The U.S. News Best Hospitals rankings and other resources can help steer you to a top-notch hospital when a procedure or condition requires exceptional skill. For routine care, such as repairing a torn rotator cuff or inserting a heart stent, most hospitals will do a fine job. Still, "most" is not "all." Sometimes a particular hospital can be the right choice for some patients but the wrong one for you.
There aren't many hospitals so terrible that they're lethal. A 50 percent death rate or other glaring red flag would prompt padlocks on the doors. But you don't want a place that has little experience with your surgical or medical needs—or is less alert than it should be for anything that could go wrong. Rates of postsurgical complications such as bleeding, infection, and sudden kidney failure vary surprisingly little, according to a recent study of nearly 200 hospitals across the country. What does differ are deaths from such complications, says John Birkmeyer, a professor of surgery at the University of Michigan Medical School and the study's coauthor. Mortality rates at some hospitals in the study were almost twice as high as at others. A good hospital, says Birkmeyer, catches problems and responds quickly. What follows are five signs that you might want to think twice about the hospital you have chosen.
Low hospital volume. A hospital that sees a regular flow of patients like you is more likely than a low-volume center to have a well-oiled system in place for their procedures and medical conditions. The hospital should be able to provide volume figures for the most recent year, along with death and complication rates. Recommended volumes have been set for a handful of procedures. The Leapfrog Group, a business-sponsored organization that evaluates hospital performance, suggests 450 a year for heart bypass surgery, 400 for coronary angioplasty and stenting, 125 for weight-loss surgery, 120 for aortic valve replacement, 50 for repair of an abdominal aortic aneurism (a weakened portion of the lower part of the aorta), and 13 and 11 for removing a cancerous portion of the esophagus and pancreas respectively. A hospital with much lower figures could still perform well, but you might ask your doctor about an alternative source of care.
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Low surgeon volume. Even high-volume hospitals can have low-volume surgeons, and the difficulty of some operations, such as aortic valve replacement, demands practice to keep the required skills sharp. Various studies have found that for some procedures, the surgeon is more of a factor than the hospital in determining complications and length of stay. In a study involving men whose cancerous prostates were removed, for example, complications were significantly lower and length of stay shorter with surgeons who did 60 or more prostatectomies a year than for surgeons who did fewer than 60. The surgeon to whom you were referred should freely provide the latest yearly total and rates of death and complications. If she bristles or says the information isn't readily available, that, too, suggests a conversation with your doctor about a different surgeon.
No intensivist. Traditionally, surgeons or other physicians were in charge of patients they sent to the intensive care unit. But studies show that deaths drop by 25 percent or more in ICUs where patients are under the care of intensivists. These specialists in critical care spend most of their time inside the ICU, while surgeons do most of their work in the OR and other medical specialists appear only intermittently. Small hospitals might not be able to carry an intensivist on staff, but those with 250 beds or more should have at least one intensivist available during the day who can get to the ICU within five minutes of being paged. In an "open" ICU, the surgeon or other doctor still has the final say over care. A "closed" ICU, in which an intensivist is completely responsible for care, is better because of the physician's daily familiarity with the patients.
Not enough nurses. Is a patient shivering after surgery still cold from the chilly OR—or could she be going into shock? It's harder for a nurse to detect subtle signals of possible distress if she can't spend time at the bedside because of a heavy patient load. A 2002 study in the Journal of the American Medical Association found that a patient's risk of dying was much higher in hospitals where nurses on surgery floors had eight or more patients during an average shift as opposed to four or fewer. Hospitals whose RNs have four-year degrees also have a lower rate of surgery-related deaths than in hospitals with two-year RNs. Linda Aiken, director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing, says patients can call the director of nursing at any hospital to find out nurse to patient ratios. Certain states like Massachusetts put hospitals' ratios online. California is the only state that limits nurses' patient load; by law, surgical nurses there can care for no more than five patients at a time.
Too many readmissions. A high rate of readmissions suggests a hospital's inability to coordinate care after discharge, says Harlan Krumholz, a cardiologist at Yale University who developed readmissions standards for heart failure, heart attack, and pneumonia for Hospital Compare, a Web page for consumers maintained by the federal Centers for Medicare and Medicaid Services. Readmission rates across U.S. hospitals tend to be fairly similar, so the best way to use those numbers is to see if rates at the hospital of interest are radically worse than those at other hospitals you might choose.
