Legal Aspects of Health Care
Administration
THIRTEENTH EDITION
George D. Pozgar, MBA, CHE, D.Litt.
Author, Speaker, Consultant
Gp Health Care
Annapolis, Maryland
Legal Review
Nina M. Santucci, MSCJ, JD
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Library of Congress Cataloging-in-Publication Data
Names: Pozgar, George D., author.
Title: Legal aspects of health care administration / George D.
Pozgar, MBA, CHE, D.Litt.
Description: Thirteenth edition. | Burlington, MA: Jones & Bartlett
Learning, [2019] | Includes bibliographical references and index.
Identifiers: LCCN 2018002863 | ISBN 9781284127171
(casebound)
Subjects: LCSH: Health services administration—Law and
legislation—United States. | Medical laws and legislation—United
States. | Medical personnel—Malpractice—United States. |
BISAC: BUSINESS & ECONOMICS / Information Management.
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LC record available at https://lccn.loc.gov/2018002863
6048
Printed in the United States of America
22 21 20 19
10 9 8 7 6 5 4 3
I dedicate this book to Denise Mirafuentes.
Your life was an inspiration.
Your love for family, friends, caregivers, and the many lives you have
touched never failed.
Your unwavering faith in God and the challenges you faced have forever
changed the lives of so many.
Your life is a testimony to goodness, kindness, and compassion.
Though the thoughts I wish to impart continue to swirl in my mind, words
alone will never suffice.
So I leave you with this my dear friend,
Your signature phrase to “Live, Laugh, and Love” describes you well.
“The best and most beautiful things in the world cannot be seen or even
touched, they best be felt with the heart.”
Helen Keller
ALOHA & MAHALO
Until We All Meet Again
Contents
Epigraph
Preface
About the Book
Acknowledgments
Chapter 1 Hospitals Through the Ages
Learning Objectives
Early Hindu and Egyptian Hospitals
Greek and Roman Hospitals
Hospitals of the Early Christian Era
Islamic Hospitals
Early Military Hospitals
Medieval Hospitals
The “Dark Age” of Hospitals
Hospitals of the Renaissance
Hospitals of the 18th Century
Early Hospitals in the United States
Late 19th Century Renaissance
20th-Century Progress
Health Care and Hospitals in the 21st Century
History Challenges Us to Do Better
Chapter Review
Review Questions
Notes
Chapter 2 Government, Law, and Ethics
Learning Objectives
Development of Law
Sources of Law
Government Organization
Department of Health and Human Services
Government Ethics
Political Malpractice
Chapter Review
Review Questions
Notes
Chapter 3 Tort Law—Negligence
Learning Objectives
Objectives of Tort Law
Negligence
Forms of Negligence
Degrees of Negligence
Elements of Negligence
Summary Case
Chapter Review
Review Questions
Notes
Chapter 4 Intentional Torts
Learning Objectives
Assault and Battery
False Imprisonment
Defamation of Character
Fraud
Invasion of Privacy
Infliction of Mental Distress
Products Liability
Chapter Review
Review Questions
Notes
Chapter 5 Tort Reform and Risk Reduction
Learning Objectives
Mediation and Arbitration
Statute of Limitations
Structured Awards
Medical Malpractice Screening Panels
Collateral Source Rule
Contingency Fee Limitations
Countersuits: Frivolous Claims
Joint and Several Liability
Malpractice Caps
No-Fault System
Regulation of Insurance Practices
Reducing the Risks of Malpractice
Collaboration in Tort Reform
Chapter Review
Review Questions
Notes
Chapter 6 Criminal Aspects of Health Care
Learning Objectives
Criminal Procedure
Healthcare Fraud
Kickbacks
Tampering with Drugs
Internet Pharmacy and Sale of Drugs
Falsification of Records
Patient Abuse
Criminal Negligence
Homicide
Manslaughter
Rape and Sexual Assault
Theft
Chapter Review
Review Questions
Notes
Chapter 7 Contracts and Antitrust
Learning Objectives
What Is a Contract?
Types of Contracts
Elements of a Contract
Breach of Contract
Corporate Contracts
Partnership
Agent
Independent Contractor
Conditions
Performance
Nonperformance Defenses
Remedies
Employment Contracts
Medical Staff Bylaws: A Contract
Exclusive Contracts
Restraint of Trade
Hospital Staff Privileges
Transfer Agreements
Insurance Contract
Chapter Review
Review Questions
Notes
Chapter 8 Civil Procedure and Trial Practice
Learning Objectives
Pleadings
Discovery
Motions
Pretrial Conference
Notice of Trial
Memorandum of Law
The Courtroom and the Judge
The Jury
Subpoenas
Burden of Proof
Res Ipsa Loquitur
Opening Statements
Examination of Witnesses
Judicial Notice Rule
Evidence
Defenses Against Plaintiff’s Allegations
Closing Statements
Judge’s Charge to the Jury
Jury Deliberation and Determination
Awarding Damages
Joint and Several Liability
Appeals
Execution of Judgments
Chapter Review
Review Questions
Notes
Chapter 9 Corporate Structure and Legal
Issues
Learning Objectives
Authority of Corporations
Corporate Committee Structure
Corporate Ethics
Corporate Negligence
Doctrine of Respondeat Superior
Governing Body Responsibilities
Corporate Reorganization and Mergers
Chapter Review
Review Questions
Notes
Chapter 10 Medical Staff Organization and
Malpractice
Learning Objectives
Medical Staff Organization
Medical Director
Medical Staff Privileges
Common Medical Errors
Patient Assessments
Diagnosis
Treatment
Discharge and Follow-Up Care
Infections
Psychiatry
Principles of Medical Ethics
Physician–Patient Relationship
Chapter Review
Review Questions
Notes
Chapter 11 Nursing and the Law
Learning Objectives
Scope of Practice
Nurse Licensure
Nursing Careers
Advanced Practice Nurses
Legal Risks of Nurses
Duty to Question Discharge
Duty to Report Physician Negligence
Chapter Review
Review Questions
Notes
Chapter 12 Hospital Departments and Allied
Professionals
Learning Objectives
Paramedics and First Responders
Emergency Department
Laboratory
Medical Assistant
Nutritional Services
Pharmacy
Physical Therapy
Physician Assistant
Radiology and Related Lawsuits
Respiratory Therapist
Chiropractor
Dentistry
Podiatrist
Security
Licensure and Certification of Healthcare Professionals
Helpful Advice for Caregivers
Chapter Review
Review Questions
Notes
Chapter 13 Information Management and
Patient Records
Learning Objectives
Information Management
Medical Record Contents
Documentation of Care
Privacy Act of 1974
Health Insurance Portability and Accountability Act
Patient Objects to Record Entries
Ownership and Release of Medical Records
Use of Patient Data Collected
Retention of Records
Electronic Medical Records
Legal Proceedings and the Medical Record
Falsification of Records
Illegible Handwriting
Timely Completion of Medical Records
Confidential and Privileged Communications
Charting: Some Helpful Advice
Chapter Review
Review Questions
Notes
Chapter 14 Patient Consent, Rights, and
Responsibilities
Learning Objectives
Patient Consent
Patient Rights
Patient Responsibilities
Chapter Review
Review Questions
Notes
Chapter 15 Healthcare Ethics
Learning Objectives
Ethics
Morality
Ethical Theories
Principles of Healthcare Ethics
Values
Pillars of Moral Strength
Religious Ethics and Spirituality
Secular Ethics
Professional Ethics
Ethics Committee
Reasoning and Decision Making
Moral Compass Gone Astray
Chapter Review
Review Questions
Notes
Chapter 16 Procreation and Ethical
Dilemmas
Learning Objectives
Abortion
Sterilization
Artificial Insemination
Surrogacy
Chapter Review
Review Questions
Notes
Chapter 17 End-of-Life Issues
Learning Objectives
Patient Autonomy
Constitutional Right to Refuse Care
Legislative Response
Defining Death
Futility of Treatment
Do-Not-Resuscitate Orders
Withholding and Withdrawal of Treatment
Euthanasia
Physician-Assisted Suicide
Advance Directives
Autopsy
Organ Donations and Transplantation
Research, Experimentation, and Clinical Trials
Human Genetics
Stem Cell Research
Chapter Review
Review Questions
Notes
Chapter 18 Legal Reporting Requirements
Learning Objectives
Abuse
Child Abuse
Senior Abuse
Communicable Diseases
Aids
Births and Deaths
Adverse Drug Reactions
Physician Competency
Incident Reporting
Sentinel Events
Look Closer, See Me
Chapter Review
Review Questions
Notes
Chapter 19 Labor Relations
Learning Objectives
U.S. Department of Labor
Unions and Healthcare Organizations
National Labor Relations Act
Norris–Laguardia Act
Labor–Management Reporting and Disclosure Act
Fair Labor Standards Act
Civil Rights Act
Occupational Safety and Health Act
Rehabilitation Act
Family and Medical Leave Act
State Labor Laws
Workers’ Compensation
Labor Rights
Management Rights
Affirmative Action Plan
Patient Rights During Labor Disputes
Injunctions
Administering Collective Bargaining Agreement
Discrimination in the Workplace
Chapter Review
Review Questions
Notes
Chapter 20 Employment at Will, Rights, and
Responsibilities
Learning Objectives
Employment at Will
Public Policy Issues and Termination
Termination
Unemployment Compensation
Wrongful Discharge
Defending a Claim for Unfair Discharge
Fairness: The Ultimate Test
Effective Hiring Practices
Employee Rights
Employee Responsibilities
The Caregiver’s Pledge
Chapter Review
Review Questions
Notes
Chapter 21 Professional Liability Insurance
Learning Objectives
Insurance Policies
Insurance Policy Provisions
Conditions of Insurance Policies
Liability of the Professional
Intentional Torts: Coverage Denied
Medical Liability Insurance
Self-Insurance
Trustee Coverage
Mandated Medical Staff Insurance Coverage
Investigation and Settlement of Claims
Chapter Review
Review Questions
Notes
Chapter 22 Managed Care and National
Health Insurance
Learning Objectives
Managed Care
Models of Managed Care Organizations
Federally Qualified HMO
State HMO Laws
Case Management Firms
Third-Party Administrators
Utilization Review
Liability for Nonparticipating Hospitals
Employee Retirement Income Security Act
Reducing Exposure to Liability
Health Care Quality Improvement Act of 1986
Ethics in Patient Referral Act (1989)
Managed Care and Legal Actions
Price Fixing
Market Power
National Health Insurance
Veterans Care
Chapter Review
Review Questions
Notes
Author’s Afterword
Glossary
Index
Epigraph
I consider ethics, as well as religion, as supplements to law
in the government of man.
