerned about Zika and holding tickets to affected areas can cancel travel for a refund even if they purchased non-refundable tickets. Re-bookings can be made without penalty.

United and American provide similar options, but only to women who are pregnant or attempting to become pregnant, and their travel companions, and their policies doesn't apply to non-refundable tickets. American requires a note from a doctor and refunds are limited for travel to only 11 countries, including Brazil, Mexico, Panama, and Puerto Rico.

Southwest Airlines, also highly rated by our subscribers, has no specific Zika policy, but it never charges penalties for changing flight plans. So any traveler concerned about Zika is free to avoid problem destinations. If you have non-refundable tickets, their full value can be applied to travel elsewhere on Southwest.

Delta did not respond to our request for comment, but the airline's website says customers may be able to change their destinations and travel dates without being charged a fee. They may also qualify for a refund if they cancel travel plans. Changes need to be made by February 29.

What you should do. If you're not pregnant or trying to become pregnant and still prefer to cancel, getting a refund may be more difficult. If you bought travel insurance that has a rider that permits cancellation for any reason, that should protect you. If you don't have the insurance, we recommend that you negotiate for a refund from the airlines. That may require that you argue that canceling your trip helps prevent the spread of the virus to the U.S. It is especially advisable if you expect to be in contact with anyone who is pregnant (there are still questions as to how easily this disease gets transmitted).


Cruises
Consumers who buy tickets for a cruise are typically subject to stiff penalties if they change or cancel travel plans. Payment in full is usually required 90 or more days before departure. If you later want to cancel, you can lose up to 100 percent of your payment depending on when you make that decision.

But if the reason for canceling has to do with the Zika virus, the cruise lines are being unusually lenient. Carnival, the largest cruise line, Disney Cruise Lines, Norwegian Cruise Lines and Princess Cruises are letting pregnant women cancel travel or change their itineraries to exclude Zika-prone destinations. They can also request credit for a future voyage.*

The new policies do not apply to those planning to become pregnant.

What you should do. If your cruise line isn't willing to help you avoid cancellation or change fees, remind them of the policies set by the other cruise lines and ask for similar treatment.

As with the airlines, if you purchased travel insurance that has a rider that permits cancellation for any reason, that should protect you. We suggest that you don't automatically take the limited insurance policy offeringsthat the cruise line sells. You're likely to get better coverage and lower fees if you shop the market more broadly by using an online broker such as InsureMyTrip.

Lodging
Hotel chains have more consumer-friendly cancellation policies and routinely require 48 to 72 hours’ notice to avoid a charge equal to one night’s stay.

However, if you cancel a prepaid stay during a peak period, you could forfeit the entire amount. Some resorts may bill you for three nights if you cancel your trip.

If you've booked a private vacation home rental through online marketplaces such as Airbnb, HomeAway, or VRBO, the homeowner sets the cancellation policy.

What you should do. Given the severity of the warning from the CDC, negotiate for a full refund or a reduced penalty waiver. It can help to contact the hotel or travel agent and explain that your doctor has warned against travel to the area.

For private vacation home rentals, check your contract for the owner's cancellation policy to see if you can get out of the deal within the rules. If you are unable to break the agreement, appeal to the owner on a personal level and try to negotiate a fair refund, given the new health threat.

Zika: The Dangerous Mosquito Virus You Must Know About

Insect repellents aren't enough to stay safe from this disease

Consumer Reports / Sue Byrne / January 28, 2015 / aired on GMA February 9, 2015

A mosquito-borne illness called the Zika virus is now spreading rapidly in South and Central America and the Caribbean, and it could arrive in the U.S. soon. It can make anyone sick for up to a week with symptoms like fever, rash, joint pain, and red eyes. But it's especially dangerous for women of childbearing age who are pregnant or considering pregnancy because it has been linked to microcephaly, a serious birth defect that causes an abnormally small head and incomplete brain development.

The outbreak has prompted the Centers for Disease Control and Prevention to issue a warning to take precautions for anyone traveling to 24 destinations in the Americas, but, most important, the CDC is recommending that all pregnant women should consider postponing their trip altogether. Here's what you should know to protect yourself and your family.

