Former surgeon, Dr. Bikram K. Paul, discusses the safety issues facing the go-to hospital for Congress and the White House, Medstar Washington Hospital Center.
WASHINGTON — Sewage that leaks down the walls and on the operating room floors is among the many problems at the go-to hospital for Congress and the White House, according to interviews and documents obtained by USA TODAY.
The D.C. health department is now investigating the leaks at MedStar Washington Hospital Center only after the department received a complaint, not because it was alerted by the hospital. The problems included the room in which Louisiana Rep. Steve Scalise had his last surgery after being shot at a congressional baseball practice in June.
In an interview, the chief medical officer, Gregory Argyros, described MedStar Washington as "the most important hospital in the most important city in the most important country in the world."
The hospital serves both a lower-income section of Washington and some of the nation's most powerful people. Designated as official Washington's trauma hospital of choice, it also suffers from some of the Washington area's worst hospital ratings.
USA TODAY interviewed two dozen current and former hospital employees, local government officials and health experts to determine how this once-venerated health care facility — dubbed "ER One" because of its emergency room's disaster focused-design — has fallen so far in reputation.
Doctors, nurses and records describe an aging, understaffed facility where:
• The last operating room in which Scalise had surgery, No. 11, had to be closed due to a sewage leak two days later. The main operating room — made up of about 20 smaller operating rooms — is in the hospital's basement and some of the rooms are under bathrooms.
• Employees in "protective" foot coverings scurried back and forth between sewage-soaked operating rooms and surgical instrument storage areas into hallways as patients passed on gurneys and lined the halls.
• Buckets have been used to catch water leaks from ceilings at least twice during surgeries. These were the same ceilings through which sewage leaked.
• Portable fans were used to eliminate strong "porta potty" odors in the operating rooms and to dry them more quickly, even though federal studies show fans can spread bacteria in the air.
• Four foreign objects were left inside patients in the 12 months ended in February, which prompted a special staff meeting on Feb. 14.
• Flies are a regular problem in operating rooms and the insects landed on open wounds at least twice and often elsewhere on patients.
"This describes a hospital that is out of control," says Lisa McGiffert, director of Consumer Reports' Safe Patient Project.
Against this backdrop, Washington Hospital Center was grappling with a $16 million shortfall after the most recent fiscal year ended in June, which prompted a memo alerting department heads that they need to cut millions from their budgets. Physicians, including anesthesiologists, left the hospital under confidential agreements although Argyros denied layoffs affected anyone involved in direct patient care.
About 400 nurses out of 1,780 left their jobs last year — up from about 300 a year between 2010 and 2015, according to data compiled by National Nurses United, which represents them. That comes to about a 22% turnover rate, compared to the 14% rate provided by hospital spokeswoman Donna Arbogast.
Infections and high nurse turnover are closely related, says Kathleen Bartholomew, a nurse and author who trains hospitals on patient safety.
These factors led several current and former employees to worry things can only get worse.
Surgeon Bikram Paul retired about two months ago as the hospital's senior attending physician after he says he was named the official White House surgeon by every president since Ronald Reagan. Paul said he told Argyros and hospital President John Sullivan at his retirement party not to allow financial constraints and staff cuts to push the hospital down "to any lower standard."
Washington Hospital Center says it is the best equipped in the D.C. area to treat patients with life-threatening injuries, noting that it ranks in the top 10% when it comes to preventing death after gun and knife wounds at level 1 trauma centers, citing non-public American College of Surgeons data. That makes it 40% less likely these patients will die at Washington Hospital Center compared to all other U.S. trauma centers, Arbogast says.
When it comes to public quality and safety scores, however, it is among the lowest rated. The center gets just two out of five stars in the Centers for Medicare and Medicaid Services' (CMS) federal safety rating, pushed down in large part by high infection rates and complications, including for those known as "never events" that shouldn't happen because they are so dangerous and preventable. These include foreign objects left inside patients' bodies. Leapfrog Group, which rates hospitals, gives it a D.
A higher rate of infection and complications is to be expected at the hospital with the city's second-busiest emergency room, the hospital and its defenders say. And infections are common after serious abdominal gunshot wounds like that suffered by Scalise and many of the victims of Washington's urban violence. They are also far more likely, however, at a hospital with as poor a record of infection control as Washington Hospital Center's — and far from the norm at other level 1 trauma centers.
Scalise, for example, had a series of surgeries and developed an infection about three weeks after he arrived, which led to two more surgeries. Argyros declined to discuss Scalise's case, citing privacy laws. In an internal memo to staff after an earlier USA TODAY story about the hospital, MedStar's David Mayer, the vice president of safety and quality, said it is improper to link in any way someone shot with a "dirty bullet from a dirty gun on a dirty ball field" with a hospital's high overall infection issues with a hospital.