—Thomas Jefferson, President of the United States (1743–1826)
In law a man is guilty when he violates the rights of others.
In ethics he is guilty if he only thinks of doing so.
—Immanuel Kant, Philosopher (1724−1804)
Books are the carriers of civilization. Without books, history
is silent, literature dumb, science crippled, thought and
speculation at a standstill. I think that there is nothing, not even
crime, more opposed to poetry, to philosophy, ay, to life itself than
this incessant business.
—Henry David Thoreau, Author, Poet, Philosopher (1817–1862)
It is curious—curious that physical courage should be so
common in the world, and moral courage so rare.
—Mark Twain, American Author, Humorist (1835−1910)
In civilized life, law floats in a sea of ethics.
—Earl Warren, Chief Justice of the United States (1891–1974)
How far you go in life depends on your being tender with
the young, compassionate with the aged, sympathetic with
the striving, and tolerant of the weak and the strong— because
someday you will have been all of these.
—George Washington Carver, American Inventor (1864–1943)
Preface
He has achieved success who has lived well, laughed often
and loved much; who has gained the respect of intelligent
men and the love of little children; who has filled his niche and
accomplished his task; who has left the world better than he found
it, whether by an improved poppy, a perfect poem, or a rescued
soul; who has never lacked appreciation of earth’s beauty or failed
to express it; who has always looked for the best in others and
given them the best he had; whose life was an inspiration; whose
memory a benediction.
—Bessie Stanley
L
egal Aspects of Health Care Administration, Thirteenth
Edition, as with the previous 12 editions, continues to be the
most comprehensive and engaging book encompassing both the
legal and ethical issues of healthcare administration. The
Thirteenth Edition continues its tradition of providing a solid
foundation in a wide range of current healthcare topics in an
understandable format that carefully guides the reader through the
complex maze of law and ethics, as well as an overview of
practical ways to improve quality and safety in the delivery of
patient care. As in previous editions, the Thirteenth Edition serves
as a valuable tool for both undergraduate and graduate programs.
Additionally, as has been well recognized by practicing healthcare
professionals, Legal Aspects of Health Care Administration
continues to be a valuable reference tool in their day-to-day work
activities.
The author infuses life into the educational process through legal
case studies that have been litigated in the courtroom or reported
in the press, as well as real-world healthcare events through
“reality checks” experienced by patients and healthcare
professionals. The author’s approach inspires dynamic discussion
and excitement in the learning process, thus creating an
atmosphere of interest and participation, which is conducive to
learning.
Although the court cases relating examples of malpractice are
often mirror images of the failures of medicine, this Thirteenth
Edition provides a comprehensive resource from which the reader
will learn how the law, ethics, and medicine intertwine. The
contents of this book serve as a reminder to its readers of the
need to learn from the mistakes and tragedies experienced by
others to avoid repeating them. The legal cases and resulting
headlines should stand as a reminder of the responsibility that
caregivers bear to the profession they have chosen.
With revised estimates that as many as 400,000 patients die each
year as a result of medical errors, according to a September 2013
study reported in the Journal of Patient Safety, it is mandatory that
caregivers be ever mindful of the nature of the life-and-death
settings within which they work. At the time of this writing the
headlines continue to repeat themselves. For example, on
December 4, 2014, an Oregon hospital’s medication error led to
the death of a 65-year-old patient. This error resulted in three
employees being placed on administrative leave. The knowledge
gained here will help prevent caregivers from becoming the next
headline.
Although there will always be a “next time” for human error, the
reader who grasps the contents in this book and understands its
lessons will better understand how failures can turn to success
and the pain of past mistakes can turn to hope. The application of
the knowledge gained from this book and in the classroom
learning process will serve to improve the competency of the
reader and the quality of life for the patient through an educational
process that will help prevent further injury in the healing process.
About the Book
Legal Aspects of Health Care Administration, Thirteenth Edition,
lays a strong foundation in both health law and ethics. Chapter 1
begins with a review of hospitals through the ages, providing the
reader with an overview of the historical development of hospitals
as influenced by medical progress. This allows the reader to see
the successes and failures of hospitals through the centuries and
how history has a way of repeating itself, thus creating a need to
learn from past mistakes in order to prevent repeating them.
Chapter 2 continues with an introduction to government, law, and
ethics.
Chapters 3 and 4 introduce the reader to negligence and
intentional torts. Chapter 5 discusses tort reform and risk
reduction, thus reducing the costs of health care. Chapter 6
reviews the criminal aspects of health care, and Chapter 7 reviews
the basics of contract law as it pertains to healthcare
professionals. The reader is then introduced to civil procedure and
trial practice in Chapter 8. The reader’s journey continues with a
discussion of corporate structure and related legal issues in
Chapter 9. A review of medical staff organization and physician
liability is covered in Chapter 10, followed by nursing and the law
and common nursing practice errors in Chapter 11. Chapter 12
reviews the legal risks of various other hospital departments and
healthcare professions.
Information management and patient records are reviewed in
Chapter 13. Issues related to patient consent, rights, and
responsibilities are reviewed in Chapter 14, followed by a
discussion of ethical theories, principles, virtues, and values.
Chapter 15 concentrates on healthcare ethics, theories, principles,
and values. This review is followed by procreation and ethical
dilemmas in Chapter 16, and end-of life issues in Chapter 17.
Legal reporting requirements are discussed in Chapter 18. Labor
relations and employment-at-will, employee rights, and employee
responsibilities are reviewed in Chapters 19 and 20, respectively.
An overview of professional liability insurance, managed care, and
national health insurance is provided in Chapters 21 and 22.
The practical application of the law and ethics in the healthcare
setting is accomplished by interspersing the thoughts of great
minds through Quotes, applicable News Clippings, provider and
organizational experiences through Reality Checks, and patient
experiences through legal rulings and summaries through Case
Law. When reviewing the various cases, the reader should
consider both the ethical and legal implications of a dilemma and
how they intertwine with one another. It is important to recognize
that the decisions in the cases described are generally governed
both by applicable state and federal statutes and common law
principles. When reviewing a case, the reader must keep in mind
that the case law and statutes of one state are not binding in
another state.
There is no one magical legal or ethics book that can possibly
compress into its pages the plethora of issues that have
bombarded the healthcare industry. This book is merely a
beginning of the study of legal and ethical issues and is an
adventure that all caregivers should take. Although there is always
much more that could be discussed on any one topic, the reader
will understand that this book provides a solid foundation for
practical everyday use as well as further study in the law and
ethics.
Each life is like a novel. Filled with moments of happiness,
sadness, crisis, defeat, and triumph. When the last page
has been written, will you be happy or saddened by what you
read?
—Author Unknown
The Thirteenth Edition presents real-world life experiences that
bring the reader through a journey of learning that provides an
effective transitional stage from the classroom to the reality of the
everyday work environment. When considering matters of law and
ethics, healthcare professionals are usually considering matters of
freedom in regard to personal choices, one’s obligations to other
sentient beings, or judgments about human character and the right
to choose. The author’s objective is to equip the reader with the
background knowledge necessary to understand that legal and
ethical behavior begins with recognizing that we have alternatives
and choices in our behavior. To make good decisions, each
individual must first understand that those decisions will only be as
good as the knowledge and understanding he or she possesses of
right and wrong. This book is not an indictment of any profession
or organization. There is a deluge of ethical issues in every aspect
of human existence. Although cultural differences, politics, and
religion influence who we are, it is all of life’s experiences that
affect who we become.
IT’S YOUR GAVEL . . .
“It’s Your Gavel” boxes offer the reader an opportunity to make
their own decisions about actual court cases. Many chapters begin
with a case that has been reviewed by the courts in state or
federal jurisdictions. After reviewing each case and subsequent
relevant material, readers can take on the role of the fact finder
and render a decision. Then, at the end of the respective chapters,
the actual court findings and reasoning for each case are given in
“The Court’s Decision” box.
▸ Case Presentation Format
When reviewing the various cases in this book, the reader should
consider what happened, why things went wrong, what the
relevant legal issues are, and how the event could have been
prevented. The reader should also consider how, if one fact in a
particular case changed, the outcome might have been different.
What would that fact be? The cases presented in the text have
been chosen because of the frequency of their occurrence. The
general format for each boxed case review is as follows:
Title: Each case has a title that signals the type of case to be
reviewed.
Case Citation: The case citation describes where a court’s
opinion in a particular case can be located. It identifies the parties
in the case, the text in which the case can be found, the court
writing the opinion, and the year in which the case was decided.
For example, the case citation of Bouvia v. Superior Court
(Glenchur), 225 Cal. Rptr. 297 (Cal. Ct. App. 1986) is described as
follows:
Bouvia v. Superior Court (Glenchur): Identifies the basic
parties involved in the lawsuit
225 Cal. Rptr. 297: Identifies the case as being reported in
volume 225 of the California Reporter on page 297
Cal. Ct. App. 1986: Identifies the case as being decided in
the California Court of Appeals in 1986
Students who wish to research a specific case should visit a law
school library, which provides access to various state and regional
reporters.
Facts: A review of the material facts of the case is presented.
Issues: This is the disputed point or question the judge or jury
must decide. The issues discussed in any given case are selected
for review based on medical and legal pertinence to the healthcare
professional. Although any one case in this text may have multiple
issues, emphasis is placed on those issues considered to be more
relevant for the reader in the context of the topic being discussed.
Holding: The court’s ruling based on the facts, issues, and
applicable laws pertaining to a case is summarized.
Reason: The rationale for the court’s decision based on the facts,
issues, and relevant laws surrounding a case is presented.
Author’s Note: This book is not a definitive treatise, but rather a
portrait of the ever-evolving story of health care through the study
of law and ethics. It is educational in nature and should not be
considered a substitute for legal advice on any particular issue.
