Pushing to get better

WEDNESDAY: A paid consultant finds there's plenty of work to do. Stephanie Hernandez gets an important piece of news about her recovery, while Vicente Sobredo goes to the operating room.

It was toward the day's end, around 5, when the tension in the conference room started to rise. The talk had turned, of all things, to the right way to disinfect a room after a patient clears out.

Maureen Shannon, 54, a nurse who had risen to vice president for quality management, had gotten word that the housekeeping staff on the 11th floor wasn't waiting long enough for a disinfectant to work when they cleaned vacated patient beds. Some appeared to be waiting only two minutes when they should have been waiting 10.

Shannon put the issue to Maria Ninivaggi, the head of infection control. Were they using the wrong disinfectant?

"It may be that they could not be using what it is you wanted them to use," she said.

Ninivaggi took a breath, then spoke deliberately: "I reviewed the labels of the manufacturers of the two germicide detergents we use," she said. "They both say 10 minutes. . . . They are taught 10 minutes."

This was exactly the sort of detail that The Joint Commission would seize upon in the upcoming inspection. The Centers for Disease Control and Prevention estimates that health care-associated infections account for about 1.7 million infections and 99,000 deaths each year, making them one of the nation's 10 leading causes of death. In 2008, NUMC scored at the state average for such infections.

Shannon said she had been told there were two products in use on the 11th floor. One required 10 minutes, and the other was a germicidal wipe used for two minutes.

Ninivaggi looked perplexed. "But the germicidal wipe is not something that would be used on a bed."

Shannon said she was told a housekeeper was using it on a bed.

"Where?" Ninivaggi said.

She was insistent. "Where? We don't do that. We don't do that. It is not allowed. I need to know who, when and where. How can we find out?"

No one said a word, and Ninivaggi cooled down.

"They need to know they can't make the bed up for 10 minutes," she continued. "They cannot make the bed up until it dries, and the dry time is 10 minutes."

"So," said Shannon, "we have got to tell nurses, because on 11 they knew to wait until it was dry but they didn't know it was 10 minutes."

Ninivaggi sighed, looked down and put her hands on top of her head.

A delicate surgery Dr. John Layke, chief resident in plastic surgery, stood leaning over a monitor in a cavernous operating room. Glowing on the screen was a black-and-white CT scan of a shattered skull.

Unconscious two feet away on the operating table was the patient, Vicente Sobredo, 72, a retired attorney from Uruguay who a week earlier had fallen down the steps of his son's Levittown home. He broke two ribs, fractured his collar bone and cracked open his right temple.

Middle-class patients such as the Sobredos are not the norm at NUMC, and they had been nervous about him being brought to a public hospital. About three-quarters of the hospital's patients either have no insurance or are on government-funded Medicaid or Medicare, according to NUMC.

Pointing to the CT scan, Layke noted where some of the fracture above the right brow had buckled. "Here, it's broken out here," he said.

Layke said the surgery would be "like repairing eggshells."

Even as NUMC readied for the upcoming inspection, the staff had a lot of other everyday work to do. NUMC is known for its top-level trauma care, but it also offers a full range of medical and surgical services, though for some specialties such as radiology it relies on doctors from the North Shore- Long Island Jewish Health System.

Plastic and reconstructive surgery, however, remains homegrown. The chairman of the department, Dr. Roger Simpson, said that NUMC, a teaching hospital with 155 medical students, is a hot spot for nearly 300 residents and fellows. Young doctors such as Layke can hone their skills handling the wide variety of cases in reconstructive and plastic surgery that come to a public hospital. Car wrecks. Household falls. But no tummy tucks - cosmetic surgery is not done at NUMC.

"It has been an interesting week," said Layke, 34, as he walked over to put on his surgical gown. A few days earlier, he had operated on Rene Castro, the man who had been struck by lightning. They had taken a strip of skin from Castro's thigh and grafted it onto his burned foot.

A little after 9 a.m. nurses helped Simpson and Layke into their gowns and painted Sobredo's face with the antiseptic Betadine. Then, in the standard precaution to ensure the right operation was being done on the right patient, a nurse called out, "This is Vicente Sobredo," and she described the operation. "All those in favor?"

The two doctors and their eight-member team of nurses and technicians responded in unison: "Yes."

To spare Sobredo more stitches and the possibility of another scar, they planned to go in through the cut from the fall above Sobredo's eye. Then, Layke said, they would lift the bones up to make them flush with the rest of the skull. Finally, they'd hold them in place with tiny plates and screws.

Layke made the first incision while Simpson dabbed away blood. The two doctors' surgical masks muffled their words.

"Where do you want to be?" Simpson said. He coached the younger man. "Let's open up this region."