Why Zika Is So Concerning

The Zika virus normally does not cause illness that requires hospitalization or leads to death. Roughly one in five people infected with the virus develop symptoms, which are usually mild. The time from getting bitten to getting sick is likely to be a few days.

The Pan American Health Organization (PAHO) reports more than 16,000 Zika illnesses since the first cases were confirmed in Brazil in October 2015. Local transmission of the virus has been confirmed through lab testing in several countries in the Americas.

"The number of cases being reported is significantly lower than the actual number of cases." says Candice Burns Hoffmann, a CDC spokeswoman. "Many countries do not regularly test for Zika virus. Also, once the outbreak becomes common in an area, most people will not go to the doctor or get tested for the virus."  

Brazil has reported 4,180 cases of microcephaly, according to The New York Times, and Colombia has reported Zika infections in 1,090 pregnant women, a spokeswoman for PAHO told Consumer Reports. In addition, Guillain-Barré syndrome, which causes muscle weakness and sometimes paralysis, has been reported in patients with a probable Zika infection in French Polynesia and Brazil. The CDC says it is examining the link between Zika and the disorder.

Because there is neither a vaccine nor medication available to prevent a Zika virus infection, the American College of Obstetricians and Gynecologists recommends that women who are pregnant or considering pregnancy follow CDC guidelines and delay travel to those regions where Zika outbreaks are occurring.

"There is much that we do not yet know about the Zika virus," Mark S. DeFrancesco, M.D., president of the ACOG, said in a statement. "However, because of the associated risk of microcephaly, avoiding exposure to the virus is best." Women who have traveled to South and Central America and the Caribbean should be evaluated for Zika virus infection.  

How to Prevent Bites

For those who are planning to travel in spite of the warnings, the CDC asks that pregnant women, women who are trying to become pregnant, and everyone else should strictly follow steps to protect themselves. Because the mosquitoes that spread Zika are aggressive daytime biters and live indoors and outdoors, it's especially important to follow the CDC's precautions during daylight hours.

That includes using insect repellent containing deet, picaridin, lemon eucalyptus, or IR3535. All have been approved by the Environmental Protection Agency for use during pregnancy. Also wear long-sleeved shirts and pants, the CDC says. At night, CDC recommends sleeping in a screened-in or air conditioned room or under a mosquito bed net.

Consumer Reports' recent tests of insect repellents found that the most effective product, Sawyer Fishermen's Formula with 20 percent picaridin, was also one of the safest, helping to keep away Aedes mosquitoes—the same type that transmit Zika—for at least 8 hours. Off Deepwoods VIII with 25 percent deet also kept Aedes mosquitoes at bay for 8 hours. Our tests showed that repellents containing natural plant oils, such as citronella and lemongrass, did not work against mosquitoes.

Two types of mosquitoes that are capable of transmitting the Zika virus live primarily 

in the southeastern U.S. Photo: Courtesy of the Centers for Disease Control and Prevention

More Actions to Take

All cases of Zika virus in the U.S. so far have been found in returning travelers to the regions mentioned above. No one has gotten sick from being bitten in the U.S. But that may be changing as the two mosquito types known to carry the disease, Aedes aegypti and Aedes albopictus, can be found here (see maps above). If a homegrown mosquito bites an infected returning traveler it could pick up the virus and then pass it along to other people in the U.S.  

For this reason, it’s wise to use insect repellent, as noted above. You can also make it harder for mosquitoes to set up shop in your backyard. Female mosquitoes lay several hundred eggs on the walls of water-filled containers. The eggs stick like glue and remain attached until they are scrubbed off. If water covers the eggs, they hatch and become adults in about a week. To prevent them from hatching:
• Empty and scrub, turn over, cover, or throw out items that hold water, such as tires, buckets, planters, toys, pools, birdbaths, flowerpots, or trash containers. Do this once a week.
• Tightly cover water storage containers (buckets, cisterns, rain barrels) so that mosquitoes cannot get inside to lay eggs.
• Use wire mesh with holes smaller than an adult mosquito if you don't have lids.

If you have a septic tank, repair cracks or gaps, and cover open vents or plumbing pipes.