Moreover, each chapter presents an overview, rather than an
exhaustive treatment, of the various topics discussed.
The author, legal reviewers, and/or the publisher cannot be
responsible for any errors or omissions, including additions to,
interpretations of, and/or changes in the regulations presented in
this book.
Acknowledgments
The author especially acknowledges the staff at Jones & Bartlett
Learning, whose guidance and assistance was so important in
making this Thirteenth Edition a reality. Special thanks to Mike
Brown, Director of Product Management at Jones & Bartlett
Learning, who has once again been truly an amazing leader and
mentor. I would like to thank Danielle Bessette, Product Specialist,
who worked diligently and tirelessly with me on this Thirteenth
Edition. I would also especially like to acknowledge Sophie
Teague, Senior Marketing Manager, Brooke Haley, Production
Assistant, and Merideth Tumasz, Rights & Media Specialist, who
worked with me on the Thirteenth Edition. Thank you for allowing
me to leave behind this legacy of writing.
I am grateful to the very special people in the more than 1,000
hospitals and ambulatory sites from Alaska to Puerto Rico with
whom I have consulted, surveyed, and provided education over
many years. Their shared experiences have served to remind me
of the importance of making this book more valuable in the
classroom and as a reference for practicing healthcare
professionals.
To my students in healthcare law and ethics classes at the New
School for Social Research, Molloy College, Long Island
University–C.W. Post Campus, Saint Francis College, and Saint
Joseph’s College; my intern from Brown University; my resident in
hospital administration from The George Washington University;
and those I have instructed through the years at various seminars,
I will always be indebted for your inspiration.
Many thanks are also extended to all of the special people at the
National Library of Medicine and the Library of Congress for their
guidance over the years in locating research materials.
© Hein Nouwers/Shutterstock, Inc.
CHAPTER 1
Hospitals Through the Ages
I was created at the end of the Renaissance, watched
pirates rule the oceans as Ivan the Terrible ruled Russia,
and witnessed the arrest of Galileo for believing the Earth revolved
around the Sun.
—I Am History
▸ LEARNING OBJECTIVES
The reader, upon completion of this chapter, will be able to:
Explain how societal conflicts due to politics, religion, and
warfare have both impeded the growth of hospitals and
contributed to their progress.
Describe how advances in medicine led to the rise of the
modern-day hospital and improved the quality of patient
care.
Describe how the knowledge gained from best practices
(e.g., infection control) can lead to progress while at the
same time result in patient harm if not consistently followed
over time.
We can learn from history how past generations thought
and acted, how they responded to the demands of their
time and how they solved their problems. We can learn by
analogy, not by example, for our circumstances will always be
different than theirs were. The main thing history can teach us is
that human actions have consequences and that certain choices,
once made, cannot be undone. They foreclose the possibility of
making other choices and thus they determine future events.
—Gerda Lerner 1
This chapter provides the reader with notable historical events,
from ancient civilizations to the present time, which continue to
revolutionize the delivery of patient care. It provides a review of
the advance of civilization as disclosed in the history of hospitals
and medical achievements through the ages. A study of the past
often reveals errors that then can be avoided, customs that persist
only because of tradition, and practices that have been
superseded by others that are more effective. The past may also
bring to light long-abandoned practices, which may be revived to
some advantage. The story of the birth and evolution of the
hospital portrays the triumph of civilization over barbarism and the
progress of civilization toward an ideal characterized by an interest
in the welfare of the community.
This chapter reviews some of the most amazing medical
discoveries and achievements in the history of medicine. It also
describes some of the failures that continue to plague the
healthcare industry. The importance of the study of history is
undeniable. The Spanish philosopher George Santayana (1863–
1952) recognized this all too well when he said, “Those who do not
remember the past are condemned to repeat it.” George Bernard
Shaw (1856–1950), an Irish dramatist and socialist, recognized
the tragedies of the history of civilization when he said, “If history
repeats itself, and the unexpected always happens, how incapable
must man be of learning from experience.” Yes, Santayana and
Shaw are right: If we do not learn from the mistakes of the past,
we are doomed to repeat them. Progress in health care will only
prevail so long as advances in medicine are practiced by each
new generation. Although the struggle to progress is a road filled
with many pitfalls, hope still looms.
Martin Makary wrote in the Wall Street Journal that “Medical errors
kill enough people to fill four jumbo jets a week . . . To do no harm
going forward, we must be able to learn from the harm we have
already done.”2 If we do not learn from historical events to those of
the present days, we are bound to repeat them. This chapter takes
the reader on a journey from the past to the present, from which to
spring forward on a better road that returns the people’s trust in
the safety net of the nation’s hospital systems. Here, we go “back
into the future” to bring forth the fruits of healthier hospitals and
healthier lives. Let the reader now travel that road.
▸ EARLY HINDU AND EGYPTIAN
HOSPITALS
Two ancient civilizations, the Hindu (in what is now India) and the
Egyptian, had crude hospitals. Hindu literature reveals that in the
6th century BC, Buddha appointed a physician for every 10
villages and built hospitals for the crippled and the poor. His son,
Upatiso, built shelters for the diseased and for pregnant women.
These examples probably moved Buddha’s devotees to erect
similar hospitals. Despite a lack of records, historians agree that
hospitals existed in Ceylon as early as 437 BC.
During his reign from 273 to 232 BC, King Asoka built 18 hospitals
that hold historical significance because of their similarities to the
modern hospital. Attendants gave gentle care to the sick, provided
patients with fresh fruits and vegetables, prepared their medicines,
gave massages, and maintained their personal cleanliness. Hindu
physicians, adept at surgery, were required to take daily baths,
keep their hair and nails short, wear white clothes, and promise
that they would respect the confidence of their patients. Although
bedside care was outstanding for those times, medicine was only
beginning to find its way.
Egyptian physicians were probably the first to use drugs such as
alum, peppermint, castor oil, and opium. In surgery, anesthesia
consisted of hitting the patient on the head with a wooden mallet to
render the patient unconscious. Surgery was largely limited to
fractures, and medical treatment was usually given in the home.
Therapy away from home was often available in temples, which
functioned as hospitals.
▸ GREEK AND ROMAN HOSPITALS
The term hospital derives from the Latin word hospitalis, which
relates to guests and their treatment. The word reflects the early
use of these institutions not merely as places of healing, but also
as havens for the poor and weary travelers. Hospitals first
appeared in Greece as aesculapia, named after the Greek god of
medicine, Aesculapius. For many centuries, hospitals developed in
association with religious institutions, such as the Hindu hospitals
opened in Sri Lanka in the 5th century BC and the monasterybased European hospitals of the Middle Ages (5th century to 15th
century AD). The Hotel-Dieu in Paris, a monastic hospital founded
in 660 AD, is still in operation today.
In early Greek and Roman civilization, when medical practices
were rife with mysticism and superstitions, temples also were used
as hospitals. Every sanctuary had a sacred altar before which the
patient, dressed in white, was required to present gifts and offer
prayers. If a patient was healed, the cure was credited to miracles
and divine visitations. If the patient remained ill or died, he or she
was considered to be lacking in purity and unworthy to live.
Greek temples provided refuge for the sick. One of these
sanctuaries, dedicated to Aesculapius, is said to have existed as
early as 1134 BC at Titanus. Ruins attest to the existence of
another, more famous Greek temple built several centuries later in
the Hieron, or sacred grove, at Epidaurus. Here, physicians
ministered to the sick holistically in body and soul. They prescribed
medications such as salt, honey, and water from a sacred spring.
They gave patients hot and cold baths to promote speedy cures
and encouraged long hours of sunshine and sea air, combined
with pleasant vistas, as an important part of treatment. The temple
hospitals housed libraries and rooms for visitors, attendants,
priests, and physicians. The temple at Epidaurus even boasted
what might be described as the site of the first clinical records. The
columns of the temple were inscribed with the names of patients,
brief histories of their cases, and comments as to whether or not
they were cured.
The aesculapia spread rapidly throughout the Roman Empire, as
well as through the Greek world. Although some hospitals were
simply spas, others followed the therapy outlined by the leading
physicians of the day. Hippocrates, for example, a physician born
about 460 BC, advocated medical theories that have startling
similarity to those of the present day. He employed the principles
of percussion and auscultation, wrote intelligently on fractures,
performed numerous surgical operations, and described such
conditions as epilepsy, tuberculosis, malaria, and ulcers. He also
kept detailed clinical records of many of his patients. Physicians
like Hippocrates not only cared for patients in the temples, but also
gave instruction to young medical students.
▸ HOSPITALS OF THE EARLY
CHRISTIAN ERA
Christianity and the doctrines preached by Jesus stressing the
emotions of love and pity gave impetus to the establishment of
hospitals, which, with the advance of Christianity, became integral
parts of the church institution. These Christian hospitals, which
replaced those of Greece and Rome, were devoted entirely to care
of the sick, and accommodated patients in buildings outside the
church proper.
A decree of Constantine in 335 AD closed the aesculapia and
stimulated the building of Christian hospitals, which, during the 4th
and 5th centuries, reached the peak of their development. Many
were erected by the rulers of the period or by wealthy Romans
who had converted to Christianity. By the year 500, most large
towns in the Roman Empire had hospitals. Nursing, inspired by
religion, was gentle and considerate, but soon began to discard
the medical precepts of Hippocrates, Antyllus, and other early
Greek physicians because of their pagan origins. Instead, health
care turned toward mysticism and theurgy (the working of a divine
agency in human affairs) as sources of healing.
Hospitals rarely succeeded during the centuries leading to the
Middle Ages; only a few existed outside Italian cities. Occasional
almshouses in Europe sheltered some of the sick, whereas inns
along the Roman roads housed others. No provision appears to
have been made for care of the thousands of helpless paupers
who had been slaves and were later set free when Christianity
was introduced into the Roman Empire.
▸ ISLAMIC HOSPITALS
The followers of Mohammed were almost as dedicated as the
Christians in caring for the sick. In Baghdad, Cairo, Damascus,
Cordova, and many other cities under their control, luxurious
hospital accommodations were frequently provided. Harun alRashid, the glamorous caliph (a title for a religious or civil ruler
claiming succession from Mohammad) of Baghdad (786–809 AD),
built a system of hospitals and paid the physicians himself.