Children's National Medical Center, which is next door, has the city's busiest emergency room and was a 2016 Leapfrog Group "Top Hospital" for the eighth time, thanks to lower infection rates and higher survival rates for high-risk procedures.
Argyros, who says the hospital is on a "high reliability journey," confirmed the four retained foreign objects and said they included a sponge, a rubber retractor, a piece of a catheter and a "tiny piece" of a drill bit.
"We need to accept no less than no patient harm," Argyros said in a recent interview at the hospital. "It's really all about the outcomes. If outcomes are not good, we haven’t met the mission."
Ratings show risk
Patients are at greater risk of harm at the hospital, an analysis of federal data shows.
Washington Hospital Center's rate for the infection Clostridium difficile, known as C. diff., is 35% higher than the average at teaching hospitals that voluntarily report to Leapfrog, according to an analysis it did for USA TODAY of CMS data updated in August. Such centers typically have trauma centers and treat poorer patients who can be more susceptible to infection.
These infections are among the most common and kill about 29,000 people a year within a month, according to the Centers for Disease Control and Prevention. Hospital-acquired infections overall kill about 99,000 people a year, CDC reports — about three times the number of people who die in car crashes annually.
"Our data sugests that patients are more likely to be harmed or die unnecessarily from an infection at this hospital than most other hospitals in the country," says Leapfrog CEO Leah Binder.
Washington Hospital Center says that since 2015, its internal data on a common type of blood infections in their intensive care and non-intensive care units dropped by 30%. Leapfrog's analysis showed it was 45% higher than its teaching hospital average.
Proper infection control procedures include frequent hand washing, glove usage, personal protective equipment such as gowns and masks and safe syringe use.
A 102-page D.C. health department inspection report from last September highlighted examples of nurses failing to wash hands after treating wounds and not wearing protective clothing. Under a negotiated corrective plan, the hospital was required to develop a policy to prevent infections, including guidance for employees on things including how to keep their hands clean, use gloves and carry trays into patient rooms.
USA TODAY obtained the reports — which DC inspectors do for CMS — under a Freedom of Information Act request.
"When this much is wrong, it seems like fines should be assessed or something more rehabilitative, like publicizing the problems," says McGiffert, who reviewed the hospital's 2015 and 2016 inspection reports for USA TODAY. "That happens with restaurants, why not hospitals?"
Few practices would be as alarming to the public and are as surprising to safety experts as hospital sewage leaks, which have bedeviled the hospital for the past couple of years and well into August.
Sewage leaks in operating rooms are dire and could jeopardize the hospital's Medicare reimbursements, says infection control expert Larry Muscarella, who added that he has never heard of such leaks.
Sewage in operating rooms
"Such sewage would violate basic infection control and hygiene standards as well as CMS regulations, and certainly could pose a infection risk," said Muscarella, who owns LFM Healthcare Solutions and the blog Discussions in Infection Control.
Anyone would be "horrified and disgusted" that the sewage leaks and other problems would go on for so long, says McGiffert, a veteran of 30 years in patient safety.
Arbogast said last week that "all pipe issues have been corrected."
The health department will decide whether the hospital is subject to a penalty after it completes its investigation of the leaks, says spokeswoman Jasmine Gossett.
As Scalise's operating room was being closed off for sterilization two days after his last surgery this summer, a doctor who asked to remain anonymous for fear of retribution said he saw liquid stool mixed in with other sewage on the floor. That suggested to the physician that the leak didn't just happen. As the room was being cleaned, a surgical procedure was taking place about five feet away in room No. 12, the doctor added and a document reviewed by USA TODAY indicates.
Employees know they must act immediately if they ever detect the smallest amount of water on the floor, Argyros says. That would assure sewage and other leaks remain far enough away from patients to prevent infections.
Besides, he notes, only two of the five sewage leaks this year occurred in operating rooms while patients were being treated. Each patient and their families were notified and they are being monitored for infections. None of the liquid waste came near the patient or the "sterile field," he says.
MedStar Washington Hospital Center spokesperson Donna Arbogast, left, Tonya Washington and Dr. Gregory Argyros during interview. (Photo: Sierra Lewter)
Along with workers likely tracking sewage into hospital hallways and operating rooms, the use of fans would have exposed employees' protective clothing, instruments and storage room bins to airborne bacteria, according to the two doctors who saw the fans and requested anonymity because of legal concerns.
Rep. Robin Kelly, D-Ill., who has been treated at the hospital, says "any time we investigate this," it shouldn't only be because safety issues could affect governmental officials. Instead, "we should use this case to address the larger issues around disparities for all the people we serve in Washington, D.C."
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