For more info go to ConsumerReports.org:

http://www.consumerreports.org/insect-repellent/zika-the-dangerous-mosquito-virus-you-must-know-about?loginMethod=auto

How your hospital can make you sick

Consumer Reports’ new Ratings of more than 3,000 U.S. hospitals show which do a good job of avoiding MRSA, C.diff, and other deadly infections

www.consumerreports.org / Published: July 29, 2015

In the ongoing war of humans vs. disease-causing bacteria, the bugs are gaining the upper hand. Deadly and unrelenting, they’re becoming more and more difficult to kill. You might think of hospitals as sterile safety zones in that battle. But in truth, they are ground zero for the invasion.

Though infections are just one measure of a hospital’s safety record, they’re an important one. Every year an estimated 648,000 people in the U.S. develop infections during a hospital stay, and about 75,000 die with them, according to the Centers for Disease Control and Prevention (CDC). That’s more than twice the number of people who die each year in car crashes. And many of those illnesses and deaths can be traced back to the use of antibiotics, the very drugs that are supposed to fight the infections.

Terry Otey appears to be one casualty in that ongoing battle. Three years ago, a few weeks after an overnight stay for back surgery at Providence Regional Medical Center in Everett, Wash., he went to the emergency room vomiting, dizzy, and with excruciating back pain. Bacteria known as MRSA (methicillin-resistant staphylococcus aureus) had taken hold in his surgical incision and quickly spread to his heart. He died in the hospital about three months later, following a cascade of serious health problems. “He just wanted to ease his back pain enough to play golf,” says his sister, Deborah Bussell.

Kellie Pearson, 49, a farmer in northern California, says she encountered a different kind of bug after having heart surgery last April. Her doctors prescribed an antibiotic in the hopes that it would prevent a postsurgical infection. Instead the drug killed off healthy bacteria in her body, and another germ, C. diff (clostridium difficile), swooped in, causing diarrhea so severe that she had to stay in the hospital an additional five days until doctors could rein in the potentially deadly infection.

She recovered but soon realized that she wasn’t the only patient suffering. “When I was able to walk down the hall in the hospital,” she says, “I was horrified to see room after room with C. diff caution signs on their doors warning that the patients inside, like me, had been infected.”

In the danger zone

“Hospitals can be hot spots for infections and can sometimes amplify spread,” says Tom Frieden, M.D., director of the CDC. “Patients with serious infections are near sick and vulnerable patients—all cared for by the same health care workers sometimes using shared equipment.”

Making the situation even more dangerous is the widespread, inappropriate use of antibiotics that’s common in hospitals, which encourages the growth of “superbugs” that are immune to the drugs and kills off patients’ protective bacteria.

It’s “the perfect storm” for infections to develop and spread, says Arjun Srinivasan, M.D., who oversees the CDC’s efforts to prevent hospital-acquired infections. “We’ve reached the point where patients are dying of infections in hospitals that we have no antibiotics to treat.”

But there’s hopeful news: Some hospitals are taking steps to reduce infections and end inappropriate antibiotic use. “But others have made little effort,” Srinivasan says.

'Be your own advocate'

Kellie Pearson recovered from a life-threatening case of C. diff caused by antibiotics she got in the hospital. But shortly after, she says, her doctor wanted to prescribe a broad-­spectrum antibiotic to prevent infection in her incision. “I was shocked because that could trigger the C. diff all over again,” she says. Her takeaway: “You have to be your own advocate.”

Red flags for bad bacteria

Methicillin-resistant staphylococcus aureus (MRSA)

We are focusing on C. diff and MRSA for two important reasons.

First, the infections are common and deadly. More than 8,000 patients each year are killed by MRSA; almost 60,000 are sickened by the infections. The bacteria often find their way into patients’ bodies through the lines and tubes that doctors use to deliver medication and nutrition to patients, or via surgical incisions, as happened to Terry Otey.

C. diff is an even bigger concern. Kellie Pearson is one of the 290,000 Americans sickened by the bacteria in a hospital or other health care facility each year. She was lucky: At least 27,000 people in the U.S. die with those infections annually.

Second, poor MRSA or C. diff rates can be a red flag that a hospital isn’t following best practices in preventing infections and prescribing antibiotics. That could not only allow C. diff and MRSA to spread but also turn the hospital into a breeding ground for other resistant infections that are even more difficult to treat.