Medical care in these hospitals was free. Approximately four
centuries later, in 1160, a Jewish traveler reported that he had
found as many as 60 dispensaries and infirmaries in Baghdad
alone. The Persian physician Rhazes, who lived from
approximately 850 to 923 AD, was skilled in surgery. He is
believed to be the first to use the intestines of sheep for suturing
and to cleanse patient wounds with alcohol. He also gave the first
rational accounts of smallpox and measles.
Islamic physicians like Rhazes received much of their medical
knowledge from the persecuted Christian sect known as the
Nestorians. Nestorius (Archbishop of Constantinople from April
428 to August 431) was driven into the desert with his followers
after having been appointed patriarch of Constantinople and took
up the study of medicine. The school at Edessa, in Mesopotamia,
with its two large hospitals, eventually came under the control of
the Nestorians, where they established a remarkable teaching
institution. Eventually driven out of Mesopotamia by the orthodox
bishop Cyrus, they fled to Persia, where they established the
famous school at Gundishapur, which is considered to be the true
starting point of Islamic medicine. Gundishapur was home to the
world’s oldest known teaching hospital and also comprised a
library and a university. It was located in the present-day province
of Khuzestan, in southwestern Iran, not far from the Karun River.
Islamic medicine flourished up to about the 15th century.
Physicians were acquainted with the possibilities of inhalation
anesthesia. They instituted precautions against adulteration of
drugs and developed a vast number of new drugs. Islamic
countries also built asylums for the mentally ill 1,000 years before
such institutions appeared in Europe. The people of Islam made a
brilliant start in medicine, but never fulfilled the great promise that
glowed in their early work in medical arts and hospitalization was
never fulfilled. Wars, politics, superstitions, and a nonprogressive
philosophy stunted the growth of a system that had influenced the
development of hospitals.
▸ EARLY MILITARY HOSPITALS
Engraved on a limestone pillar dating back to the Sumerians (2920
BC) are pictures that depict, among other military procedures, the
assemblage of the wounded. The Book of Deuteronomy records
that Moses established outstanding rules for military hygiene. Out
of the urgency of care for the wounded in battle came much of the
impetus for medical progress. Hippocrates is quoted as saying that
“war is the only proper school for a surgeon.” Under the Romans,
surgery advanced largely because of experience gained through
gladiatorial and military surgery. Throughout the centuries, warfare
has been a two-edged sword, producing tragic events while
providing an environment for the advancement of surgery and
medicine. From an ethical point of view, the question arises: What
surgical and medical advancements might have been lost due to
the failure of mankind to sit at the table of peace and compromise
on differences based on logic and reason?
▸ MEDIEVAL HOSPITALS
Religion continued to be the most important factor in the
establishment of hospitals during the Middle Ages. A number of
religious orders created hospitia, or travelers’ rests, and infirmaries
adjacent to monasteries provided food and temporary shelter for
weary travelers and pilgrims. One of these, the famous alpine
hospice of St. Bernard, founded in 962, gave comfort to the weary
and sent its renowned dogs to the rescue of lost mountain
climbers.
The hospital movement grew rapidly during the Crusades, which
began in 1096. Military hospital orders sprang up, and
accommodations for sick and exhausted crusaders were provided
along well-traveled roads. One body of crusaders organized the
Hospitallers of the Order of St. John, which in 1099 established in
the Holy Land a hospital capable of caring for 2,000 patients.
Knights of this order took personal charge of service to patients
and often denied themselves so that the sick might have food and
medical care. For years, these institutions were the best examples
of hospitals of that period.
Although physicians cared for physical ailments to afford relief,
they rarely attempted to cure the sick. Dissection of a human body
would have been sacrilege because the body was created in the
image of God.
Finally, an active period of hospital growth came during the late
12th and early 13th centuries. In 1198, Pope Innocent III urged
hospitals of the Holy Spirit to be subscribed for by the citizenry of
many towns. He set an example by founding a model hospital in
Rome, known as Santo Spirito, in Sassia. Built in 1204, it survived
until 1922, when it was destroyed by fire. In Rome, nine other
hospitals were founded shortly after completion of the one in
Sassia; it is estimated that in Germany alone, 155 towns had
hospitals of the Holy Spirit during early medieval times.
Although most hospitals constructed during the Middle Ages were
associated with monasteries or founded by religious groups, a few
cities, particularly in England, built municipal institutions. Like all
hospitals of the period, the buildings were costly and often
decorated with colorful tapestries and stained glass windows, but
the interiors were frequently little more than large drafty halls with
beds lining each side. Some hospitals were arranged on the ward
plan, usually built in the shape of a cross. Floors were made of red
brick or stone, and the only ventilation came from the cupola in the
ceiling.
With the spread of leprosy during the 12th and 13th centuries,
lazar houses sprang up, supplying additional hospital facilities.
Made up of crude structures, lazar houses were usually built on
the outskirts of towns and maintained for the segregation of lepers
rather than for their treatment. Special groups of attendants,
including members of the Order of St. Lazar, nursed the patients.
The group represented an important social and hygienic
movement because their actions served to check the spread of
epidemics through isolation. The group is credited for virtually
stamping out leprosy.
During the same period of hospital growth, three famous London
institutions were established: St. Bartholomew’s in 1137, St.
Thomas’s before 1207, and St. Mary of Bethlehem in 1247. St.
Bartholomew’s, founded by Rahere (reportedly the court jester of
Henry I), cared for the sick poor but, unlike many hospitals of that
day, was well organized. St. Thomas’s Hospital was founded by a
woman who was later canonized St. Mary Overie. It burned in
1207, was rebuilt 6 years later, and was constructed again on a
new site in 1228. St. Mary of Bethlehem was the first English
hospital to be used exclusively for the mentally ill.
The Hotel-Dieu of Paris was probably typical of the better hospitals
of the Middle Ages. Built at the beginning of the 13th century, the
hospital provided four principal rooms for patients in various
stages of disease, as well as a room for convalescents and
another for maternity patients. Illustrations by artists of the time
show that two persons generally shared one bed.
Heavy curtains sometimes hung from canopies over the bed to
afford privacy, but this advantage was more than offset by the fact
that the draperies, which were never washed, spread infection and
prevented free ventilation. The institution was self-contained,
maintaining a bakery, herb garden, and farm. Often, patients who
had fully recovered remained at the hospital to work on the farm or
in the garden for several days in appreciation for the care they had
received.
▸ THE “DARK AGE” OF HOSPITALS
Pictures and records of hospitals during the Middle Ages illustrate
how many hospitals commonly crowded several patients into one
bed regardless of the type or seriousness of the illness. A mildly ill
patient might be placed in the same bed as an occupant suffering
from a contagious disease. A notable exception to the general
deterioration in medicine during this era was the effort of those
monks who copied by hand and preserved the writings of
Hippocrates and other ancient physicians.
The great Al-Mansur Hospital, built in Cairo in 1276, struck a
contrast to the European institutions of the Middle Ages. It was
equipped with separate wards for the more serious diseases and
provided outpatient clinics. The handful of hospitals like Al-Mansur
would lay the groundwork for hospital progress to come in later
centuries.
▸ HOSPITALS OF THE RENAISSANCE
During the revival of learning around the close of the 14th century,
hundreds of medical hospitals in Western Europe received the
new, more inquiring surgeons that the Renaissance produced.
New drugs were developed, and anatomy became a recognized
study. Ancient Greek writings were printed, and dissection was
performed by such masters as Leonardo da Vinci, known as the
originator of cross-sectional anatomy, and Andreas Vesalius,
author of De Humani Corporis Fabrica (On the Fabric of the
Human Body), on human anatomy. Hospitals became more
organized. Memoranda from 1569 describe the duties of the
medical staff in the civil hospital of Padua, a city that was home to
the most famous medical school of the 16th century. These read:
There shall be a doctor of physic upon whom rests the duty of
visiting all the poor patients in the building, females as well as
males; a doctor of surgery whose duty it is to apply ointments
to all the poor people in the hospital who have wounds of any
kind; and a barber who is competent to do, for the women as
well as the men, all the other things that a good surgeon
usually does.3
The practice of surgery during the Renaissance became more
scientific and progressive. Operations for lithotomy and
hernioplasty were undertaken without the use of anesthetics, and
surgery was practiced by the long-robe surgeons, a small group
who were educated in the universities and permitted to perform all
types of operations, and by the short-robe surgeons, the barbers
who, in most communities, were allowed only to leech and shave
the patient, unless permission was granted to extend the scope of
treatment. Both groups were regarded as inferior to physicians.
In 1506, a band of long-robe surgeons organized the Royal
College of Surgeons of Edinburgh. By 1540, both the long- and
short-robe surgeons in England joined to form the Company of
Barber-Surgeons of London. In 1528, Thomas Linacre, physician
to Henry VIII, founded and became the first president of the Royal
College of Physicians of England.
Although English physicians were organized during the 16th
century, Henry VIII of England ordered that hospitals associated
with the Catholic Church be given over to secular uses or
destroyed. The sick were turned out into the streets. Conditions in
hospitals became so intolerable that the king was petitioned to
return one or two buildings for the care of patients. Henry
consented and restored St. Bartholomew’s in 1544. Practically the
only hope for the sick poor from outlying towns was to journey
many miles to London.
The dearth of hospitals in England continued throughout the 17th
century, when the medical school was developed. The French and
the English quickly accepted what had originated in Italy—the first
attempt to make medical instruction practical. St. Bartholomew’s
took the lead in education by establishing a medical library in 1667
and permitted apprentices to walk the wards for clinical teaching
under experienced surgeons.
In 1634, an outstanding contribution was made to nursing by the
founding of the order of the Daughters of Charity of St. Vincent de
Paul. Originating at the Hotel-Dieu of Paris as a small group of
village girls who were taught nursing by the nuns, the order grew
rapidly and was transplanted to the United States by Mother Seton
in 1809.
▸ HOSPITALS OF THE 18TH CENTURY
During the 18th century, the building of hospitals began to revive.
Because of poverty, the movement made slow progress in
England, but a few hospitals were built and supported jointly by
parishes. By 1732, there were 115 such institutions in England,
some of them a combination of almshouse and hospital. As
hospitals grew in number, new advances in health care began.