As if choreographed, a nurse smoothly lifted instruments arrayed on a tray and placed them in the doctors' waiting hands. As Layke cut, Simpson either dabbed or sutured. Theirs was a quiet ballet of hands and fingers.

Steps to recovery His mouth set, Rene Castro steeled himself and gripped the crutches under his arms.

Physical therapist Robert Hughes stayed close to Castro's side as he took his first steps down the hall of the sixth-floor burn center. It was 10:50 a.m. The doctors had told Castro he might leave the next day.

"Make sure those crutches are out front," Hughes said. Castro carefully moved the crutches forward. Then he moved his heavily bandaged left foot, followed by his right. Castro paused, breathing heavily. "Good," Hughes said.

After two or three steps, Hughes asked an aide to get Castro a chair and the sneaker for his unburned foot to replace the hospital sock he was wearing. When the chair was brought, Castro fell heavily into it.

Meanwhile, two doors down, Stephanie Hernandez sat in bed staring at Barney on TV. Her mother, Thelma Garcia, was nearby.

Stephanie had told her mother she was worried whether she'd be permanently scarred. She wasn't eating much, either.

Both looked up when Dr. Louis Riina, the assistant director of the burn center, entered the room. In Spanish, Garcia explained her daughter's worries. Riina spoke a blend of American-accented Spanish and English.

"Usually I give burns two weeks to heal," he said in English. "Usually if they heal within that time period, generally the incidence of scarring is very small, and that's my hope for her. No problema. She's just in medio [the middle]."

But Stephanie said she didn't understand.

"Which part don't you understand?" he asked. He perched in a chair next to the bed and looked directly at her.

"All of it," she said in a small voice.

He smiled and spoke gently. "You got a burn from what fell on your chest," he said. "You're healing really good. And the more you eat, the better you are going to heal and the nicer your skin is going to be. And you're right in the middle of your treatment."

"My skin is coming back?" she asked. Hope crept into her voice.

"Yes, and it's in the middle of coming back. You just have to be patient while you're healing. While you're healing, eat lots and lots of food because that's what brings your skin back, OK?

"Does it help to know all the details?" he asked.

She nodded.

Surprised by care At 1:30 p.m. Simpson walked into the waiting area on the second floor. The Sobredos rose together to meet the plastic surgeon.

"Everything went well," Simpson said. "He's going to be fine."

In a darkened recovery room 40 minutes later, Sobredo's wife, Maria, and the rest of the family saw him lying in bed. Bandages covered his head. A nurse said he had been agitated but now was sleeping. His daughter-in-law, Andrea Sobredo, confessed that the family had been anxious about the care he might get at a public hospital. But she said NUMC had been stellar. She described the hospital's finance people, who helped the family access the grandfather's private insurance in Uruguay, as "angels."

Maria and Andrea hugged each other for a long time and said nothing.

Insider's view The 18-foot-long, 9-foot-high hyperbaric chamber, painted baby blue, looks like a submarine. Its inch-and-a-half-thick steel hull is studded with portholes and laced with intricate piping.

The chamber, pumped with 100 percent oxygen, is used to speed up wound healing or to treat divers who have the bends - decompression sickness caused when breathing nitrogen under pressure. At that moment three patients and a hyperbaric tech were inside. They call it "taking a dive."

At 2:15 p.m., Kurt Patton walked in with barely a glance at the towering chamber.

In a quiet and even voice, he asked to see three randomly selected patient charts.

Patton, a consultant, had been hired for three days to appraise NUMC's readiness for The Joint Commission survey. He was on his second day, and his visits to various parts of the hospital were unannounced. He was one of several consultants hired to make sure NUMC administrators got a diverse range of advice.

Patton, 57, was an insider. He was a pharmacist who had worked for the commission as executive director of accreditation services and for the state Office of Mental Health for many years. That day, he had already visited four other areas. In his travels, Patton has seen plenty of hospitals where the staff is interested chiefly in passing The Joint Commission "test." He said he was impressed with NUMC because "they are not dressing for a theatrical part; they want to change behaviors."

Patton flipped through the hyperbaric chamber charts and asked for what was called the ambulatory summary list, a rundown of all of a patient's visits and treatments.

Donna Hangan, a nurse in the hyperbaric, burn and wound clinic, said she didn't have that.

Patton explained that it was designed to be a "snapshot summary" of care.

"They'll be looking for that," said Patton. He meant The Joint Commission surveyors.

"We have weekly staff meetings on Monday morning, and once a month we have full staff meetings," the nurse said. She looked flustered. "I'll bring it to the attention of the big staff meeting this Monday."

Asked if she was worried about The Joint Commission survey, she said, "Now I'll be because there's a piece of information missing from our charts. But normally things are very much in order. But now, this paper is missing."