For example, as dangerous as MRSA is, an infection can be cured if it is treated promptly with vancomycin, long held out as an “antibiotic of last resort.” But, in part because that drug is now so often used in hospitals, another resistant strain of bacteria—vancomycin-resistant staphylococcus aureus, or VRSA—is emerging. “VRSA infections pose special challenges; they can be even more difficult to treat than MRSA,” Srinivasan says.

Hospitals that rate well

Clostridium difficile (C. diff)

To earn our very top rating in preventing MRSA or C. diff, a hospital has to report zero infections—an admittedly high bar. Still, 322 hospitals across the country were able to achieve that level in our MRSA ratings, and 357 accomplished it for C. diff, showing that it is possible. (Experts say some hospitals might game the system. Read more about how hospitals fudge the numbers, and help us identify those that might not accurately report infections.)

More hospitals were able to earn either of our two highest ratings—indicating that they reported either zero infections or did much better than predicted compared with similar hospitals: more than 623 hospitals received high marks for MRSA, and 917 did so for C. diff.

Hospitals really begin to distinguish themselves when they earn high ratings against both infections: 105 hospitals succeeded in that. Even better, some hospitals excel against not only MRSA and C. diff but also other infections that the CDC tracks and that are in our hospital Ratings. Those include surgical-site infections and infections linked to urinary catheters or central-line catheters, large tubes that provide medication and nutrition.

“Hospitals that do well against infections across the board have figured something out and deserve special mention,” Peter says. Only nine hospitals in the country—those featured in the “Highest-Rated in Infection Prevention” chart earned that high honor. (Note that some of hospitals listed in that chart differ from those in the September 2015 issue of Consumer Reports magazine because new data was released by the federal government after the magazine went to press.)


And hospitals that don't

You won’t find any familiar, big-name hospitals on that top-performing list. In fact, several high-profile hospitals got lower ratings against MRSA, C. diff, or both, including the Cleveland Clinic in Cleveland, Johns Hopkins Hospital in Baltimore, Mount Sinai Hospital in New York City, and Ronald Reagan University of California Los Angeles Medical Center.

Those are all large teaching hospitals in urban areas, which in our analysis did not do as well as nonteaching hospitals of similar sizes in similar settings. That could be because teaching hospitals may do a better job of reporting infections. Or, as a representative for Ronald Reagan UCLA Medical Center told us, they may see sicker patients or have more patients undergoing complex procedures.

Although the CDC adjusts the data to account for some of those factors, teaching hospitals tend to perform worse. For example, only 6 percent of teaching hospitals received one of our two top scores against C. diff, compared with 14 percent of similar nonteaching hospitals.

“Yes, teaching hospitals face special challenges. But they are also supposed to be places where we identify best practices and put them to work,” says Lisa McGiffert, director of the Consumer Reports Safe Patient Project. “Obviously, that is not happening as well as it should.”

Larger hospitals also tended to do worse in our Ratings. That could be because patients in smaller hospitals are less likely to be exposed to infections. But some larger hospitals managed to do a good job avoiding infections. Case in point: Harlem Hospital Center in New York City earned high ratings against MRSA and C. diff. Or consider Northwest Texas Healthcare System in Amarillo, Texas. It made it onto our list of top hospitals in the prevention of all of the infections included in our Ratings.

What safe hospitals do

Good hospitals focus on the basics:

Use antibiotics wisely

Almost half of hospital patients are prescribed at least one antibiotic, Srinivasan says, but “up to half the time the drug is inappropriate.” To combat antibiotic misuse, many good hospitals have “antibiotic stewardship” programs, often headed by a pharmacist trained in infectious disease, to make sure that patients get the right drug, at the right time, in the right dose.

Such programs often monitor the use of broad-spectrum antibiotics. Doctors at some hospitals use three times more of those all-purpose bug killers than others. Reducing broad-spectrum prescriptions by 30 percent would “cut hospital rates of C. diff by more than 25 percent, plus reduce antibiotic resistance,” says Clifford McDonald, M.D., a CDC epidemiologist.