The Royal College of Physicians established a dispensary where
medical advice was free and medicines were sold to the needy at
cost. Controversies and lawsuits, however, brought an untimely
end to this early clinic. Not discouraged by this experience, the
Westminster Charitable Society created a similar dispensary in
1715. The same organization, in 1719, founded Westminster
Hospital, an infirmary built by voluntary subscription, in which the
staff gave its services gratuitously. Ten years later, the Royal
College of Physicians in Edinburgh opened the Royal Infirmary.
London Hospital, another notable institution, was founded in 1740.
Admission of charity patients to the London Hospital was
apparently by an admission ticket. Among its historical relics is an
admission card that had on the back of the card a representation
of a biblical scene drawn by the artist William Hogarth.
In 1727, John Theophilus Desaguliers invented a machine for
pumping fresh air into and foul air out of rooms. It was first used in
prisons and public buildings and later installed in hospitals. Other
mechanical improvements for the care of the sick were sadly
wanting, but worse was the lack of cleanliness and the crude and
careless treatment of patients.
In the Elizabethan period, with its materialistic and cold culture, the
deterioration of hospital service that had set in under Henry VIII
continued. The lowest point in the deterioration of hospitals came
during the 18th and first half of the 19th centuries. Considering the
increase in knowledge during the 18th century, development of
educational opportunities, and steady growth in population and
wealth, the few hospitals built at that time were inadequate. As far
as hospital progress is concerned, the 18th century was not only
decidedly uneventful; it was a period of regression. The full revival
did not begin until well after the middle of the 19th century.
Antony van Leeuwenhoek (1632–1723) succeeded in making
some of the most important discoveries in the history of biology.
Although van Leeuwenhoek did not invent the first microscope, he
was able to perfect it. His many discoveries included bacteria,
free-living and parasitic microscopic protists, sperm cells, blood
cells, and microscopic nematodes. His research opened up an
entire world of microscopic life. Often referred to as the “father of
microbiology,” van Leeuwenhoek had a pronounced influence on
the creation of the sciences of cytology, bacteriology, and
pathology. His discoveries have forever improved patient care.
▸ EARLY HOSPITALS IN THE UNITED
STATES
Manhattan Island claims the first account of a hospital in the New
World, a hospital that was used in 1663 for sick soldiers. Fifty
years later, in Philadelphia, William Penn founded the first
almshouse established in the American colonies. The Quakers
supported the almshouse, which was open only to members of
that faith. However, Philadelphia was rapidly growing and in need
of a public almshouse. Such an institution for the aged, the infirm,
and persons with mental illness was established in 1732. The
institution later became the historic Old Blockley, which, in turn,
evolved into the Philadelphia General Hospital.
Philadelphia was the site of the first incorporated hospital in
America, the Pennsylvania Hospital. Dr. Thomas Bond wanted to
provide a place where Philadelphia physicians could treat their
private patients. With the aid of Benjamin Franklin, Dr. Bond
sought a charter for the Pennsylvania Hospital, which was granted
by the Crown in 1751. Franklin assisted in designing the hospital.
It included a central administration unit and two wings opened to
the public. The first staff consisted of Dr. Phineas Bond, Dr. Lloyd
Zachary, and the founder, Dr. Thomas Bond, all of whom gave
their services without remuneration for 3 years.
Rich in the history of hospitals, Philadelphia is credited with the
first quarantine station for immigrants (created in 1743) and the
first lying-in hospital (established in 1762), a private institution
owned by the noted obstetrician William Shippen. The quality of
American health care seemed to be improving. However, by 1775
Dr. John Jones published a book calling attention to the frightful
conditions that existed in hospitals. He charged that hospitals
abroad were crowded far beyond capacity and that Hotel-Dieu of
Paris frequently placed three to five patients in one bed—putting
the convalescent with the dying and fracture cases with infectious
cases. He estimated that one fifth of the 22,000 patients cared for
at Hotel-Dieu died each year. Wounds were washed daily with a
sponge that was carried from patient to patient. The infection rate
was said to be 100%, and mortality after amputation was as high
as 60%. Jones’s call to action had a positive effect on American
health care.
As late as 1769, New York City, with nearly 300,000 inhabitants,
was without hospitals. In 1771, a small group of citizens, Dr. Jones
among them, formed the Society of the New York Hospital and
obtained a grant to build a hospital. The society purchased a fiveacre site and made plans for a model structure that would allow a
maximum of eight beds per ward and provide improved ventilation.
The hospital fell into the hands of the British troops during the
American Revolution and was used as a barracks and military
hospital.
During postwar reconstruction, the New York Hospital broadened
its services. Under the supervision of Dr. Valentine Seaman, the
hospital began providing instruction in nursing, and in 1779, it
introduced vaccination in the United States and established an
ambulance service. Other early American hospitals of historic
interest include the first psychiatric hospital in the New World,
founded in Williamsburg, Virginia, in 1773, and a branch of federal
hospitals created by the passage of the U.S. Marine Hospital
Service Act in 1798. Under this act, two marine hospitals were
established in 1802: one in Boston and another in Norfolk,
Virginia.
The Massachusetts General Hospital (MGH), which pioneered
many improvements in medicine, originated in Boston. Its first
patient, admitted in 1821, was a 30-year-old sailor.
More than a decade earlier, two Boston doctors had appealed
to the city’s “wealthiest and most influential citizens” to
establish a general hospital. The War of 1812 delayed the
dream, but on July 4, 1818, the cornerstone was finally laid.
The original building, designed by Boston’s leading architect,
Charles Bulfinch, is still in use. One of the world’s leading
centers of medical research and treatment has grown up
around it. The original domed operating amphitheater, where
anesthesia was first publicly demonstrated in 1846, is now a
Registered National Historic Landmark. MGH has achieved
countless medical milestones, including the first successful
reattachment of a human limb.4
In 1832, the Boston Lying-In Hospital opened its doors to women
unable to afford in-home medical care. It was one of the nation’s
first maternity hospitals, made possible because of fundraising
appeals to individuals and charitable organizations.
Despite the increased number of institutions providing care for the
sick, the first half of the 19th century stands as a dark period in
hospital history. Surgeons of the day had sufficient knowledge of
anatomy to lead them to perform many ordinary operations, and
as a result, more surgery was most likely undertaken than during
any previous era. Although the medieval and ancient surgeons
had sought to keep wounds clean, even using wine in an attempt
to accomplish this purpose, 19th-century surgeons believed
suppuration (the production and discharge of pus) to be desirable
and encouraged it. Hospital wards were filled with discharging
wounds, which made the atmosphere offensive enough to warrant
the use of perfume. Some patient wards had multiple patients with
multiple conditions allowing for the spread of infections, as
depicted in FIGURE 1-1.
FIGURE 1-1 Patient ward.
© chippix/Shutterstock
Nurses of that period are said to have used snuff to make
conditions tolerable. Surgeons wore their operating coats for
months without washing. The same bed linens served several
patients. Pain, hemorrhage, infection, and gangrene infested the
wards. Mortality from surgical operations rated as high as 90–
100%. Nathan Smith, in the second decade of that century,
advocated a bichloride of mercury solution for reducing infection,
but his ideas were ignored.
▸ LATE 19TH CENTURY
RENAISSANCE
Florence Nightingale, the famous English nurse, began her career
by training at Kaiserswerth on the Rhine in a hospital and
deaconess home established in 1836 by Theodor Fliedner and his
wife. Florence Nightingale wrote disparagingly of her training
there, particularly of the hygiene practiced. Returning to England,
she put her own ideas of nursing into effect and rapidly acquired a
reputation for efficient work.
By 1854, during the Crimean War, the English government,
disturbed by reports of conditions among the sick and wounded
soldiers, selected Florence Nightingale as the one person capable
of improving patient care. Upon her arrival at the military hospital
in Crimea with a small band of nurses whom she had assembled,
she found that the sick were lying on canvas sheets in the midst of
dirt and vermin. There was neither laundry nor hospital clothing
and beds were made of straw. She proceeded to establish order
and cleanliness. She organized diet kitchens, a laundry service,
and departments of supplies, often using her own funds to finance
her projects. Ten days after her arrival, the newly established
kitchens were feeding 1,000 soldiers. Within 3 months, 10,000
soldiers were receiving clothing, food, and medicine. As a result of
her work, the death rate substantially declined. She has been
credited with observing:
A good nursing staff will perform their duties more or less
satisfactorily under every disadvantage. But while doing so,
their head will always try to improve their surroundings, in such
a way as to liberate them from subsidiary work, and enable
them to devote their time more exclusively to the care of the
sick.5
Because of her organizational skills, many consider Florence
Nightingale to be the first true healthcare administrator. Later she
extended her administrative duties to include planning the details
of sanitary engineering in a new military hospital.
As the field of nursing continued to progress, so did medicine. Dr.
Crawford Williamson Long first used ether as an anesthetic in
1842 to remove a small tumor from the neck of a patient. He did
not publish any accounts of his work until later. However, the
discovery of an anesthetic is often attributed to Dr. W.T.G. Morgan,
a dentist who developed sulfuric ether and arranged for the first
hospital operation under anesthesia at MGH in 1846. Although not
put to practical use immediately, ether soon took away some of the
horror that hospitals had engendered in the public mind. Sir James
Simpson first used chloroform as an anesthetic in 1847 for an
obstetrical case in England.
The year 1847 was the year that the American Medical
Association (AMA) was founded under the leadership of Dr.
Nathan Smith Davis. The association, among its main objectives,
strived to improve medical education, but most of the
organization’s tangible efforts in education began at the close of
the century. The AMA was a strong advocate for establishing a
code of ethics, promoting public health measures, and improving
the status of medicine.
The culmination of Florence Nightingale’s work came in 1860,
after her return to England. There, she established the Nightingale
School of Nursing at the St. Thomas’s Hospital. From this school,
a group of 15 nurses graduated in 1863. They later became the
pioneer leaders of nurse training.
In 1886, the Royal British Nurses’ Association (RBNA) was
formed. The RBNA worked toward establishing a standard of
technical excellence in nursing. A charter granted to the RBNA in
1893 denied nurses a register, although it did agree to maintain a
list of persons who could apply to have their name entered thereon
as nurses.6
The first formally organized American nursing schools were
established in 1872 at the New England Hospital for Women and
Children in Boston (Brigham and Women’s Hospital), and then in
1873 at Bellevue, New Haven, and Massachusetts General
Hospitals. In 1884, Alice Fisher was appointed as the first head of
nurse training at Philadelphia Hospital’s (renamed as the
Philadelphia General Hospital in 1902) nurses’ training program.
She had the distinction of being the first Nightingale-trained nurse
recruited to Philadelphia upon recommendation by Florence
Nightingale.
Mrs. Bedford Fenwick, a nurse leader in the English nurse
registration movement, traveled to Chicago in 1893 to arrange for
nursing exhibits to be displayed in the women’s building at the
World’s Fair.
This event showcased America's social, cultural, and scientific
advances and its growing cultural parity with Western Europe.
This was the first major exposition in which women played a
prominent role. Integral to the fair was a series of Congresses
that provided an international platform for discussion of social
issues. The Congress on Hospitals, Dispensaries, and Nursing,
a section of the International Congress of Charities, Correction,
and Philanthropy, particularly focused on health care issues.”7
As part of the Congress on Hospitals and Dispensaries, the
nursing section included papers on establishing standards in
hospital training schools, the establishment of a nurses
association, and nurse registration. The group formulated plans to
improve nursing curriculum and hospital administration in the first
concerted attempt to improve hospitals through a national
organization.
Progress in Infection Control
Dr. Ignaz Philipp Semmelweis of Vienna, Austria, unknowingly laid
the foundation for Louis Pasteur’s later work. In 1847, at the
Vienna Lying-In Hospital, Europe’s largest teaching obstetrical
department, he boldly declared that the alarming number of deaths
from puerperal fever was a result of infection transmitted by
students who came directly from the dissecting room to take care
of maternity patients. “Puerperal fever is due to an infection, most
often of the placental site within the uterus. If the infection involves
the bloodstream, it constitutes puerperal sepsis.”8 Semmelweis
noted that Division 1 of the hospital was a medical student–
teaching service and Division 2 was used for midwife trainees.
Maternal deaths for Division 1 averaged 10%, whereas the rate for
Division 2 averaged 3%. Medical students performed autopsies;
midwives did not. As a result of these findings, an order was
posted on May 15, 1847, requiring all students to scrub their
hands in chlorinated lime until the cadaver smell was gone. The
order was later revised to include hand washing between patients.
Despite having made bitter enemies, Semmelweis had the
satisfaction of seeing the mortality rate in his obstetrical cases
drop from 9.92% to 1.27% as a result of the aseptic technique he
developed. A few years later, Louis Pasteur, a French chemist and
microbiologist, demonstrated the scientific reason for
Semmelweis’s success when he proved that bacteria were
produced by reproduction and not by spontaneous generation, as
was then generally believed. From his work came the origin of
modern bacteriology and clinical laboratories.
Despite the attention given to the control of infections in hospitals,
adherence to hand-washing protocols continues to be a problem
well into the 21st century, as noted by the following reality check
and depicted in FIGURE 1-2.
FIGURE 1-2 Patient Room.
© Monkey Business Images/Shutterstock
FAILURE TO FOLLOW HAND HYGIENE
GUIDELINES
Sheri was a healthy 30-year-old female until she suddenly
experienced neck pain with a numbness radiating down her left
arm. She was diagnosed with cervical rib outlet syndrome and
agreed to a surgical procedure by Dr. Botchit for removal of her
first cervical rib. Sheri was admitted to a postsurgical care unit at
a major teaching hospital. Upon entering her assigned four-bed
room, she and her husband Bill observed a bloody suction bottle
hanging from the wall at the head of her assigned bed. The bed
rails were rusting with dried bloody body fluids from a previous
patient. They were uneasy about having a surgical procedure
performed but they decided the physician’s skills were more
important than an unclean room. Bill commented, “Well, at least
the sheets appear clean.”
Elda, the first patient on the left upon entering the room greeted
Sheri and Bill. She said, “The room isn’t very clean is it? Could
you watch out for the nurses?” She then smiled as she removed
Tylenol from her bedside table. She took a few and said, “I don’t
want my doctor to cancel my surgery, so I have to lower my
temperature before the nurses retake my temperature. I think I
have an infection. I have waited so long to get my surgery
scheduled. I am just so worried my surgery will be canceled.”
The morning following surgery, a third-year resident entered the
room with three first-year residents and beginning with Elda,
examined each of four postsurgical patients. Elda was a
postsurgical amputee, who was later diagnosed with a staph
infection. Sheri was the fourth patient to be examined in the
room. Even though each of the patient’s wounds had been
examined and dressings changed, the physicians failed to
change their surgical gloves between patients. Following
examination of Sheri, they proceeded to remove their gloves
and tossed them in Sheri’s bedside wastebasket. They then
washed their hands at the only sink in the room, which was by
Sheri’s bedside.
Sheri’s temperature began to rise. Bill asked if a wound culture
had been taken. Carol, the nurse manager after checking
Sheri’s chart said, said, “No culture was ordered.” He asked,
“Can you please have a culture ordered?” The nurse replied that
she would call Dr. Green to see if he would order a blood
culture.” Bill asked, “Who is Dr. Green?” Carol replied, “Dr.
Green is covering for Dr. Botchit while he is on vacation. Dr.
Botchit left on a family skiing trip the day after surgery to Aspen,
Colorado.”
Bill learned the following day that the blood tests came back
positive for a staph infection and learned that no antibiotics had
been prescribed by Dr. Green. Bill became increasingly
concerned about the lack of care and went back to the nursing
station to describe his concern about the lack of treatment for
Sheri. Carol suggested that he call Dr. Green.
Bill placed a call to Dr. Green and relayed his concern about his
wife’s deteriorating health. Dr. Green returning Bill’s call said, “I
hear you are unhappy with my care. I am merely providing
coverage for Dr. Botchit. I have my own patients to be
concerned with and treat.” Bill replied, ”Well if you are covering
for another physician you need to address my wife’s infection.”
Dr. Green replied, “I am doing a favor for Dr. Botchit by covering
his patients as well as mine. I will get to the hospital when I
can!”
Upon returning to his wife’s bedside, Sheri looked up at him and
said, “The priest was here and administered last rites to me.”
Looking at his mother-in-law, who was trying to be strong,
holding back the tears, Bill devotedly said, “I will fix this.” He
called Dr. Field, who he knew was a physician educator at the
medical center, and explained his concerns. Dr. Field said, “I
can help. I will get a team of infectious disease specialists to
Sheri’s bedside. They are the best in the city, probably the
world. But please do not use my name in any dispute that you
may have with Dr. Botchit or Dr. Green.” Sheri survived but the
staph infection had taken its toll on her immune system.
Sheri and Bill never thought much about it at the time, but in
hindsight, Elda’s infection was most likely the contributing factor
to the staph infections that eventually affected the other three
patients in the room. History repeated itself. Despite being
adopted by the hospital, the CDC hand-washing guidelines,
which could have helped prevent the infection, were not
followed,.
This reality check illustrates how the failure to follow established
protocols in the prevention of infections can have disastrous
consequences for patients. Progress in the delivery of patient
care can move forward only as long as complacency does not
stymie progress.
This case also provides an important lesson for patients who
treat themselves, masking their physical symptoms, as in this
case where the patient took Tylenol to hide her fever, an
indicator that the patient may have an active infection. Staff
should be alert to patients who self-treat and confiscate all home
and store bought medications upon admission to the hospital.
The lessons here also apply to family members, who must not
honor patient requests for medications.
This reality check serves as a reminder that history continues to
repeat itself. Strict adherence to CDC guidelines and hospital
policy must become the norm and not the exception for acceptable
hand hygiene in order to prevent the spread of infection by both
caregivers and patients. The Joint Commission’s (TJC) 2017
Hospital Accreditation Standards recognize the importance of
complying with hand hygiene guidelines. The standards require
hospitals and other accredited TJC organizations to follow current
CDC or World Health Organization guidelines for hand hygiene.9
When hand-washing guidelines have to be declared a TJC
national patient safety goal, it would appear that caregivers have
much to learn from Dr. Semmelweis, who determined in 1847 that
poor hand-washing technique can be attributed to being a major
cause of hospital-acquired infections. Dr. Ernst von Bergmann’s
introduction of steam sterilization in 1886 and Dr. William Stewart
Halsted’s introduction of rubber gloves in 1890 aided in reducing
the incidence of hospital-acquired infections.
By the end of the century, Dr. Joseph Lister carried Pasteur’s work
a step further and showed that wound healing could be hastened
by using antiseptics to destroy disease-bearing organisms and by
preventing contaminated air from coming into contact with these
wounds. Lister was not content with obtaining better results in his
own surgical cases; he devoted his life to proving that suppuration
is dangerous and that it could be prevented or reduced by the use
of antiseptics to destroy disease-bearing organisms. Despite his
successful work and eloquent pleas, his colleagues persisted in
following their old methods. Years after his discovery, they
continued to deride him and his technique, which consisted of
spraying carbolic solution so profusely about the operating room
that both surgeons and patients were drenched. The use of
antiseptics and the techniques of using them continued to
improve. Eventually even the skeptics were impressed by the
clinical results in reducing infection rates. Surgeons, at last,
realized that they could undertake major operations with less fear
of morbidity and mortality.
Discovery of Anesthesia
As the 19th century neared its close, surgery was becoming more
frequent. The discovery of anesthesia and the principle of
antiseptics were two of the most significant influences in the
development of surgical procedures in the modern hospital.
Anesthesia improved pain control, and hygiene practices helped
reduce the incidence of surgical site infections. Although patients
did not immediately flock to hospitals as a result of these
discoveries, these innovations set the stage for the remarkable
growth of the 20th century.
Modern Hospital Laboratory
The study of cytology originated around the middle of the 19th
century and influenced the development of the modern hospital
clinical laboratory. The cell theory was first advanced in 1839 by
the German anatomist Theodor Schwann and was further
developed by Dr. Jacob Henle, whose writings on microscopic
anatomy appeared in 1850. Rudolf Virchow, known as the Father
of Pathology, was the most eminent proponent of the cell theory.