Keep it clean

C. diff and MRSA can live on surfaces for days and can be passed from person to person on hospital equipment or the hands of health care workers. To prevent that, hospitals must be kept scrupulously clean. “Infection control is all about the basics, starting with hand hygiene,” says Christine Candio, president and CEO of St. Luke’s Hospital in Chesterfield, Mo., which earned higher Ratings against both MRSA and C. diff.

She reminds patients, “it’s your right to ask” staff to wash up. In fact, fastidious hand washing slashes rates of C. diff, MRSA, and other infections. St. Luke’s also “prioritizes cleanliness,” in some cases exceeding infection-control guidelines—cleaning the rooms of C. diff patients twice daily, for example, and replacing curtains between patients.

What more needs to be done

Steps such as those, plus federal mandates for some public reporting of infections data, have already led to reduced rates of certain infections. Still, McGiffert says hospitals need to do more:

• Consistently follow the established protocols for managing superbug infections, such as using protections including gowns, masks, and gloves by all staff.
• Be held financially accountable. Already, hospitals in the bottom 25 percent of the government’s data at preventing certain complications now have Medicare payments docked 1 percent. But they should also have to cover all costs of treating infections patients pick up during their stay.
• Have an antibiotic stewardship program. That should include mandatory reporting of antibiotic use to the CDC.
• Accurately report how many infections patients get in the hospital. And the government should validate those reports.
• Be transparent about infection rates. For instance, Cleveland Clinic acknowledges its below-average performance in C. diff prevention on its website. “That’s refreshingly candid,” Peter says.
• Promptly report outbreaks to patients, as well as to state and federal health authorities. Those agencies should inform the public so that patients can know the risks before they check into the hospital.

Germ warfare: Protect yourself against superbugs

First step: Check our Ratings to see how hospitals in your community compare in preventing infections and other measures of hospital safety. 

But bad things can happen even in good hospitals. For example, Terry Otey developed his infection after a 2012 surgery in a hospital that now gets one of our higher ratings against MRSA. Our experts say there are several things you can do when you’re in the hospital and after you’re discharged to minimize your risk and spot symptoms of possible infection early:

In the hospital

Consider MRSA testing. A nasal swab can detect low levels of MRSA and allow medical staff to take precautions, such as having you wash with a special soap before your procedure.

Insist on cleanliness. Ask to have your room cleaned if it looks dirty.

Take bleach wipes for bed rails, doorknobs, and the TV remote. Insist that everyone who enters your room wash his or her hands.

Keep your own hands clean, washing regularly with soap and water.

Question antibiotics. Make sure that any anti­biotics prescribed to you in the hospital are needed and appropriate for your infection.

Watch out for heartburn drugs. Medications such as Nexium and Prilosec increase the risk of developing C. diff symptoms by reducing stomach acid that appears to help keep the bug in check. So ask whether the drug is needed and request the lowest dose for the shortest possible time.

Ask every day whether ‘tubes’ can be removed. The risk of infection increases the longer items such as catheters and ventilators are left in place. If you’re not able to ask, be sure a friend or family member does.

Say no to razors. If you need to be shaved, use an electric hair remover, not a razor, because any nick can provide an opening for infection.

At home

If you’ve been in the hospital, “assume you’ve been exposed to potentially dangerous bacteria,” says Lisa McGiffert, director of the Consumer Reports Safe Patient Project. Here’s what to do when you get home to keep yourself and your family safe:

Watch for warning signs. They include fever, diarrhea, worsening pain, or an incision site that becomes warm, red, and swollen. People at particular risk include adults older than 65 as well as infants, anyone on antibiotics, and people with a compromised immune system.

Practice good hygiene. If you or someone you live with receives a diagnosis of a hospital-acquired infection after being discharged from the hospital, take extra precautions to make sure that it doesn’t spread. Steps you should consider take include cleaning frequently touched surfaces with 1 part bleach mixed with 10 parts water and reserving a bathroom for the infected person. If that’s not possible, use the bleach solution to disinfect surfaces between uses. And don't share toiletries or towels; use paper towels rather than cloth hand towels.

Editor's Note:
This article also appeared in the September 2015 issue of Consumer Reports magazine.

Note that there are some differences between the print and online versions of the story because new data was released by the federal government after the issue went to press.