His studies in cellular pathology supported further research in the
etiology of disease.
Changing Hospital Structure
With nursing, anesthesia, infection control, and cytology under
way, a change in hospital structure began in the last quarter of the
19th century. Buildings of the Civil War days were still in use, with
as many as 25 to 50 beds in a ward with little provision for
segregating patients. In New York City in 1871, Roosevelt Hospital
was constructed on the lines of a one-story pavilion with small
wards, and this set the style for a new type of architecture that
came to be known as the American plan. A noteworthy feature
was ventilation by means of openings in the roof, which was an
improvement in hospital construction. Hospitals had been
characterized by a lack of provision for ventilation. Dr. W.G. Wylie,
writing in 1877, said he favored this type of building, but he
advocated that it be a temporary structure only, to be destroyed
when it became infected.
As noted in the following reality check, hospital construction and
building maintenance programs are essential in preventing the
spread of infections.
All caregivers must be observant of the cleanliness of the
environment within which they care for patients. FIGURE 1-3
illustrates the not so uncommon finding of soiled vents and ducts
by those who inspect hospitals. Such findings contribute to the
spread of infections between staff and patients. Caregivers who
observe such issues should notify designated staff members who
are responsible for ensuring the correction of such environmental
deficiencies.
FIGURE 1-3 Soiled vents and ducts.
© decoplus/Shutterstock
STERILE SUPPLY STORAGE
Mark was assigned a 3-day survey at Anytown Medical Center
(AMC). During a tour of the hospital’s facilities, Robin, AMC’s
survey coordinator, Bill, the building engineer, and Jack, the
maintenance supervisor, accompanied Mark. While conducting
the building tour, Mark had asked to see the neonatal intensive
care unit (NICU). After being introduced to Helen, the NICU
nurse manager, Mark and Robin gowned up to enter into the
nursery with Helen. Bill and Jack waited in the hospital corridor.
Mark noticed during his tour of the nursery a door marked
“Sterile Supply Storage.” Mark looked at Helen and asked, “Can
we enter the storage room?” Helen replied, “Sure thing.” Upon
entry to the room Mark observed that cardboard boxes marked
“sterile supply” were stored on the floor. He glanced up at the
ceiling tiles and noticed that they were damp and had green and
black mold. Mark asked for a flashlight to look at the air vents
and ducts. He observed a significant amount of mold on the
exhaust vents. He shined the flashlight up into the vent and
observed that the air ducts had a buildup of mold. Robin,
somewhat concerned, said, “We can get this all cleaned up
before the end of the survey.” Mark said, “I am also concerned
that the sterile supplies stored on the floor, even though in
cardboard boxes, have been compromised. The cardboard
boxes are damp from mopping of the floor. Let’s go out to the
corridor and speak to Bill and Jack. After Mark described what
he saw in the clean storage area, Bill replied, “Oh, there was a
toilet that overflowed in a patient bathroom a few weeks ago in
the floor above. Jack interrupting said, “Well, I do not recall
seeing a maintenance slip from the NICU describing the
problem.”
The risks of infection in healthcare settings require healthcare
organizations to provide continuing education and training for
caregivers. Documentation of in-service training should be
placed in employee personnel files. It is important for managers
to be alert to and correct hazardous conditions observed in the
working environment. Both hospital surveyors (e.g., TJC) and
state inspectors, as part of their training, are required to observe
the working environment and employees who may breach
infection control protocols, such as following proper hand
hygiene prior to caring for each patient. Breaches in protocol
that are observed are included in both state and TJC formal
reports pertaining to the hospital’s compliance with infection
control standards. Hospitals are required to develop, implement,
monitor, and improve the environment to help prevent the
spread of infections.
Changing Hospital Function
Promoted by the wealth of bacteriologic discoveries, hospitals
began to care for patients with communicable diseases. During the
decade from 1880 to 1890, the tubercle bacillus was discovered,
and Louis Pasteur developed vaccines for anthrax and rabies. He
also developed the process for pasteurization. Robert Koch
isolated the cholera bacillus, diphtheria was first treated with
antitoxin, the tetanus bacillus and the parasite of malarial fever
were isolated, and inoculation for rabies was successful. “On
March 24, 1882, Robert Koch announced to the Berlin
Physiological Society that he had discovered the cause of
tuberculosis.”10 Treatment of patients with some of these
infections necessitated isolation, and hospitals were the logical
place for observation of communicable diseases. Consequently, at
the end of the century, in addition to their many surgical cases,
hospitals were crowded with large numbers of patients suffering
from scarlet fever, diphtheria, typhoid, and smallpox, all of which
were contagious diseases.
Discovery of the X-Ray
Wilhelm Conrad Röntgen’s discovery of the X-ray in 1895 was a
major scientific achievement. The first use of the X-ray symbolizes
the beginning of the period that necessitated equipment so costly
that the average practitioner could not afford to install it. The
natural result was the founding of community hospitals in which
physicians could jointly use such equipment. Nineteenth-century
inventions also included the clinical thermometer, the
laryngoscope, the Hermann von Helmholtz ophthalmoscope, and
innumerable other aids that have led to more accurate diagnoses.
Although the medical and nursing professions of the later half of
the 19th century did not reap the full reward of their discoveries,
they provided the 20th century with a firm foundation upon which
to build.
▸ 20TH-CENTURY PROGRESS
The treatment of metabolic diseases and nutritional deficiencies,
the importance of vitamins, and the therapy of glandular extracts
played an important role in the advancement of medicine in the
20th century. As early as 1906, Frederick Gowland Hopkins began
investigations into vitamins. Two years later, Carlos Finlay
produced experimental rickets by means of a vitamin-deficient
diet. This, in turn, was followed by Kurt Huldschinsky’s discovery
that rickets could be treated successfully with ultraviolet light. In
quick succession came Casimir Funk’s work with vitamins, Elmer
McCollum’s discovery of vitamins A and B, Joseph Goldberger’s
work in the prevention of pellagra, and Harry Steenbock’s
irradiation of foods and oils. Other outstanding contributions to the
science of nutrition include Frederick Banting’s introduction of
insulin in 1922, the studies in anemia carried out by Dr. George
Hoyt Whipple and Dr. Frieda Robscheit-Robbins, a pathologist
who worked with Dr. Whipple. This led to Dr. George R. Minot and
Dr. William P. Murphy’s successful treatment of pernicious anemia.
This achievement was considered a major advancement in the
treatment of noninfectious diseases. As a result of their research,
Hoyt, Minot, and Murphy were awarded the Nobel Prize in
Physiology or Medicine.
Dr. Willem Einthoven invented the electrocardiograph (ECG) in
1903. The machine measures the electrical changes that occur
during contractions of the heart muscle. The ECG records these
graphically, thus allowing the physician to diagnose abnormalities
in a patient’s heartbeat. He coined the term electrocardiogram for
this process, marking the beginning of an era of diagnostic and
therapeutic aids. Shortly after that invention came the first basal
metabolism apparatus, then the Wassermann (August Von) test in
1906, and tests for pancreatic function. Invention of the
fluoroscopic screen followed in 1908. Subsequently, the
introduction of blood tests and examinations of numerous body
secretions required well-equipped and varied laboratories.
Concurrent with this progress in the field of internal medicine was
the introduction of radium for the treatment of malignant growths,
increasing the use of the clinical laboratory for microscopic
examination of pathologic tissue and developments in antibiotics.
The result of these many new aids was the conquest of diseases
formerly regarded as incurable, which in turn, resulted in improved
public confidence in hospitals. The discovery of the structure of
DNA is by far one of the most famous scientific discoveries of the
20th century.
The discovery in 1953 of the double helix, the twisted-ladder
structure of deoxyribonucleic acid (DNA), by James Watson
and Francis Crick marked a milestone in the history of science
and gave rise to modern molecular biology, which is largely
concerned with understanding how genes control the chemical
processes within cells. In short order, their discovery yielded
ground-breaking insights into the genetic code and protein
synthesis. During the 1970s and 1980s, it helped to produce
new and powerful scientific techniques, specifically
recombinant DNA research, genetic engineering, rapid gene
sequencing, and monoclonal antibodies, techniques on which
today’s multi-billion dollar biotechnology industry is founded.
Major current advances in science, namely genetic
fingerprinting and modern forensics, the mapping of the human
genome, and the promise, yet unfulfilled, of gene therapy, all
have their origins in Watson and Crick’s inspired work.11
The 20th century was also characterized by rapid growth in
nursing education. The earlier schools were maintained almost
entirely to secure nursing service at a low cost. The nurse’s duties
were often menial, hours long, and classroom and laboratory study
almost entirely lacking. Nurses themselves had begun to organize
for educational reforms. By 1910, training increasingly emphasized
theoretical studies. This movement was largely a result of the work
of organizations such as the American Nurses Association and the
National League for Nursing, along with the organization of the
Committee on the Grading of Nursing Schools. In 1943, the U.S.
Cadet Nurse Corps was organized to spur enrollment of student
nurses in nursing schools to help meet the shortages caused by
enlistment of graduate nurses for military service. As a result,
efforts increased to train practical nurses and nurses’ aides in
order to relieve the shortage of graduate nurses.
Reform in medical education began early in the century and was
almost wholly a result of the efforts of the Council on Medical
Education and Hospitals, which was established in 1905 by the
AMA. Immediately after its organization, this council began
inspection of medical schools. The council, by establishing
standards and by grading the schools, brought about gradual
elimination of most of the unethical, commercial, and unqualified
institutions.
A great stimulus to the profession of hospital administration has
been the work of the American Hospital Association. Organized in
1899 as the Association of Hospital Superintendents, it took its
present name in 1907. Since its inception, the organization has
concerned itself particularly with the problems of hospital
management. As early as 1910, the association held educational
programs for hospital chief executive officers and trustees. The
American College of Surgeons was founded in 1913 under the
leadership of Dr. Franklin H. Martin, the first director general of the
organization. One of the most dramatic achievements of the
American College of Surgeons was the hospital standardization
movement that began in 1918. The founders drew up what was
known as “The Minimum Standard,” a veritable constitution for
hospitals, setting forth requirements for the proper care of the sick.
An annual survey of all hospitals having 25 or more beds made
the standard effective. When the first survey was conducted, only
89 hospitals in the United States and Canada could meet the
requirements.
The hospital standardization movement focused its efforts on the
patient, with the goal of providing the patient with the best
professional, scientific, and humanitarian care possible. The
growth of this movement is remarkable, given that participation in
hospital standardization programs is voluntary. Following several
name changes over the years, The Joint Commission today
conducts unannounced accreditation surveys, with emphasis on
ongoing improvements in the quality of patient care.
The years following 1929 will long be remembered as one of the
most trying periods in the history of hospitals. Due to critical
economic conditions, many institutions found it difficult to keep
their doors open. A declining bed occupancy and an everincreasing charity load, coupled with steadily decreasing revenues
from endowments and other sources of income, created hardships
on private institutions. Fortunately, however, every economic crisis
brings forth new ideas and means and methods of organization to
benefit humanity.
In the latter half of the 20th century, competition among hospitals
began to grow as for-profit hospital chains began to spring up and
compete with nonprofit organizations. Advances in medical
technology, such as computed tomography (CT), magnetic
resonance imaging (MRI), positron emission tomography (PET)
scanners, and robotic surgery, as well as an ever-growing list of
new medications, have revolutionized the practice of medicine.
During this period, less invasive surgical procedures and a trend
toward care in outpatient settings has reduced the need for
lengthy stays in hospitals and various long-term care facilities.
Laparoscopic surgery, performed through one or more small
incisions using small tubes and tiny cameras and surgical
instruments, has proven to be one of the remarkable movements
forward in the history of surgical procedures.
▸ HEALTH CARE AND HOSPITALS IN
THE 21ST CENTURY
So how safe is your hospital? Two new rating systems help
you check before you check in. Hospital safety score
(hospitalsafetyscore.org), launched in June (2012), assigns grades
of A, B, C, D or F to more than 2,600 U.S. hospitals based on 26
safety measures and standards—from hand-washing policies to
foreign objects left in body cavities after surgery. Nearly half of the
hospitals received a C or lower.
—Bill Hogan12
The struggle for hospitals to survive continues well into the 21st
century but the news is not always kind. In the nation’s capital, one
would dream that it would represent the “model city of hope” for
the healthcare system. But all to often we learn of its failures and
not its progress. Howard University Hospital, for example, opened
its doors in 1863 as Freedman’s hospital, and it provided care to
the freed African American slaves. It soon “became an incubator
for some of the brightest African American slaves.” But over the
past decade, the once-grand hospital that was the go-to place for
the city’s middle-class black patients has been beset by financial
troubles, empty beds, and an exodus of respected physicians and
administrators, many of whom said they are fed up with the way it
is run.”13 This follows the closure of DC General Hospital, which
many had hoped would be rebuilt. Other hospitals, including the
VA system, have struggled and continue to struggle, some even to
survive. The overflow of patients into the city’s remaining hospitals
affects the ability of those hospitals to handle the needs of
patients. Many physicians now tell their patients, “My goal is to get
you in and out of the hospital as fast as I can. I don’t want you to
get sicker.” The challenges remain as history repeats itself.
RURAL AMERICA’S DYING HOSPITALS
. . . Nearly 80 have closed since 2010, including 9 in Tennessee,
more than in any state but Texas. Many more are considered
fragile—downstream victims of federal health policies, shifts in
medical practice, and the limited tolerance of distant corporate
owners for empty beds and financial losses.
In every rural community, the ripple effects of a lost hospital are
profound, reverberating beyond the inability of would-be patients
to get immediate care.
—Amy Goldstein, The Washington Post, April 12, 2017
The delivery of health care in the modern hospital continues to be
the revolutionary product of a long and arduous struggle. The
continuing stream of new medicines and treatments, as well as
legal, financial, and human resource issues, continues to test the
healthcare system. Many of today’s healthcare challenges have
carried over from the 20th century. The challenges include
exorbitant malpractice awards, excessive insurance premiums,
high expectations of society for miracle drugs and miracle cures,
fairly balancing the mistakes of caregivers with the numerous
successful events, negative press that increases public fear, and
numerous ethical dilemmas involving abortion, human cloning,
physician-assisted suicide, how to fairly distribute limited
resources, and the dwindling number of rural hospitals, are but a
few of the challenges of the 21st century.
According to a study written by Sy Mukherjee in ThinkProgress,
there is an increased risk of dying in rural hospitals.
Critical access hospitals (CAHs) are medical providers located
in America’s most isolated regions, serving rural communities
that do not otherwise have easily available access to care.
Since the closest alternatives to these hospitals are usually
over 35 miles away, they provide an essential resource for
Americans living in secluded communities—and therefore
receive enhanced funding from the federal government to carry
out their work. But according to a Harvard School of Public
Health study, death rates at these hospitals are significantly
higher than national averages—and are on the rise.14
As advances in medicine rapidly move the nation’s healthcare
system in the direction of high-cost care and treatment, small rural
hospitals are increasingly unable to meet the challenges of both
procuring expensive capital equipment and attracting qualified
specialists. This, in turn, is leading to the demise of rural hospitals’
ability to provide the more complex care available in modern
medical centers.
Translational Medicine
Translational medicine began to be recognized as a significant
development at the end of the 20th century and well into the 21st
century. Both the researcher and the practitioner began to better
understand the importance of knowing each other’s contribution in
the healing process.
The translation of biomedical discovery into clinical benefit is
the essence of translational medicine, which continued to
experience remarkable growth in 2012. The University of
Dundee, Scot., for example, received almost £12 million ($19.2
million) for the completion of a Centre for Translational and
Interdisciplinary Research, and a £24 million ($38.4 million)
Institute for Translational Medicine was slated for development
in Birmingham, Eng. Scientists continued to work to coordinate
the application of new scientific knowledge in clinical practice
with basic observations and questions in the laboratory.15
Minimally Invasive Surgery
The ever-evolving precision of minimally invasive surgery (MIS)
will catapult medicine into a limitless future of exotic discoveries.
MIS allows physicians to use a variety of techniques to operate
with less damage to body tissues than with open surgery and is
believed by some surgeons to be more noteworthy than the
discovery of anesthesia. MIS is associated with less pain, a
shorter hospital stay, fewer complications and medical errors,
while improving the accuracy of complex surgical procedures.
Decision making during surgery often involves thousands of
pieces of information that are considered during a surgical
procedure. This can lead to increased physician fatigue and the
possibility of human error. MIS reduces the fatigue factor by
assisting the surgeon in the decision-making process by reducing
the time required for a surgical procedure, and the surgeon
concentrates on the surgical skills necessary for completing a
successful surgery. The bells and whistles and blinking lights
become less of a distraction, by allowing the surgeon to
concentrate on the surgical field (e.g., patient’s abdomen).
Robotic surgery provides a magnified 3-D view of the surgical site
and helps the surgeon operate with precision, flexibility, and
control. The popular da Vinci System robotic equipment is used for
cardiac, colorectal, general, gynecologic, head and neck, thoracic,
and urologic surgical procedures. It allows surgeons to operate
through several small incisions with enhanced vision, precision,
and control inside the human body.16
Surgical Simulation Training
Advances in surgical simulation training (SST) will enhance the
training of residents, enabling them to transition more effectively to
performing more precise surgical procedures with fewer errors and
improved patient outcomes. Pilots are trained in a simulator before
ever flying a plane. Surgeons have historically been in the dark
stages of SST, even though “they are in charge of carrying out the
procedures that may either save or kill the patient at hand.”17 The
patient will one day no longer be the experimental subject in the
hands of a surgeon-in-training. Surgical simulation, so long waited
for, will produce a generation of surgeons who have practiced
surgical procedures, just as pilots do before flying a plane.
Social Media Impacts on Caregivers
The advent of social media has raised concern among caregivers
and hospitals. Patients post both positive and negatives reviews
on the World Wide Web (e.g., Healthgrades, Facebook,
GooglePlus, Twitter, YELP, ZocDoc). Reviews may include long
waits and rude staff members, which can affect a physician’s
social media ratings. Patients who complete multiple forms prior to
an office visit often discover the physician has not reviewed them.
Instead, the physician conducts a hurried review of the documents
at the time of a patient’s scheduled appointment, reviewing with
patients the ailments with which they are familiar and not
addressing or leaving less time to discuss the patient’s current
concerns, reason for being there, and the treatment plan.
Unfortunately, patients who experience long waits to see their
physicians often tarnish their physician’s reputation by posting
negative remarks. It is not the wait time that should be judged. It is
the skills of a physician in diagnosis and presentation of treatment
options that makes the difference in the quality of life. Not only are
physicians impacted by the challenges of social media, but
hospitals are also concerned with their image in the community. All
care organizations and caregivers must be sensitive to the fact
that social media will not go away, and the concerns of patients
need to be addressed in a positive way by addressing the
concerns of the community.
National Health Insurance
The Patient Protection and Affordable Care Act (PPACA), passed
by Congress and signed by President Barack Obama on March
23, 2010, was designed to ensure that more Americans receive
healthcare benefits. The costs, however, associated with national
health insurance continue to rise. Insurance premiums have risen
by as much as 10% in 2017 for those who are not eligible for
subsidies. “Aetna, Humana and United HealthCare Group said
they would stop selling Obamacare policies in most states next
year, citing financial losses due to a flood of older, sicker enrollees
and not enough young, healthy people to offset the costs.”18
As healthcare politics continue to rage on in Congress, the
greatest health challenge of the 21st century requires that each
member of society take a more responsible and proactive role in
his or her health and well-being by maintaining a healthy lifestyle.
Boutique Medicine
The problem of accessibility to care is further exacerbated by an
increasing number of physicians who turn to boutique medicine, a
plan of care whereby a patient pays an annual retainer fee in
exchange for expedited access to a physician for health care. As a
result, physicians who elect to practice boutique medicine find it
necessary to limit the number of patients they can treat due to the
need to be readily available to patients in their practice. In other
words, increased access leads to fewer patients, and arguably,
better care for those who can afford the fees.
Medical Errors Plague Hospitals
The uncanny number of medical errors described in the following
news feature quote illustrates the depth of the failure to
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